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Prevalence and pattern of acne vulgaris among adolescents in Ibadan, south-west Nigeria

Okoro, Emeka; Ogunbiyi, Adebola; George, Adekunle

Journal of the Egyptian Women's Dermatologic Society: January 2016 - Volume 13 - Issue 1 - p 7–12
doi: 10.1097/01.EWX.0000470561.85599.0d
Original articles
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Background Acne vulgaris is a chronic inflammatory skin disease that commonly affects adolescents. Its prevalence varies widely, with higher figures reported from the developed countries. Recent reports suggest that there might be an increase in prevalence in the developing world.

Objective To determine the current prevalence, pattern, and risk factors for acne vulgaris among school adolescents in Nigeria.

Patients and methods A total of 464 adolescents were recruited from four (two private and two public) secondary schools in Ibadan, Nigeria, between September and November 2011. The students were interviewed with the aid of a questionnaire for symptoms and possible risk factors of acne. The participants were examined for acne and the severity of acne was graded using the global acne grading scale. The stress level of the students was evaluated using the perceived stress scale and their BMI was recorded.

Results The prevalence of acne was 64.4%. Mild acne was the predominant grade of acne among adolescents. The presence of acne was associated with late adolescent age (P<0.001) and school type (P=0.013). There was a significant association between BMI and presence of acne (P<0.001), with a higher prevalence of acne among students with higher BMI (underweight, 47%; normal, 65.1%; overweight, 89.3%; and obese, 88.9%). There was no significant association between the stress level of the students and acne prevalence (P=0.213).

Conclusion The prevalence of acne vulgaris appears to be increasing in adolescents in our environment. Increasing age, high BMI, and school type were associated with the risk of developing acne vulgaris. Further studies are needed to clarify the role of diet in these findings.

aDepartment of Medicine, Dermatology Unit, Federal Medical Center, Keffi, Nasarawa State

bDepartment of Medicine, Dermatology Unit, University of Ibadan, Oyo State, Nigeria

Correspondence to Emeka Okoro, MBBS, FMCP, FWACP, Dermatology Unit, Department of Medicine, Federal Medical Center, P.M.B 1004, Keffi Nasarawa, Nigeria Tel: +234 813 835 3294; e-mail: emybum@yahoo.com

Received October 2, 2014

Accepted July 21, 2015

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Introduction

Acne vulgaris is a chronic inflammatory disease of the pilosebaceous units characterized by increased sebum secretion, comedones, erythematous papules, and superficial pustules. Less frequently, nodules, deep pustules, or pseudocysts occur. Complications of acne include postinflammatory hyperpigmentation, scarring (pitted scars), and keloids 1.

It is a common skin disease affecting 85% of the world’s population aged 11–30 years 2. In the USA, 85% of about 40 million individuals affected by acne vulgaris are adolescents and young adults between the age of 12 and 24 years 3. Similar trends have been observed in other developed countries where the prevalence of acne is in the range of 82.1–94.9% 4–6.

Earlier reports from West Africa reported prevalence rates below 50% 7,8. However, a study from Northern Nigeria reported a prevalence of 90.7% 9.

The lower prevalence of acne in the developing world has been associated to diets with low glycemic index 10. With the increasing westernization in the developing world, it is believed that the prevalence of acne in these areas will also increase 11,12.

Acne vulgaris has enormous psychological effects, with poor quality of life among patients suffering from acne 13. In addition, the complications of acne, such as postinflammatory hyerpigmentation, are common in our environment.

We decided to document the current prevalence, possible precipitating factors, and clinical features of acne among school adolescents in our environment.

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Patients and methods

This was a cross-sectional descriptive study among adolescents (10–19 years) selected from four secondary schools in Ibadan North Local Government Area (IBNLGA) from September to November 2011. There are 12 geopolitical wards with 28 public and 32 private registered secondary schools in IBNLGA. Each school comprises three junior and senior secondary school classes. The study was approved by the University of Ibadan/University College Hospital, Ibadan ethical board. The students gave assent to the study and informed consent was obtained from their guardians before the study was commenced.

The minimum number of students studied to determine the prevalence of acne among adolescents was obtained using the sample size formula for estimating single proportion. Using the acne prevalence of 35.5% among adolescents from a previous study by Ogunbiyi et al.7, the calculated minimum sample size was 375 at 95% level of confidence. Assuming a nonresponse rate of 10%, a minimum of 412 students were required. A total of 464 students were selected randomly using a multistage sampling method from the geopolitical wards, schools, classes, and students. A total of 230 students were selected from two private schools (115 from each school), whereas the remaining 234 were selected from two public schools (117 from each school). The number of students selected from each class was calculated using simple proportion.

where X is the number of students selected from each class.

Doctors in the dermatology unit, who had been trained, administered the questionnaire and test instruments. The questionnaire, which was developed by the researchers, seeks information about the participant’s demographic data, history of acne, treatment of acne, and risk factors for acne such as family history of acne, cigarette smoking, drugs, stress, and BMI. Each participant was examined separately under well-lit condition in an enclosed space to ensure privacy. The types of acne lesion (comedones, papules, pustules, and nodules) on each part of the face (forehead, nose, right and left cheeks, chin, and perioral areas), upper back, and chest were documented. The global acne grading scale 14 was used to assess the severity of acne in the participants. The presence or absence of perioral lesions was noted as it has no formal score in the global acne grading scale. The perceived stress scale (PSS) 15 was used to assess the global stress level of the students in the senior secondary class. The PSS is a widely used instrument for assessing an individual’s perception of stress, using which we measured the extent to which life events were considered as stressful by the participants during the last 1 month. The answers to the questions were scored from 0 to 4 and thereafter the total PSS score was determined. The BMI was calculated for each student. The BMI was classified as underweight, normal, overweight and obesity based on participant’s age and sex 16.

The students were divided into early (10–14 years) and late (15–19 years) adolescent age groups 17.

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Statistical analysis

Data were analyzed using Statistical Programs for Social Science (SPSS), version 16, statistical software (SPSS Inc., Chicago, Illinois, USA). Quantitative variables were summarized using means and SD, whereas frequencies and proportions were used for qualitative variables. Comparison of means was made using independent Student’s t-test. Association between the presence of acne and variables was tested using the χ2-test. The variables that were significant on the χ2-tests were entered into a multiple logistic regression model to identify independent factors associated with the presence of acne. Odds ratios and 95% confidence intervals were reported. Level of significance was set at P value less than 0.05.

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Results

Data of 464 students were analyzed. The data of 16 students were not complete. An overall 67.8% of the students were female. In the public schools, 130 students (55.6%) were in the early adolescence age group, whereas 104 (44.4%) were in the late adolescence age group. In the private schools, 167 (72.6%) students were in the early adolescence age, whereas 63 (27.4%) were in the late adolescence age. A total of 299 students (64.4%) had acne vulgaris, of whom 265 students (88.6%) were classified as having mild acne and 34 (11.4%) as having moderate acne. Severe acne was not documented in this study. The prevalence of acne was higher among female students in the early adolescent age group (Fig. 1). This was significant (P=0.004) unlike in the late adolescent age group (P=0.34). A total of 242 respondents (53.1%) had a family history of acne. The relations reported to have acne included brother (40.5%), sister (46.3%), mother (20.7%), and father (5.4%).

Figure 1

Figure 1

There was a significant association of presence of acne with school type, adolescence age group, family history of acne, and BMI (Table 1). A higher proportion of students in private schools compared with those in public schools had acne (P=0.013). The prevalence of acne was significantly higher in the late adolescence age group (P<0.001). A higher prevalence of acne was also found among those with a higher BMI (P<0.001) and family history of acne (P=0.040). There was no significant difference in the level of stress between students with acne vulgaris and those without acne (Table 1). The presence of acne was regressed on variables significant from the χ2-tests in a multiple logistic regression model and the results are shown in Table 2. Age group, BMI, and type of school attended by the students remained statistically significant. Family history of acne was no longer significant.

Table 1

Table 1

Table 2

Table 2

The mean age at onset of acne was 12.4±1.6 years (Table 3). The mean age at onset of acne was higher in male students (12.6±1.6 years) than in female students (12.0±1.6 years). This was statistically significant (P=0.032). The mean age at acne onset was also significantly higher among students with mild acne (P=0.006). The students in private schools had significantly higher BMI compared with those in public schools (P<0.001).

Table 3

Table 3

About half of the respondents had lesions in the forehead, cheeks, and nose (Table 4). Less than a third had lesions in the chin, chest, and upper back. The most common lesion on the forehead was papules, followed by comedones. Comedones and papules were commonly found in other areas. Perioral lesions were found in 32 (6.9%) students.

Table 4

Table 4

A positive history of treatment of acne was significantly associated with moderate acne (n=12, 35.3%) than with mild acne (n=44, 16.6%, P=0.009). Among the students that reported the type of treatment they used for acne, 40.9% used creams containing potent steroids.

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Discussion

The prevalence of acne vulgaris in our study was 64.4%. This suggests an increase in the prevalence of acne in this environment, as earlier reports from the same area (south-western Nigeria) had shown lower figures (35.5–43.8%) 7,8. Henshaw et al.18 reported an acne prevalence of 35.1% in Calabar (Southern Nigeria), which was also lower than that reported in our study. A study conducted in the Northern Nigeria by Yahaya 9 reported a prevalence of 90.7%. There are differences in the climate, cultural habits, diet, and genetic makeup of those in the northern part of Nigeria. Further studies are needed to clarify the difference in the prevalence between the southern and the northern parts of the country. Reports from other African countries showed a prevalence of 59.8% 19 in Cameroon and 12.9% in Ghana 20. Only inflammatory lesions were assessed in the Ghanaian study, which may explain the low prevalence.

Despite the increase in prevalence of acne in our study, it is generally lower than the prevalence of acne in many other developed countries 4–6,21,22.

The prevalence of acne in our study was higher in the late adolescence age group than in the early adolescence age group. This had been reported in previous studies 3,5,20. This is due to higher level of androgens and sebum production with pubertal age 23. Androgens stimulate increased sebum production and predispose to ductal hypercornification with formation of comedones 24–26.

The prevalence of acne in our study was higher in female students than in male students. This was significant in the early adolescence age (10–14 years). This is similar to the reports from previous studies 7,19,20. However, some studies reported higher prevalence in the male population 9,27. An earlier onset of acne in female students was observed in our study. Puberty occurs earlier in girls 28. This explains the initial higher prevalence of acne among girls between 10 and 14 years of age. This difference disappears or reverses in late adolescence.

Our study revealed a significant association between family history of acne and presence of acne. However, this was no longer significant after the logistic regression. The association of family history of acne with acne has been reported in a previous study 22. The history of acne in the siblings of the students was higher than that for the parents, which may be a result of general increase in acne in the environment or inadequate knowledge of their parent’s medical histories. A history of acne in the mother was found to be high among our students with acne. Ghodsi et al.22 had reported a history of acne in the mother as the most influential family history of acne. Nevertheless, the exact pattern of inheritance has not been defined despite the documented evidence of familial tendency of acne. A previous study had suggested an association of family history of acne with an earlier age of onset of acne and an increased number of acne lesions 27. However, similar associations were not found in our study.

Our study, found that higher BMI was significantly associated with the presence of acne. The finding of increased BMI among adolescents with acne vulgaris has been reported in previous studies 29,30. High BMI is associated with peripheral hyperandrogenism, which may lead to the development of acne 31. The students from private schools had significantly higher BMI than those from public schools. This may explain the higher prevalence of acne in students from private schools found in our study. In south-west Nigeria, Fetuga et al.32 had reported a higher BMI among students from private schools than among students from public schools. In a developing nation like Nigeria, it is generally thought that students in private schools are likely from higher socioeconomic background. Socioeconomic status is an important factor in determining the BMI and dietary habits among Nigerians 32,33. The role of diet in this will require further investigation.

We found no association between the level of stress and the presence of acne vulgaris as documented by other studies 34,35. Previous reports had attributed worsening of acne by stress to increased level of factors, such as corticotrophin-releasing hormone, which stimulates lipogenesis in sebocytes 36,37. However, it is possible that the different methods of the studies could account for the varying results.

Most of the students had mild acne, whereas a few had moderate acne in our study. Mild acne had been reported as the most common grade of acne in previous community-based studies 9,27,38. However, hospital-based studies reported moderate/severe acne as the predominant grade of acne 39,40. This is expected as moderate/severe acne patients are likely to seek treatment in hospitals. Lesions were seen on forehead, nose, right cheek, left cheek, chin, perioral region, chest, and upper back in our students. Comedones were the most common type of lesions, followed by papules. This finding was similar to those previously reported 6,9. We found no difference as regards sex in the affection of the various parts of the body, unlike the report in Korea by Suh et al.41.

The age at onset of acne vulgaris was earlier in students with moderate acne compared with those with mild acne in our study. Previous studies had reported no significant difference in age at onset of acne between patients with mild and moderate acne 19. The earlier onset of acne in patients with moderate acne may be due to a longer exposure to higher androgen levels during puberty.

History of treatment was significantly associated with moderate acne vulgaris, which is similar to that reported in a previous study 42. The severity of acne is an important factor in determining the treatment-seeking behavior of adolescents with acne. Unfortunately, some of the students were using skin-lightening agents containing steroids, attempting to clear the postinflammatory hyperpigmentation. The use of topical steroids in the treatment of acne vulgaris by Nigerian adolescents had been reported by Henshaw et al.18. Topical steroids can induce acneiform eruption by causing focal degeneration of the follicular epithelium leading to seepage of sebum into the surrounding dermis and inflammation 43. In addition, comedone formation results from increased responsiveness of the follicular epithelium to comedogenic factors by steroids 43,44. This may affect the pattern and severity of acne vulgaris.

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Conclusion

The limitations of this study were the absence of other possible risk factors for acne, such as dietary history of the students, menstrual history, and association of application of greases to hair. In addition, the use of topical steroids by some of the students with acne vulgaris could have altered the pattern and severity of the acne lesions. The prevalence of acne is increasing in sub-Saharan Africa. The association of high BMI with acne vulgaris may contribute to the differences in acne prevalence in developed and developing countries. Diet may play a significant role in this. Further studies are needed to clarify the role of diet in acne vulgaris.

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Acknowledgements

Conflicts of interest

There are no conflicts of interest.

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Keywords:

acne vulgaris; adolescents; Nigeria; pattern; prevalence

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