Psychological Impact of Acne Vulgaris in Basic Science Medical Students in Nepal

Introduction: Acne vulgaris is a disorder of the sebaceous gland affecting mostly the adolescent age. Although acne does not cause direct physical impairment, it can produce significant psychosocial stress. Due to the paucity of data, there is a poor understanding of etiopathogenesis, treatment and psycho-social impact of acne in the Nepalese population. This study is the first of its kind in Nepal.Objectives: To determine the beliefs, knowledge, misconceptions, myth, psycho-social impact about acne in recently joined undergraduate medical students attending basic science.Materials and Methods: A cross- sectional study was conducted in two medical colleges in Kathmandu affiliated to Kathmandu University (KU), which followed the same curriculum. Medical students of basic science were enrolled in the study. Self-administered questionnaire was used to collect the data regarding their belief and perception about acne.Results: A total of 247 students constituted the study population and female to male ratio was 1:1.62. Stress, oily skin, poor hygiene were the most common causative factors for acne. Belief and perception of acne included bad blood, menstrual cycle, eve teasing, evil eye. According to them, the best way to treat acne was herbal remedies. They liked to explain acne as being related to puberty, followed by dirty face. Psychological impact of acne was embarrassmentfollowed by lack of confidence and impaired social contact. Suicidal tendency due to acne was found in 3.6%.Conclusion: Misconception about acne are widespread and enduring among basic science medical students. Health education program on acne is needed to improve their condition.


Introduction
A cne vulgaris is a disorder of sebaceous gland aff ec ng mostly the adolescent age group with prevalence of 91% in males and 79 % females. 1 Similarly, in medical students it varies from 56% to 62%. 2 Although acne does not cause direct physical impairment, it can produce signifi cant psychosocial stress.There are many researches on the e opathogenesis, treatment and psycho-social impact of acne among pa ents outside Nepal, but there is a poor understanding of this in the Nepalese popula on due to the paucity of data available.Misconcep ons exist in the community regarding factors that can exacerbate and progress acne vulgaris.Thus, taking this into considera on, the purpose of our present study was to determine the beliefs and misconcep ons, myth about acne in recently joinedbasic science medical students.The main objec ves of our study were to assess the belief, knowledge, misconcep on and psycho-social impact of acne vulgaris in basic science undergraduate medical students in their medical career.

Materials and Methods
A cross-sec onal study was conducted in two medical colleges in Kathmandu, affi liated to Kathmandu University (KU) at Kathmandu Medical College Teaching Hospital, Sinamangal and Kathmandu University teaching hospital, Dhulikhel.The study was conducted between April 2015 to May 2016 a er ethical clearance in 2015 March.According to KU schedule, dermatology lecture and clinical pos ng is only conducted in third and fourth year of medical schooling, hence we enrolled the medical students of basic science (fi rst and second years).A pilot study was conducted in fi rst 20 students to check the understanding and clarity of ques onnaires.Based on the results, ques ons were made to avoid confusion to make easier understanding and interpreta on by students.Students who had a history of acne in thepast or present were included in the study.Before the distribu on of the ques onnaire, a verbal consent was obtained from each student.The students completed the ques onnaire during regular lecture class (teaching me) without discussion with peer partners.
The ques onnaires were divided in four parts: 1) socialdemographic data 2) causa ve factor 3) knowledge and beliefs about acne and 4) psychological eff ects of acne in theirmedical career.The iden fi ca on of student was not disclosed, only the data collected from the ques onnaire were used.
Data entry and descrip ve analysis were done using SPSS version 16.0 for windows.

Results
A total of 247 students with known cases of acne inthepast and present cons tuted the study popula on.The mean age was 20.05±1.107years.Age of the students ranged from 18 years to 23 years.The female to male ra o was 1:1.62.Onset of acne was most common in student of age group 15-20 years (48.2%)(Table :1).Posi ve family history was present in 74 (30%) students.

Opinion about belief and percep on of acne:
The third part of the ques onnaire pertained to opinion about belief and percep on of acne.They believed that acne was due to evil eye (11.3%), eve teasing (21.9%), bad blood (46.2%), menstrual cycle (71.3%).Around 83% believed that there was a role of medica on in the treatmentof acne and similarly, 87% thought that acne could be cured (Figure 1).When means of treatment for acne was asked to the students, only 16.2% chose Allopathic medicines (Table 3).
The second part of ques onnaire was about a tude towards acne."As a medical student, how do you explainto your family?"Around 63%explained acne as being puberty related, 28% students explained it as being dirty face related, 26% studentsexplained as being climate related (summer), 23.1% explained as food related and similarly, by use of many cosme cs (15.8%), family history of acne in23.9%,sebaceous gland disorder (49.4%) and dirty blood (9.7%) (Table 4).
Similarly, an open ques on was asked regarding popular medica on used in acne.They responded as topical clindamycin followed by oral an bio cs and herbal face wash.About 35% did not know about the medicines used in the treatment of acne (Table 5).

Opinion about psychological impact:
The fourth part included ques onnaire on psychological eff ect of acne intheir medical career.The eff ects included aggression (8.1%), poor performance in study (13.4%), depression (13.8%), anxiety (15.8%), impaired social contact (16.2%), lack of confi dence (31.2%) and embarrassment (45.3%).The impact of acne on opposite sex rela on was found in 55.5%, and interference in family rela on due to acne was found in 11.1%.Around 40% students considered that there was a bias in prac cal examina on.History of suicidal tendency was present in 3.6% (Table 6).

Discussion
Acne vulgaris is a very common chronic skin disease present in adolescents that con nue seven a er twen es.Acne does not cause physical disability, but it frequently disfi gures the pa ent if not treated in early phase. 2 Ul mately, the psychosocial and occupa onal consequence of disfi gurement is much more relevant than pure physical limita on. 1 The knowledge about acne is s ll inadequate with a lot of misconcep ons and myth.Thus, we studied the percep on, knowledge and psychosocial impact of acne in basic science medical students.
In our study, we found that acne was more common in females (62%) as compared to males (38%).A similar study done in protuguese medical students revealed more females than male. 2 The most common causa ve factor in our study was considered to be oily skin followed by puberty related condi on, stress and diet.In a study by Al-Hoqail IA, 79% of acne pa ents believed that acne was related to diet. 3 Similarly, in a study by Poli F et al, diet was thought to exacerbate acne. 4Green J and colleague in their study on fi nal year medical graduates of University of Melbourne, Australia found the same result but in lower frequency. 5 An open ques on was asked about the most common medica on they had heard about acne.Around 68% believed that blood purifi er would improve acne, around 35% sample answered as none and 12% answered as clindamycin.Misconcep ons about acne are prevalent not only among adolescence and young adults and acne pa ents but also among family physician. 6Explana on of acne as a medical student to family members was as puberty related by 62.8% and as sebaceous gland disorder by 49.4%.
Regarding the psychological impact of acne, 45.3% felt embarrassment followed by lack of confi dence in 31.2%,depression was highly thought to be a possible consequence of acne in 13.8% and impaired social contact in 16.2%.Likewise, in Riyadh, more than half of the studied groups indicated that acne had an impact on loss of self-confi dence. 3In the same study by Al-Hoqail IA, most of the pa ents (73%) clarifi ed that acne had no or minimal eff ect on their rela onship which was similar to our study (55.5%). 3A Nigerian study accomplished in 2009 summarized that only a small number reported that acne severely aff ected their rela onship with their ability to make friends, rela on with family member, which was similar to our study. 7Around 4% of our students thought that acne could lead to suicidal a empts, whereas, in a study done in Jeddah, Saudi Arabia, it was 17% which was much higher as compared to our study. 3 Limitations 1) Study sample was less, only two medical college students were enrolled.2) In the ques onnaire, there were mul ple responses for the same ques ons.

Conclusion
Basic science medical students may have impact directly, as those having acne themselves will suff er and secondly, they may disseminate the misconcep on in the community.Therefore, a health educa on program is needed from the community level and in all schools from secondary level.This may be achieved by organizing lectures or seminar at school along with a short-talked program in media including magazine, television, and radio.Problem Based Learning (PBL) including common skin disease should be discussed individually to all undergraduate medical students during basic science, as they play akey role in dissemina ng their knowledge in the community.
Financial disclosure: None.Confl ict of interest to disclosure: Non declared. ://dx.doi.org/10.3126/njdvl.v16i1.19401 Licensed under CC BY 4.0 International License which permits use, distribution and reproduction in any medium, provided the original work is properly cited.httpNJDVL.Vol 16, No.1, 2018

Table 1 :
Demographic Data

Table 2 :
Causa ve Factors for Acne.

Table 3 :
Preferred means of treatment

Table 4 :
Terminologies used to explain about acne to the family members.

Table 5 :
Most common / popular acne medica ons.

Table 6 :
Psychological Impact of acne.
Figure 1: Belief and percep on of acne.