The results of the study indicated a high prevalence of Acne in our setting which is per a Malaysian study that reported a prevalence of 68.1% and a study among Portuguese medical students reporting the prevalence of 62.2%.[13][14] However, studies were done in Saudia Arabia (Middle East), France, Belgium, Italy, and Spain (Europe), Egypt (Africa), and China (Asia) which reported much lower prevalence rates.[5,15-17] The difference in the results could be attributed to the disease being multifactorial and being affected by lifestyle, gender, age, genetics, and other environmental factors.[18] Of the students affected, more than half (68%) were females, which is similar to the female predominance found in studies done on students in Portugal (68%) by G Gonçalves and in Egypt (60%) by Al-Hamd MA.[14,16] In contrast, only 14.4% of female medical students were affected by Acne according to another study in Pakistan.[11] The Malaysian study revealed gender association to be statistically insignificant, while a study in Nigeria showed a more male population suffering from Acne.[13,19]
Concerning the help-seeking behaviours of the patients in our study group, only less than half (47.3%) had consulted a physician. Similar results came out in a community study conducted by Smithard A.[20] According to studies done in schools and hospital OPDs in the UK, reasons could include embarrassment, Acne not being severe enough, feeling that doctor was unapproachable or busy. In contrast, a Pakistani study showed that 80% of the students’ preferred medical advice from a dermatologist, which reflected an increase in medical students awareness in recent times about Acne is a treatable medical condition.[21-22]
Academic years of study were positively associated with knowledge and causative factors. Shiva Swamy KN et al. also reported a similar relationship with an increase in mean scores of up to 16.5% from pretest to posttest questionnaires possibly due to increased clinical exposure and learning during ward rotations as the academic year advances.[6] The most common causative factors were believed to be hormonal changes (82.4%) and stress (64.7%) with a p<0.001 and p=0.004, respectively. Al Robaee AA also noted in his study that 56% of students had adequate knowledge about Acne, and the majority of the students believed hormones and stress to be the commonly associated factors with Acne.[23] However, only 44% of students in another study were able to identify this link.[6] Farid-ur-Rehman et al. noted in his study that diet had a significant relationship as a causative factor of acne vulgaris.[24] Hereditary and genetics were perceived not to cause Acne (p=0.004). This was in support of a Pakistani study where the Acne was not believed to be a familial disease.[22] A British case-control study in 2005, however, found a greater risk of Acne in relatives of control proving genetic association.[25] More than half (52.8%) of the students used topical agents to be the treatment for Acne as compared to a medicated soap (66%) in Nigeria.[19] As is the case with another Pakistani research, our study also shows that misconceptions were pervasive among undergraduate medical students.[24] This is probably because the subject is not given adequate importance as a general community pathology and is taught only as a final year subject.[25] We advocate that medical universities give it relevance by teaching about it from pre-clinical years. Also, if these beliefs are not addressed, medical students could spread the misinformation to the general community, compounding the problem.[26] This is because Acne is not just a skin problem but has a far-reaching psychological impact on its patients.[15,18,27]
Lifestyle was significantly related to gender where females suffered exacerbations of Acne in periods of stress (p=0.02). Chiu A also found a positive correlation between acne severity grade and mean perceived stress scores during examinations in university students (p<0.01).[28] This was explained in a 2017 study where the basis of the association was due to an interaction of cutaneous neurogenic factors such as corticotropin-releasing hormone, melanocortins, and substance P, with a pathogenic cascade involving cutaneous microbial residents and the immune system in Acne.[29] Authorities should arrange stress management seminars and counselling sessions to address and improve the psychological health of medical students, especially females.[30] No significance was found between hormones (p=0.9) or a diet including chocolates and coffee (p=0.6), dairy products (p=0.4), and fried, processed food items (p=0.4) as lifestyle factors causing Acne. This proved that although the hormonal change was believed to be an important causative factor, many patients in our study did not experience this link.