Prevalence of acne and its impact on quality of life and practices regarding self-treatment among medical students

Acne vulgaris is one of the most common skin diseases worldwide and causes great distress to patients. In addition, most acne patients suffer from low self-esteem and social withdrawal. This study aimed to assess the prevalence of acne and its impact on quality of life among medical students. It also evaluates the patterns of self-treatment use. The study population consisted of all medical students from An-Najah National University (ANU) and the hospital. The questionnaire consists of three parts, and the first part consists of questions regarding demographic information. The second part consisted of questions to measure the severity of acne using the acne severity scale as well as the Cardiff Disability Index, which assesses the quality of life concerning acne in medical students. Finally, the third part consisted of questions exploring and assessing acne self-treatment. The mean age of our study sample was 21.3 ± 1.9 years, with a female predominance of 72.3%. The prevalence of acne among medical students was 80.9%, and 36.6% practiced self-medication. Acne was strongly associated with female sex (p < 0.001) and skin type (p = 0.024). Regarding diet, dairy consumption (p = 0.007), sweets (p < 0.001), chocolate (p < 0.001), and oily food (p = 0.006) were all significantly associated with acne. Skin type was strongly associated with the severity of acne (p < 0.001) and the Cardiff acne disability index (p = 0.016). Gender (p = 0.039) was also associated with Cardiff acne disability. A significant correlation was found between the severity of acne and impaired quality of life. The most commonly used topical agent for self-treatment remedies was antibiotics (70.3%). The most commonly used oral agent was isotretinoin (9.4%). A total of 22.7% of the students used herbal products, while 47.7% used home remedies. Acne is prevalent among medical students, with a high percentage of students having different degrees of impairment in their daily lives. As a result, self-medication among acne sufferers is highly common. Awareness of the appropriate use of self-medication should increase among medical students.

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Inclusion and exclusion criteria
The target population in our study was medical students from An-Najah National University and Hospital.The inclusion criteria dictate that medical students of all ages and sexes be enrolled at the university and hospital in Nablus, Palestine, from the first to the final year.The exclusion criteria dictate nonmedical students.

Statistical analysis
The study used IBM-SPSS version 21, a software program commonly used for statistical analysis, to analyze the data.The data are presented as percentages and frequencies.The Kolmogorov-Smirnov test was used to test for normality of the variables.The Kruskal-Wallis test and Mann-Whitney U test were applied as appropriate.These tests were used to compare groups of continuous or ordinal data that were not normally distributed.The chi-square test was used to test for significant differences between categorical variables, which can be placed into categories or groups.The Pearson test was used to assess the correlation between two continuous variables, specifically between the acne severity index and the Cardiff acne disability score.A p-value less than 0.05 was considered statistically significant.

Demographic data and other characteristics
The mean age of our study sample was 21.3 ± 1.9 years.Of the 350 respondents, 72.3% responded to the questionnaire, suggesting a gender preference.Although 63.1% of the students had a normal body mass index (BMI), i.e., (18.5− < 25), 23.1% were overweight with a BMI of 25− < 30 kg/m 2 .A total of 6.6% had an obese BMI (30), and 7.1% were underweight with a low BMI (< 18.5).Among the female participants, 83.8% had normal menarche at 12-15 years of age.A total of 77.5% reported that their period was regular, and no abnormalities regarding menses were reported with respect to menses, such as heavy bleeding, bleeding at irregular intervals, or severe pain during menses.Most of our study participants (67.4%) were in the clinical stage, i.e., in the fourth, fifth, or sixth year.Regarding smoking, 86.6% of the students reported that they were nonsmokers.The predominant skin type was oily (33.1%), followed by combination skin (28.6%) and normal skin (25.7%).Medical students are under significant stress, as 49.7% of the students reported that their current mental status is stressed.A total of 50.9% of the participants reported consuming oily foods as a major part of their daily diet, while approximately 46% reported consuming dairy, sweets and chocolate.Table 1 presents the demographics and characteristics of the participants in detail.

Sample characteristics associated with acne prevalence, severity, and disability
The prevalence was 80.9%.Gender (p < 0.001), smoking status (p = 0.017), and skin type (p = 0.024) were significantly associated with acne occurrence.Regarding diet, dairy products (p = 0.007), sweets (p < 0.001), chocolate (p < 0.001), and oily food (p = 0.006) were strongly associated with acne.However, the analysis did not find significant associations between acne and age, BMI, emotional status, or use of cosmetics.Table 2 presents the associations between sample characteristics and acne occurrence.www.nature.com/scientificreports/ The mean acne severity score was 10.2 ± 7.6.The severity of acne was strongly associated with the type of oily skin type, with a p value < 0.001 (Table 3).The median Cardiff acne disability index for females was significantly greater than the median for males with acne.Furthermore, patients with stress had a median [Q1-Q3] of 3 [1][2][3][4][5][6] , which was substantially greater than the median of unstressed individuals (Table 4).

Severity and disability of acne
Increasing acne severity was significantly and positively associated with acne disability from acne (r = 0.175, p = 0.003) (Table 5).

Self-medication and acne remedies used by students
In our study, 36.6% of the students practiced self-treatment for acne, representing 45.2% of the acne students.Among those ranging from acne face washes, 26.6% were cosmetic acne cream (coal cream mask, blackhead remover cream, etc.).28.9%, topical retinoids 10.2%, topical salicylate 17.2%, topical antibiotics 70.3%, and topical corticosteroids such as betamethasone were used by 6.3%, while herbal products, for example (chamomile, green tea, etc.) 22.7%.A total of 47.7% used home remedies such as yogurt, honey, and coffee masks.Oral acne medications, such as isotretinoin (9.4%), antibiotics (tetracycline) (7.8%) and oral contraceptives (4.7%), were minimal.Finally, 1.6% spironolactone was used.Table 6 describes the different types of acne self-medications and remedies.

Discussion
This group is regularly faced with clinical rotations such as those for dermatology, physicians who could influence their decisions about self-treatment of acne, and books that need to be studied for those rotations that include information on acne and acne treatment.
Acne is a well-known but still mysterious skin disease that has and still impacts people worldwide 22 .Unfortunately, acne research has not been established for Palestine or the West Bank, let alone for self-treatment of acne among medical students in Palestine.Therefore, this study was conducted to closely investigate this issue and dissect it to better understand acne, its predisposing factors, and the knowledge and attitudes of medical students toward acne and its self-treatment.Although our study revealed that the prevalence of acne was 80.9%, according to other studies around the globe, the incidence of acne ranged from 34.4% in Bangladesh 23 to 97.9% among Saudi female medical students 24 , while two other studies in Saudi Arabia reported a prevalence of 55% 25 and 55.5% 26 .Furthermore, the prevalence of acne was 68.1% in Malaysia 27 , 66.6% in India 28 , 62.2% in Portugal 29 , 57.8% in several European countries 30 , and 55.9% in Pakistan 31 .In China, 10.4% of students complain of moderate to severe acne 32 .
The prevalence of acne among women was greater in this study (85.8%), with a p value < 0.001, than in other global studies that have shown that females have a greater incidence of acne, such as a study in Egypt (28.6%) 33 and a study in Iran (90%) 34 .This may be due to the frequent use of comedogenic makeup and the predisposition of women to acne 35 .Gender was also an important factor in determining life disability according to the Cardiff Disability Index.A study conducted in India revealed that women aged 18-25 years were severely affected by acne in terms of emotional and social impairment 36 .A previous study showed that personality type could explain the connection between acne and subjective well-being.Therefore, the study recommended strategies addressing psychological aspects, particularly stress and mood management, that may effectively enhance life satisfaction in individuals with acne 37 .
In our study, 63.1% of the students had a normal BMI (18.5-< 25), and 23.1% were overweight and had a BMI of 25-< 30 kg/m 2 .A total of 6.6% were obese (BMI ≥ 30), and 7.1% were underweight (BMI < 18.5).These results exclude the possibility that an increased BMI is correlated with an increased prevalence of acne 38 .Skin type is an essential and significant determinant of acne predisposition and development.In our study, the predominant skin type was oily (33.1%).This distribution was found to be essential for both acne and its development.Oily skin type was strongly associated with acne, with a p value of 0.024.The pathogenesis of acne probably explains this; it dictates overproduction as sebum clogs the pores and creates a sustainable medium for bacterial growth 39 .Sebum is produced in greater quantities in oily skin types, as supported by a previous study conducted in Seoul, Korea, on this topic 40 .An interesting finding was the association between acne severity and skin type.Our study revealed that the severity of acne was strongly associated with skin type, with a p value < 0.001.We could not find similar findings in further research.This is very noteworthy and should be considered when treating acne patients.Skin type was also linked to greater life disability in terms of emotional and social impairment, which is another reason to consider skin type when treating patients with acne.
Furthermore, in our study, diet was investigated, and we found that 50.9% of the oily foods consumed were associated with the development of acne (p = 0.006), which can be explained by the fact that increased fatty www.nature.com/scientificreports/acids modulate the inflammatory response 41 , which is a determining factor in the pathogenesis of acne.A total of 46.0% of the participating students consumed dairy associated with acne (p = 0.007).This is likely because the bacterium of the P. acnes phenotype, which is involved in the development of acne, is found in dairy and IGF-1, which is also found in dairy and plays a role in acne pathogenesis 41,42 .Approximately 46% of the students consumed chocolate and sweets, which were associated with acne (p < 0.001).According to a study conducted in France, these foods have a high glycemic index and increase inflammatory cytokines 32 , which stimulate the inflammatory process of acne 43 .Medical students face significant stress 44 , as 49.7% of the students reported their current mental state as stressed.This stressful mental status was associated with the Cardiff acne disability index, with a p value of 0.005.Although stressed students had a higher acne severity score, this difference was not significant compared to that of nonstressed students.A previous study in Saudi Arabia revealed that significant stress levels were correlated with increased severity of acne 24 .
In our study, 36.6% of the students practiced self-treatment for acne, representing 45.2% of the acne students.This finding seems similar to that of a study conducted in Pakistan that revealed that the incidence of acne selftreatment was 50.4% 45 .Another study conducted in India reported a prevalence of 59.2% 1 .Of the participants, 26.6% used acne face washes.Additionally, some participants used cosmetic acne creams, such as coal cream masks and blackhead remover creams.28.9%, topical retinoids 10.2%, topical salicylate 17.2%, topical antibiotics 70.3%, and topical corticosteroids such as betamethasone were used by 6.3%.Topical acne treatments can explain why they seem safer than oral treatments 46 .Furthermore, topical treatments are widely used and have proven effective with minimal side effects, thus encouraging medical students to use them without prescription 47 .Herbal products (chamomile, green tea, etc.) were used by 22.7%, and home remedies such as yogurt, honey and coffee masks were used by 47.7%.These remedies have always been known to help with skin issues, so participants reported no harm from using natural remedies to treat acne or the availability of these products.Furthermore, our study reported the use of oral acne medications such as isotretinoin (9.4%) and tetracycline (7.8%), and oral contraceptives were minimally used (4.7%).Finally, 1.6% spironolactone was used.This also explains why students were more hesitant to use oral medications for fear of side effects.In addition, it was not known how to use them properly or if they were even indicated for their acne.
An impressive finding was the significant and positive correlation between acne severity and impaired quality of life.Similarities were found in previous papers 33,48,49 , while another study reported no significant correlation 50 .

Strengths and limitations
The strengths of our study include that this is the first study to be conducted in Palestine on the self-treatment of acne and its impact on quality of life.However, our study included only medical students at ANU, one of the four universities in Palestine for medicine.Additionally, we did not exclude students with depression and anxiety.This is considered a limitation of our study.Another limitation was the cross-sectional design of the current study and the small sample size, which impeded us from generalizing the study's findings.

Conclusions
Acne is a highly prevalent condition among medical students, and self-medication for acne is also common.The use of antibiotics without prescriptions was high, and allopathy was the most common type of self-medication used by students.Additionally, there was a significant correlation between acne severity and quality of life.Selfmedication is part of self-care, so minor illnesses should be encouraged, but this should be based on detailed knowledge and restricted to over-the-counter drugs.Therefore, awareness of the appropriate use of oral medications should increase among medical students to reduce self-medication practices.In addition, the rational prescription and prevention of adverse effects of these drugs or worsening of acne should be improved.

Table 2 .
Associations between sample characteristics and acne incidence (n = 350).Significant are in value[bold].

Table 4 .
Cardiff acne disability index scale subgrouped according to demographic data (n = 283).Significant are in value [bold].

Table 5 .
Correlations between the acne severity index and the Cardiff acne disability score.**The correlation is significant at the 0.01 level (2-tailed).Significant are in value [bold].