Clinico- Psychological Profile of Acne Vulgaris Among
department of Medical College, Sharda Hospital, Greater Noida, India, who consented to participate were included in the study. Exclusion criteria was - Patient with drug induced acne or other acneform
lesions.
- Female patients with signs of hyper and rogenicity.
(Hormonal acne)
- Patients with some other associated chronic medical disorder like hypothyroidism, tuberculosis, diabetes etc.
The study was conducted from December 2009 to June 2010. Parameters evaluated included age, sex, age at the time of onset, duration of lesion, site of lesions, number and type of acne lesions (comedones, papule, pustule, nodule), grading of acne and psychological impact. Acne vulgaris was graded using a simple grading system taking into account the predominant lesion to grade acne, which classifies it into four grades.
Grade I- predominantly comedones Grade II- predominantly papules Grade III- predominantly pustules Grade IV- nodulo-cystic acne & scarring
Questionnaires were provided to students regarding psychological impact of acne on their life.
Simple proportion and percentage was used to represent the data collected.
RESULT
Two hundred forty students having acne vulgaris attending skin OPD were included in the study. The age group, which was studied, was 16-22 years. Of the 240 patients 84 females (35%) and 148 (65%) were males. Male to female ratio was 1.76:1.
Face was involved in all the patients with acne vulgaris. However, face alone was involved in 202 (65.4%). This was followed by the involvement of the back (28.2%), chest (20.1%), neck (9.4%) and arms (10%).
As shown in chart-1, the most common type of lesion in this study was comedones, present in all patients. They were followed by papules in 140 (58%) patients while pustules were found in 72 (30%) number of patients. Nodules and cysts were found in 50(21%) patients. (Figure 1)
A total of 84 patients (35%) had grade I acne, 60 (25%) had grade II, 52 (22%) had grade III while 44 (18%) had grade IV acne Vulgaris.
Post-acne scarring was seen in 100 patients (42%).
Cheeks were the most common site of post-acne scarring, being involved in all the 100 patients.
Post-acne hyper pigmentation was observed in 140 patients (58%). Seasonal variation was observed only in 42 patients (18%); 35 patients (15%) exacerbated in summer and 7 patients (3%) in winter.
Psychological impact- Total of 128 (53%) students had feeling of low self-esteem because of acne. Ninety-six students (40%) revealed they avoided social gatherings and interaction with opposite sex because of acne.
Forty-nine out of total 84 females (58%) had social inhibition because of acne. Suicidal ideation was found in 8 students (3%). Twenty males and eight females
Fig. 1: Patient with grade IV acne.
Nodules, cysts and comedones are seen
Chart 1: Type of acne lesion
Fig. 2: Post acne scarring
Psychological Symptoms Males Females Total 1. Felling of low self esteem 70 58 128
2. Social inhibition 47 49 96
3. Suicidal ideation 5 3 8
4. Fear of not getting good placement 20 8 28
DISCUSSION
Acne vulgaris is a chronic condition that is more or less universal in adolescence. An individual is more likely to develop acne than any other skin disease1. Adityan B et al. in their study on acne vulgaris in south Indian population reported 1.06% while Al- Ameer and Al-Akloby, had reported 11.2% prevalence of acne patients in the new patients attending their hospitals3,4. In our study mean age of presentation was 18 years in females and 19 years in males. Al- Ameer and Al-Akloby4 also observed similar age of presentation in their study. Kane et al. in their study noted that the mean age of presentation of their patients was 25.58 years5. Due to earlier onset of puberty in females, acne appears earlier in them, it reflected in our study also.
Face is the most common site of acne vulgaris, as acne is a disorder of pilo-sebaceous unit, which are found in abundance over face. All of our patients (100%) had involvement of face, which was followed by back (28.2%). Chest was involved in 20.1%, neck was involved in 9.4% and arms were involved in 10%.
Adityan B et al. in their study on acne vulgaris also observed similar findings. Acne vulgaris is a polymorphic disease characterized by presence of comedones, papules, pustules and cysts. Most common lesion found in our study was comedone (100%). Kilkenny et al, Cunliffe et al and Adityan B, in their respective studies also reported that comedones were the most common type of lesion3,6,7.
In our study, we graded the severity of acne vulgaris, using a simple and quick system of classification using a four-grade system8. In our study
grade I acne was most common, as previously established by other studies. As comedone is the most common acne lesion, grade I is rightly the most common grade. Adityan B et al and Kane et al also noticed similar finding in their study3,5. Few studies have shown lower incidence of scarring in their acne patients6,9. We noticed high incidence of post acne scarring (42%) as well as post acne hyper pigmentation (58%). Adityan B et al, in their study also noticed high incidence of post acne scarring in south Indian population3.
Post inflammatory hyper pigmentation is a common complication of acne vulgaris, particularly in pigmented skin. Acne has traditionally been accepted in the society as a self-limiting condition. It is the complication of acne in the form of hyper pigmentation and scarring that warrants timely treatment. We observed high (58%) incidence if post- acne hyper pigmentation. Kane et al (67.7%), Yeung et al (52.6%) and Taylor et al (52,6%) also observed higher post acne hyper pigmentation in their respective studies5,9,10. Adityan B et al in their study in south Indian patients observed lower incidence of hyper pigmentation3.
Studies done in the past have shown conflicting results regarding seasonal variation in acne vulgaris.
In our study seasonal variation was observed only in 42 patients (18%); 35 patients (15%) exacerbated in summer and 7 patients (3%) in winter. Previous Indian study done by Adityan B et al also reported similar findings while Al-Ameer and Al-Akloby in their Saudi Arabian study has shown the reverse trend, that acne exacerbates in winter, and often improves during the summer months3,4.
Our study observed great psychological impact of acne on college students. Total of 128 (53%) students revealed feeling of low self-esteem because of acne.
Ninety-six students (40%) said they avoided social gatherings and interaction with opposite sex because of acne. College time is very crucial for students, as it affects overall personality of the student in his future professional life, so acne may have great impact on student's life. Forty-nine out of total 84 females (58%) had social inhibition because of acne. In our study suicidal ideation was found in only 8 students (3%).
Similar study done by Rehn LM et al reported much higher (14.5%) suicidal ideation tendency11. This is a positive trend observed by us. Twenty males and eight females students felt that they had less chance of getting good scoring in their placement interview because of acne. Their fear to some extent can be justified as there has been evidence to support that employers are inclined to favour those with clear complexions when making job offers12.
students felt that they had less chance of getting good scoring in their placement interview because of acne.
(Refer- chart 2)
Chart 2: Psychological impact of acne
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CONCLUSION
To conclude, our study included 240 patients with acne vulgaris. Face was involved in all patients followed by back, chest, arms & neck. 72 patients (30%) had grade I acne, 60 (25%) had grade II, 64 (27%) had grade III while 44 (18%) had grade IV acne Vulgaris.
Out of total 240 students, 53% had feeling of low self- esteem because of acne and 40% revealed they avoided social gatherings and interaction with opposite sex because of acne. Suicidal ideation was found in 8 students (3%) while 28 students thought acne would lead to difficulty in getting them a good job. Thus acne vulgaris has lot of negative psychological impact on students, which included low self-esteem, social inhibition and fear of not getting a good job. Our study thus brings out the clinical profile and psychological impact of acne vulgaris in students attending a teaching hospital in north India.
ACKNOWLEDGEMENT
We would like to acknowledge all the students who participated in the study. We are especially thankful to Dr. Nitin Vora, Professor, Dermatology, B.J. Medical College, Ahmedabad for his guidance during conduction of this study.
CONFLICT OF INTEREST None.
REFERENCES
1. Simpson NB, Cunliffe WJ. Disorders of sebaceous glands. In: Burns T, Breathnach S, Cox N, Griffiths C, editors. Rook's Textbook of Dermatology, 7th ed., Oxford: Blackwell Publishing; 2004. p. 43.1- 43.75.
2. Ikaraoha CI, Taylor GOL, Anetor JI, Igwe CU et al. Demographic features, beliefs and socio- psychological impact of acne vulgaris among its
sufferers in two towns in Nigeria. Online J Health Allied Scs. 2005; 1; 3.
3. Adityan B, Thappa DM. Profile of acne vulgaris- A hospital-based study from South India. Indian J Dermatol Venereol Leprol 2009; 75: 272-278.
4. Al-Ameer AM, Al-Akloby OM. Demographic features and seasonal variations in patients with acne vulgaris in Saudi Arabia: A hospital-based study. Int J Dermatol 2002; 41: 870-871.
5. Kane A, Niang SO, Diagne AC, Ly F, Ndiaye B.
Epidemiological, clinical, and therapeutic features of acne in Dakar, Senegal. Int J Dermatol 2007; 46: 36-38.
6. Kilkenny M, Merlin K, Plunkett A, Marks R. The prevalence of common skin conditions in Australian school students: 3, Acne vulgaris. Br J Dermatol 1998; 139: 840-845.
7. Cunliffe WJ, Holland DB, Clark SM, Stables GI.
Comedogenesis: some new aetiological, clinical and therapeutic strategies. Br J Dermatol 2000;
142: 1084-1091.
8. Tutakne MA, Chari KV. Acne, rosacea and perioral dermatitis. In: Valia RG, Valia AR, editors. IADVL Textbook and atlas of dermatology, 2nd ed., Mumbai: Bhalani Publishing House; 2003. p. 689-710.
9. Taylor SC, Cook-Bolden F, Rahman Z, Strachan D. Acne vulgaris in skin of color. J Am Acad Dermatol 2002; 46: 98-106.
10. Yeung CK, Teo LH, Xiang LH, Chan HH. A community-based epidemiological study of acne vulgaris in Hong Kong adolescents. Acta Dermatol Venereol 2002; 82: 104-107.
11. Rehn LM, Meririnne E, Hook-Nikanne J, Isometsa E et al. Depressive symptoms, suicidal ideation and acne: a study of male Finnish conscripts. J Eur Acad Dermatol Venereol. May 2008; 22 (5):
561-567.
12. Graham-Brown R, Bourke J. Mosby's Color Atlas and Text of Dermatology, 2nd edition, Elsevier;
2008, p.234.
Correspondence Address:
Shoaleh Bigdeli
Assistant Professor, Department, Faculty of Medicine, Tarbiat Modarres University, Tehran University Medical Sciences, Tehran - 14155-5983, Iran
Tel.: +98-21-88622607;
Fax: +98-21-88622607.
E-mail address: sh-bigdeli@tums.ac.ir/shb555@yahoo.com INTRODUCTION
A Large body of research has investigated different aspects of adolescence health1, 5,7 13,15, 23, 24, among these, a study on depressive symptoms and risky behaviors shows that depressive symptoms of adolescence are significantly associated with parental depression, family dysfunction, problems with peers, low self- esteem, alcoholism, feminine gender, and large family size1. Furthermore, in comparison to their peers, adolescents from poor families, with either one or both parents unemployed, inadequate emotional support, and frequent conflicts significantly engage in more risky behaviors23.
Moreover, during adolescence, growth, development, and adaptation to developmental changes of this era, often take place within an environment of drug abuse, increased sexual relationship and weakened family structure24. Among adolescence developmental changes, the tendency to
become independent from family members, as well as, an increased inclination to follow peers is remarkable. The influence of peers on each other as a normal evolutionary process and a prerequisite for socialization in adolescence, as an identity-seeking period, can bring harms7 due to separation from family and significant others and joining to peers. Considering the vulnerability of the youth and the fact that relationship with peers can increase this vulnerability, addressing the subject of friendship in adolescence is of outmost importance.
Friendship is crucial to psychological health of adolescents5. Accordingly, another study15 investigated the association between social relations and psychological health complaints, and emphasized that stressed relations are strongly associated with psychosomatic complaints15. Moreover, friendship with deviant friends increases the risk of antisocial behavior during adulthood8. Furthermore, there is evidence that insufficient family and friend support, peer victimization, physical and/or sexual abuse, and emotional neglect positively correlate with adolescence suicide13.
However, the existing literature on adolescence holds little qualitative evidence available on the youth friendship and health, especially in Iranian context. In addition, evaluation of the youth lived experiences and deep emotions, as a risk-prone group, are not easily Soroor Parvizy*, Fazlollah Ahmadi**, Shoaleh Bigdeli***
*Associate Professor, Department of Community Health Nursing, Nursing and Midwifery Faculty, Centre for Educational Research in Medical Sciences, Tehran University of Medical Sciences,
Tehran, 14197-33171 Iran.
*Associate Professor, Nursing Department, Faculty of Medicine, Tarbiat Modarres University, Tehran, 14155-4838, Iran
***Assistant Professor, Department of Medical Education, Faculty of Medicine, Tehran Universtity of Medical Sciences, Tehran, 14155-5983, Iran.
ABSTRACT
This study is an attempt to explore Iranian adolescents’ perspectives on friendship and health.
Purposeful sampling was used (n=41). Interviews were recorded and transcribed for further analysis.
Results showed three main themes, two of which are the focus of this paper as: positive and negative impact of peers, friendship with the opposite sex.
To maintain a healthy society, considering the multilayered dimensions of adolescence and recognition its characteristics is critical for families, teachers, curriculum planners, health workers and policy makers
Key words: Adolescence, Content analysis, Health, Peer group, Qualitative approach
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achievable by the current quantitative research.
THE IRANIAN CONTEXT
Iran with more than fifteen million adolescents, approximately 30% of the country’s total population, is one of the youngest countries in the world18. The tendency to show risky behaviors among the youth, confronts countries with a challenging situation.
Within the Iranian context, friendship has an influential role on the youth, and friends are crucially important to live a healthy or unhealthy life. In Iranian culture friendship is considered vital and family is regarded as a sacred being; therefore, sometimes, adolescents may keep their relationships, especially with the opposite sex, secret from their immediate family members. Furthermore, in Iran, due to social and educational development, and changing employment policies, Iranian adolescents live in a transitional period; however, they still prefer to enjoy more family emotional support, and need to be attached to their family members while seeking more independence26.
In this section, we will report the results of some Iranian studies on adolescents and their peers. A comparative study on adolescents’ attachment to mother, father, and peers in Shiraz guidance schools has revealed that there is a positive correlation between age and attachment to peers, while this attachment to father and mother shows a negative correlation26. A quasi-experimental study compared the effects of teaching breast self-examination by peers and health care personnel on students’
knowledge and attitude, the results of which showed that the mean score of knowledge in the group trained by their peers was higher than those trained by health care personnel2. Moreover, the results of a longitudinal quasi-experimental study which employed a skill-based intervention to prevent and reduce substance abuse among urban adolescents in Tehran, showed that the intervention significantly decreased substance abuse, improved knowledge, changed attitudes, improved say NO skills, and increased level of self- control, self-efficacy, and perceived susceptibility among the intervention group; whereas, level of self control and attitudes against substance abuse among the control group were deteriorated 3. In another study on the influence of peers, adolescents who met their friends regularly and had a stronger tie with them, brushed their teeth twice or more a day. In addition, girls were significantly more likely to brush their teeth; however, they had weaker peer social networks than boys10. According to the importance of the issue, this qualitative content analysis is an attempt to explore adolescents’
perspectives on health and friendship.
METHODS
In-depth, open-ended semi-structured interviews were carried out in were conducted in one or two sessions within an average of one hour natural settings through purposive sampling, which were tape- recorded and, transcribed for further analysis. To understand, interpret and conceptualize the meaning in qualitative data14, 17, after each interview, the content is read and reread for several times. Then, it was broken down into smaller meaningful units called codes, which were categorized into sub-themes and themes, through constant comparative analysis till a sense of satisfaction to researchers and reasonable stability toward data is reached17.
TRUSTWORTHINESS OF THE DATA Data trustworthiness was confirmed by prolonged engagement, member, peer, and external check. The maximum variation of sampling is used for data conformability and credibility30.
ETHICAL CONSIDERATIONS
The ethics research review board of Tehran University of Medical Sciences, Nursing and Midwifery School approved the research ethical considerations. all aspects of ethical guidelines with respect to human rights were applied including consent forms were also secured.
RESULTS
The findings are explained according to the demographic data and the emerged themes (Table 1 and 2).
Table 1. Demographic data
Demographic Characteristics Number Percent Sex:
Male 17 41
Female 24 59
Education
Secondary School 14 34
High School 22 54
University 5 12
Employment
Student 36 87
Worker 4 10
Shopkeeper 1 3
Total 41 100
Table 2. The Emerged Themes and Sub-themes Consequences of * Positive effects relationship with peer group * Negative effects
Friendship with the * Reasons
opposite sex * Limitations
The positive and adverse effects of peers
The positive or negative outcomes of friendship and its influence on the onset of undesirable habits such as smoking, alcohol consumption, and drug abuse have emphasized by the participants. Male participants mostly reported undesirable and unwanted behaviors under the influence of their peers (peer obedience), while there is seldom a report on their positive influence:
“I was a villain… my friend encouraged me to share our secrets and deeds. He stopped me from doing mischief. He accompanied me to mosques and religious gatherings….to attend a mosque was a good experience; I enjoyed attending religious places, because it was a very unique experience.” 15, 16 year old boy
Friendship with the opposite sex
Developing friendship with the opposite sex was one of the most challenging issues for which participants brought up and explained various motives. A number of participants mentioned modernity and its challenges, satellites and the internet, seeking affection and decreased family relationships as a grownup, as the main reasons for developing relationship with the opposite sex, while others emphasized the need to know others, and the need to feel as a grownup.
In this regard, one of the adolescents mentioned:
“Some girls seek friendship with boys because of modernity and to be more stylish, it is “a must” for them and they want to follow modes; while others seek affection, and when a guy loves them, they become attracted to him. However, in fact, they never receive what they want.” P. 22, 18 year old girl Friendship with the opposite sex might provide a context for development of various social deviations ranging from familial conflicts, educational decline, and emotional dependency to possible transmission of sexual diseases, some of which were reported as the worst consequence of illegal relationship with the opposite sex.:
“These friendships usually damage our school work. Parents do not agree friendship with a girl friend; we cannot talk to them about friendship with the opposite sex. In our country, falling in love with an opposite sex should be kept as a secret and it is a misery.” P.12, 18-year-old male.
“Today, one of the diseases that threaten life of the youth is AIDS that can be acquired from sexual relationship between adolescents.” P.13, 17-year-old- boy.
In addition, imposing limitations on the relationship between the opposite sexes and forbidding them will bring about unwanted, undesirable effects:
“Being restricted is ridiculous, cause forbidding these relationships, worsen the situation.” P.23, 16 year old girl.
DISCUSSION
Content analysis was according to the qualitative methodology. The first extracted theme, has two sub- themes: positive and negative effects of friendship on adolescents, the participants emphasized the role of peers which is similar to what has been reported in the literature9,11, 15, 27,28. Moreover, they stated that they got a sense of “energy and euphoria, psychological vitality, superiority and a sense of identity” through interaction with peers that act as a psychological support for them.
Abnormal friendship leads to higher rates of complicated behaviors in adolescents, and interaction with deviant peers leads to emergence of antisocial behavior in early adulthood8. In contrast, it is shown that peers were successful to run a stop smoking program in schools of both genders4. Therefore, increasing body of knowledge about coping with peer pressure may provide a particular promising route of intervention in adolescents’ substance use and abuse24.
Participants of the study stated that friendship with the opposite sex is one of their main health challenges.
In addition, the male participants of the study narrated more negative experiences due to their relationships, because in Iran they are less limited, have more joys, and can spend more time with peers, than females.
Although, friendship with the opposite sex in Iran is significantly less popular than Western countries; yet, transition from a traditional to a modern society and signs of adolescent’s identity crisis add to the severity of the problem21. In Iran, according to the socio- cultural-religious views, pre-marital relationship with the opposite sex is still a taboo; but, satellites and the internet propagate the western model of relationship with the opposite sex, especially for the youth.
Culture and various contextual factors affect the extent of relationship between the sexes, these may include, a range from simple friendship to having romantic or sexual involvement7. According to the participants, transmitted diseases acquired from a sexual relationship are the worst consequences of secret premarital friendships. Adolescents are highly at risk to acquire AIDS. And, the program of “Healthy People till 2010” has addressed this issue31. Recently,
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