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Brief Report
ARTICLE IN PRESS
doi:
10.25259/IJDVL_898_2021

Myths, misconceptions and attitudinal trends among patients with acne

Department of Dermatology, Venerology & Leprosy, RNT Medical College, Udaipur, Rajasthan, India
Corresponding Author: Dr. Farzana Ansari, Department of Dermatology, Venerology & Leprosy, RNT Medical College, Udaipur, Rajasthan, India. ansarifarzana539@gmail.com
Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Ansari F, Khare AK, Gupta LK. Myths, misconceptions and attitudinal trends among patients with acne. Indian J Dermatol Venereol Leprol doi: 10.25259/IJDVL_898_2021

Abstract

Background

Despite acne being a common dermatological problem, there is a paucity of literature addressing the knowledge, attitude and practice about it.

Aims/Objectives

To find out what patients know about acne, its cause and treatment, as well as myths, misconceptions and attitude towards it.

Methods

A cross-sectional, descriptive questionnaire-based study on acne patients at Maharana Bhupal Hospital, RNT Medical College, Udaipur, Rajasthan, India.

Results

Most (84.8%) patients belonged to the age group of 16-25 years. The majority (63.9%) presented 12 months after the onset of acne. More than half had average knowledge, a positive attitude and good practices, related significantly to gender and education.

Limitations

A standardized questionnaire suitable for all dialects and regional languages would have yielded more uniform results.

Conclusion

Study revealed that acne patients still need to acquire accurate, adequate and easily accessible information to seek timely and appropriate treatment, and alleviate their psychological suffering.

Keywords

Knowledge
attitude
practice
acne vulgaris
beliefs

Plain Language Summary

Acne is one of the commonest skin conditions encountered in dermatology OPD’s, but there is a paucity of literature addressing the knowledge, attitude and practice about it. So we conducted a study at Maharana Bhupal Hospital, RNT Medical College, Udaipur, Rajasthan, India, to find out what patients know about acne, its cause and treatment, as well as myths, misconceptions and attitude towards it. To do the same, we prepared a questionnaire/proforma with a few questions about each domain (knowledge, attitude and practice). Most (84.8%) patients belonged to the age group of 16–25 years. The majority (63.9 %) presented 12 months after the onset of acne. More than half had average knowledge, a positive attitude and good practices, related significantly to gender and education. A standardized questionnaire suitable for all dialects and regional languages would have yielded more uniform results. The study revealed that acne patients still need to acquire accurate, adequate and easily accessible information to seek timely and treatment and alleviate their psychological suffering.

Introduction

Acne vulgaris is a common skin problem that leads to impaired quality of life. Patients rarely regard it as a disease and often fall prey to unscientific treatment. Many delay seeking medical help or do not seek it at all.1 A few studies on the assessment of knowledge, beliefs and perceptions about acne are available.1,2 We aimed to assess the same in our population. In addition, we assessed attitudes and practices towards acne, which were lacking in most other studies.

Methods

A cross-sectional study was conducted to assess knowledge, attitude and practice (KAP) amongst 1000 acne vulgaris patients visiting Maharana Bhupal Hospital, RNT Medical College, Udaipur, Rajasthan, India, using a pre-tested questionnaire that comprised 23, 18 and 8 questions on knowledge, attitude and practices. The minimum sample size required for the study was calculated to be 890 acne patients, calculated at a 95% confidence interval and 10% relative allowable error assuming that 31% of the acne subjects have moderately favorable attitudes (as per the seed article).3 Assuming a 10% non-response rate the sample size was further increased and rounded off to 1000 acne patients. The sample size calculated, considering other KAP points, was less than the above-calculated sample size. Sample size was calculated using the formula n = (4×pq)÷ L2 where n = sample size, p = prevalence (33%), q = 1-p (67), L = allowable error (10% of 33 = 3.3).

A total of 1000 patients were selected using systematic random sampling. Institutional Ethics Committee clearance was obtained. Written informed consent was taken. All patients filled the questionnaire by themselves or with assistance from the assessor. The data was collected, scored and entered into the tabulated form using Microsoft excel version 2010. A prior validation of the questionnaire and scoring was done by the faculty of dermatology and community medicine. Two and one point respectively were given for correct and incorrect responses for knowledge and practice assessment. The attitude was assessed using 3-point Likert’s scale,4 where 3 points were given for favorable, 2 for moderately favorable and 1 for unfavorable attitude. Amongst the parameters of KAP, a score of >75%, 60-75% and <60% was graded as good, average and poor knowledge respectively. Likewise, a score of >75%, 60-75% and <60% were considered as favorable, moderately favorable and unfavorable attitudes respectively. A practice score of >75% and <75% was considered good and bad respectively. The demographic data and scores were analyzed using inferential statistics with P < 0.05 level of significance by Statistical Package for Social Sciences (SPSS) Inc., Chicago Illinois, USA. Descriptive statistics were analyzed using mean, range, standard deviation, Pearson Chi-Square test and Fisher’s exact test.

Results

Demographic characteristics [Table 1]

Table 1:: Demographic characteristics of study cases (n = 1000)
Male Female Total P-value
No. % No. % No. %
Age group (years)
 10-15 42 7.7 36 8 78 7.8 0.000
 >15-20 373 67.9 241 53.4 614 61.4
 >20-25 115 21 119 26.4 234 23.4
 >25-30 17 3.1 39 8.7 56 5.6
 >30 2 0.4 16 3.6 18 1.8
Residence
 Rural 273 49.7 169 37.5 442 44.2 0.000
 Urban 276 50.3 282 62.5 558 55.8
Total disease duration
 <1 month 17 3.1 22 4.9 39 3.9 0.000
 1-3 month 93 16.9 93 20.6 186 18.6
 >3-6 month 62 11.3 47 10.4 109 10.9
 >6-12 month 17 3.1 10 2.2 27 2.7
 >1-3 years 285 51.9 181 40.1 466 46.6
 >3-5 years 52 9.5 51 11.3 103 10.3
 >5-10 years 22 4.0 39 8.7 61 6.1
 >10 years 1 0.2 8 1.8 9 0.9
Education level
 Illiterate 4 0.7 7 1.6 11 1.1 0.000
 Primary school 14 2.6 18 4.0 32 3.2
 Middle school 62 11.3 50 11.1 112 11.2
 High school 264 48.1 155 34.4 419 41.9
 Graduation/
Diploma
30 5.5 13 2.9 43 4.3
 Post-graduate 139 25.3 195 43.2 334 33.4
 Professional 36 6.6 13 2.9 49 4.9

Most (84.8%) patients belonged to the age group of 16-25 years and the male to female ratio was 1.22:1. Maximum (41.9%) patients had high school education, followed by post-graduation (33.4%). Urban subjects (55.8%) outnumbered rural subjects (44.2%). Most (46.6%) patients had acne of 1-3 years duration. Males predominated in the group of >3 months to 3 years’ duration while females predominated in the group of >3 years duration.

Response to the questionnaire

A statistically significant difference with the age was found for some questions, details of which are shown in Table 2.

Table 2:: Response of patients about acne
Response (years) Age groups (years) Total P-value
10-15 16-20 21-25 26-30 ≥31
No. % No. % No. % No. % No. 0 No. %
Commonest age of acne
≤9 1 1.3 2 0.3 1 0.4 0 0 0 0 4 0.4 <0.01
>9-19 69 88.5 524 85.3 119 50.9 22 39.3 7 38.9 741 74.1
>20 2 2.6 69 11.2 105 44.9 29 51.8 10 55.6 215 21.5
Don’t know 6 7.7 19 3.1 9 3.9 5 8.9 1 5.6 40 4
Knowledge about spontaneous resolution of acne
Yes 21 26.9 159 25.9 65 27.8 14 25.0 2 11.1 261 26.1 <0.01
No 20 25.6 128 20.9 53 22.7 21 37.5 9 50 231 23.1
Don’t know 37 47.4 327 53.3 116 49.6 21 37.5 7 38.9 508 50.8
Hormones as a cause of acne
Yes 25 32.1 270 44 116 49.6 25 44.6 11 61.1 447 44.7 0.009
No 14 18.0 50 8.1 28 12 4 7.1 3 16.7 99 9.9
Don’t know 39 50 294 47.9 90 38.5 27 48.2 4 22.2 454 45.4
Pollution as an aggravating factor of acne
Yes 35 44.9 321 52.3 147 62.8 37 66.1 12 66.7 552 55.2 0.018
No 15 19.2 78 12.7 30 12.8 5 8.9 3 16.7 131 13.1
Don’t know 28 35.9 215 35 57 24.4 14 25 3 16.7 317 31.7
Lack of sleep aggravating acne
Yes 10 12.8 74 12.1 42 18 16 28.6 8 44.4 150 15 <0.01
No 22 28.2 181 29.5 70 29.9 11 19.6 5 27.8 289 28.9
Don’t know 46 59.0 359 58.5 122 52.1 29 51.8 5 27.8 561 56.1
Aggravation of acne by squeezing /scratching
Yes 55 70.5 485 79 198 84.6 49 87.5 14 77.8 801 80.1 0.032
No 9 11.5 35 5.7 14 6.0 3 5.4 3 16.7 64 6.4
Don’t Know 14 18.0 94 15.3 22 9.4 4 7.1 1 5.6 135 13.5
Stress related aggravation of acne
Yes 14 18 162 26.4 85 36.3 29 51.8 5 27.8 295 29.5 <0.01
No 13 16.7 109 17.8 41 17.5 6 10.7 2 11.1 171 17.1
Don’t Know 51 65.4 343 55.9 108 46.2 21 37.5 11 61.1 534 53.4
Role of make-up in aggravating acne
Increase 30 38.5 256 41.7 125 53.4 34 60.7 13 72.2 458 45.8 0.015
Decrease 3 3.9 10 1.6 3 1.3 1 1.8 0 0.0 17 1.7
Unaffected 7 9.0 68 11.1 20 8.6 2 3.6 1 5.6 98 9.8
Don’t know 38 48.7 280 45.6 86 36.8 19 33.9 4 22.2 427 42.7
Acne causing sleep disturbance
Yes 8 10.3 142 23.1 49 20.9 15 26.8 5 27.8 219 21.9 0.001
No 70 89.7 472 76.9 185 79.1 41 73.2 13 72.2 781 78.1
Desire of subjects to learn more about acne
Yes 61 78.2 538 87.6 201 85.9 50 89.3 14 77.8 864 86.4 0.001
No 17 21.8 76 12.4 33 14.1 6 10.7 4 22.2 136 13.6
Acne and its effect on social interaction
Yes 29 37.2 253 41.2 72 30.8 14 25 9 50.0 377 37.7 0.004
No 40 51.3 332 54.1 152 65 39 69.6 7 38.9 570 57
Don’t know 9 11.5 29 4.7 10 4.3 3 5.4 2 11.1 53 5.3
Acne and its impact on day to day activity
Yes 22 28.2 229 37.3 96 41 23 41.1 7 38.9 377 37.7 0.004
No 35 44.9 315 51.3 112 47.9 31 55.4 10 55.6 503 50.3
Don’t know 21 26.9 70 11.4 26 11.1 2 3.6 1 5.6 120 12
Total 78 100 614 100 234 100 56 100 18 100 1000 100

Knowledge about acne

Most (59.5%) patients had average knowledge scores (60-75%). More females (21.3%) had good knowledge scores compared to males (16%), the difference being statistically insignificant. Higher knowledge scores were found with higher levels of education and the difference was statistically significant with a P -value of 0.001. Other factors affecting the knowledge with significant P- value were the education of the father, mother and spouse (0.001, 0.012 and 0.006 respectively) and urban background (P -value <0.001). No statistically significant difference was found in knowledge scores with age, occupation, marital status, income, dietary habits, total disease duration and treatment history.

Attitude towards acne

Favorable, moderately favorable and unfavorable attitude was recorded in 55.2%, 44.3% and 0.5% respectively. Attitude was statistically found to be dependent upon gender (P value <0.001), education (P value< 0.001) and education of father and mother (P value 0.036 & <0.001). Other parameters did not show any statistically significant difference.

Practices related to acne

More than half (53.6%) of the patients had good treatment practices and 46.4% had bad practices. Practices were statistically significantly dependent upon gender (P value <0.001), education (P value 0.001) and treatment history (P- value <0.001 and Fisher’s exact test value <0.001).

The KAP amongst acne patients is depicted in Figure 1. Correlation of KAP with gender and education status is depicted in Table 3.

Figure 1:: Bar chart showing total KAP scores KAP: Knowledge, attitude and practice

KAP: Knowledge, attitude and practice

Table 3:: Correlation of KAP with education status and gender
Education level Gender
Illiterate Primary school Middle school High school Graduate/Diploma Post graduate Professional Male Female Total
Knowledge
Poor No. 0 6 30 113 10 55 7 131 90 221
% 0 18.8 26.8 27 23.3 16.5 14.3 23.9 20 22.1
Average No. 7 22 68 246 22 202 28 330 265 595
% 63.6 68.8 60.7 58.7 51.2 60.5 57.1 60.1 58.8 59.5
Good No. 4 4 14 60 11 77 14 88 96 184
% 36.4 12.5 12.5 14.3 25.6 23.1 28.6 16 21.3 18.4
P-value 0.001 0.064
Attitude
Unfavourable No. 0 0 3 1 0 0 1 4 1 5
% 0 0 2.7 0.2 0 0 2 0.7 0.2 0.5
Moderately No. 5 19 65 202 18 109 25 277 166 443
favourable % 45.5 59.4 58 48.2 41.9 32.6 51 50.5 36.8 44.3
Favourable No. 6 13 44 216 25 225 23 268 284 552
% 54.6 40.6 39.3 51.6 58.1 67.4 46.9 48.8 63.0 55.2
P-value 0.000 0.000
Practice
Bad No. 7 22 68 189 21 137 20 226 238 464
% 63.6 68.8 60.7 45.1 48.8 41.0 40.8 41.2 52.8 46.4
Good No. 4 10 44 230 22 197 29 323 213 536
% 36.4 31.3 39.3 54.9 51.2 59.0 59.2 58.8 47.2 53.6
P-value 0.001 0.000

Discussion

Level of awareness about acne was found to vary amongst participants. Almost half (47.6%) of the patients were not aware, whether acne is a disease compared to 22% in another study.5 Most (74.1%) patients knew that acne occurs more commonly in age 10-19 years, while all the patients in a study conducted in Nepal3 had this knowledge. Correct response to this question, significantly decreased with increasing age, which might be due to the fact that adult onset acne patients may not consider it as acne. Significantly more males considered adolescence as most common age, because acne is more common and more severe in males during adolescence, while women are more frequently and severely affected by it in adulthood.6 Acne is usually known to resolve with age but only 26.1% patients of our study agreed to it, as in some other studies.5,7,8 Contagious nature of acne was believed by 21-70% participants in literature5,9,10 and 24.5% cases of our study.

Role of diet in causation/aggravation of acne has been reported by 18-85% participants in past studies1,2,5,6,8,10-16 and 53.3% cases of current study. Out of 533 participants of our study, who believed that food aggravates acne, 513 (96.3%) considered that fatty/junk foods aggravate acne, a figure relatively higher compared to other studies (18-73%).5,11,13,17,18 In our study, only 27.6% (147/533) of participants related their acne with intake of milk and dairy products, compared to 78.2% in the study by Al-Shobaili.14 Likewise, chocolates have been reported to cause/aggravate acne by 14-80.3% respondents in some studies.3,8,10-12,14,16,17 This was stated by 44.8% (239/533) of our study subjects also.

Hormones as the causal/aggravating factor have been considered by 42-65.3% participants in most studies1,2,6,7,11-14,18 and 44.7% patients of our study. In the index study, 55.2% participants thought that pollution aggravates acne, which was reported by 10.7-62.5% subjects in various studies.2,6,8,11,17 Sleep deprivation as an aggravating factor of acne was reported by few subjects in two studies (0.93%7 and 16.7%19),was similar to our study (15%). However, a higher number of participants (39.3%19 and 40.8%16) of another two studies had this belief. Most (80.1%) of our patients believed that squeezing/scratching aggravates acne, similar to the study by Poli et al. (>70%).17

Stress may aggravate acne by secretion of adrenal androgens and subsequent effects on sebaceous hyperactivity.7 Stress, as an aggravating factor in acne was considered by 29.5% of our study subjects, compared to 13% and 26.2%1 patients of Croatian13 and Lithuanian1 studies. Cosmetics as an aggravating factor was believed by 45.8% subjects in our study compared to 18.4-84.1% in previous studies.1,2,5,6,11,14,16-19 Studies on improvement of acne by frequent washing of face with water have shown variable figures ranging from 43.8 to 80.7%,10,11,12,14,16,17,19 Only 25.4% of our study participants believed this.

The desire to learn more about acne was expressed by 86.4% patients. In the Nepalese3 and Lithuanian1 studies, 52% and 95% subjects showed this interest. In our study, 57% patients responded that acne doesn’t affect their social interactions compared to 31.5% and 66% in studies by Su et al. and Al-Hoquail.15

Only 29.8% participants, sought initial consultation with a doctor, while others either sought other remedies or did not care at all. This shows that initial awareness of acne patients is low. Eventually most patients (95.3%) consulted a dermatologist, possibly due to increased awareness about the disease with time. Initial consultation with a doctor has been reported to range between 7 and 50% in the previous studies.1,7,9,16,17 In a study by Karciauskiene et al.1 and Su et al.7 beauticians were consulted for treatment by 8.5% and 17.6% subjects respectively, while only 4.7% of our patients consulted beauticians for acne.

Most (59.5%) of our patients had average knowledge about acne, a figure close to 48%3 and 50%14 in two other studies. Education status had a favourable effect as reported in the Nepalese study also.3 unlike the Zambian study,19 where knowledge was unrelated to education status. A study1 showed that girls had more knowledge than boys about acne and this correlated positively with age of the patients. In our study females showed a higher knowledge scores but it did not show any significance with age.

In a study,3 69% of the students had favourable attitude towards acne and 31% of them had moderately favourable attitude. These figures were 55.2% and 44.3% respectively in our study. A relatively higher proportion (53.6%) of subjects had good treatment practices. In the index study a positive, although poor correlation, was found between knowledge, attitude and practice. A significant negative correlation between knowledge and attitude, meaning that good knowledge may not lead to good attitude and vice versa has also been reported.3

Conclusion

Despite acne being a very common adolescent problem, the knowledge, attitude and practices about acne are still far from satisfactory. Better knowledge about the disease can immensely help improve the outcome of disease and quality of life.

Acknowledgement

Late Dr Rahul Prakash, Professor and Head, Department of preventive and social medicine

Dr B R Ranwah, Ex Professor and Head, Department of Genetics and Plant Breeding

Declaration of patient consent

Institutional Review Board (IRB) permission obtained for the study.

Financial support and sponsorship

Nil.

Conflict of interest

There are no conflicts of interest.

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