Acne vulgaris in Nigerian adolescents prevalence, severity, beliefs, perceptions, and practices

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1 Oxford, IJD International Blackwell XXX UK Publishing Journal Ltd, of Dermatology 2008 Tropical medicine rounds Yahya Tropical vulgaris medicine in Nigerian rounds adolescents Acne vulgaris in Nigerian adolescents prevalence, severity, beliefs, perceptions, and practices Husain Yahya, MSc, FMCP From the Dermatology Unit, Department of Medicine, Barau Dikko Specialist Hospital, Kaduna, Nigeria Correspondence Husain Yahya, MSc, FMCP Department of Medicine Barau Dikko Specialist Hospital PO Box 9727 Kaduna Nigeria Abstract Background Community-based studies of acne vulgaris conducted in many parts of the world show that it is very common in adolescents but little is known from Africa. Methods In a cross-sectional study, 539 randomly selected students aged years in a secondary school in Kaduna, Nigeria were administered a questionnaire to assess self-report of acne, its severity and impact; beliefs and perceptions of causes, and treatments used. 418 students were later examined to detect and grade acne severity. Results 274 (50.8%) were male while 265 (49.2%) were female. Mean age for respondents was 16 years. 320 students (59.4%) self-reported acne. Of 418 students examined, 379 had acne giving a prevalence of 90.7%. There was no significant gender difference in prevalence at all ages of adolescence. Prevalence of acne increased with age (76.7% at age years; 88.2% at age years; 97.1% at age years). 353 of 379 (93.1%) had mild acne while 26 of 379 (6.9%) had moderate acne. The severity of acne was similar in boys and girls. 47.7% of students reported feeling very sad/unhappy about their acne although in more than 70% of those who self-reported, this did not interfere with relationship with family, friends or school work. Diet was the commonest factor believed to cause acne. Cleansing agents were the most commonly used treatments. Conclusions Acne vulgaris is very common in Nigerian adolescents, although it is mild acne in most. 498 Introduction Acne vulgaris, a chronic disorder of the pilosebaceous units, is common in adolescents. Community-based studies in the UK, Australia, New Zealand, and Singapore have found prevalence rates ranging from 27% in early adolescence to 93% in late adolescence. 1 4 Acne is also the most common skin disease in adults. 5 The proportions of acne vulgaris in hospital-based studies of skin disease in Africa have been reported to be 4.6% in Ghana, 6 6.7% in Nigeria, 7 and up to 17.5% in South Africa. 8 Although, in a preliminary study of the dermatologic needs of a small rural community in Ethiopia, Figueroa et al. 9 found that only three of 66 children (4.5%) between the ages of 10 and 16 years attending a school had acne, the knowledge of the prevalence and severity of acne in the larger community in Africa is very poor. Acne is not a trivial disease the physical, social, and psychologic morbidity associated with the disease can be profound, and the quality of life in sufferers can be severely impaired. 10,11 A knowledge of patients beliefs, perceptions, and practices with regard to their acne, which is also poor in Africa, is necessary in planning educational programs about the condition and creating awareness about the availability of effective treatments and, therefore, prevention of unnecessary suffering. The objectives of this study were to assess the prevalence and severity of acne vulgaris in students in a selected secondary school in Kaduna, Nigeria, and to determine their beliefs, perception, and practices in relation to their condition. Methods This is a cross-sectional survey of acne vulgaris in adolescents attending a secondary school in Kaduna, Nigeria. Abubakar Gumi College, a coeducational school with a wholly black student population of 3050, was chosen as the study site because of its location in Tudun Wada, a neighborhood whose ethnic and socioeconomic characteristics are typical of Kaduna, a city in north-central Nigeria (current population, 1.5 million). 12 The study was approved by Kaduna State s Ministry of Education, the Director of Abubakar Gumi College, and the Ethical Committee of Barau Dikko Specialist Hospital, Kaduna. Students of junior and senior secondary school sections were eligible to participate if their parents gave written informed consent and if they were aged years (defined by the World Health Organization as the age of adolescence). 13 Students were told International Journal of Dermatology 2009, 48, The International Society of Dermatology

2 Yahya Acne vulgaris in Nigerian adolescents Tropical medicine rounds 499 they could refuse to participate in the study or withdraw from the study at any point. A questionnaire, adapted from Tan et al., 14 was administered during school time to a group of students, selected by the simple random sampling technique (see Appendix for questionnaire). Participants were asked to report whether they had acne at the time of the study or in the previous year, what treatment(s) were used and which were successful, whether and what healthcare worker they had consulted, and what they believed caused or exacerbated their acne. They were also asked to assess the degree of severity of their acne, how it made them feel, and, to what extent, if any, it had affected their relationship with their friends, family, or school work. This questionnaire was pilot-tested for comprehension in 20 students and was also discussed with volunteers who were teachers at the school. Students were asked to complete the questionnaires in groups of 40 on the same day at the same time under the supervision of the author and the volunteers. Subsequently, participants were examined by the investigator in groups for the presence and severity of acne vulgaris. Examinations were carried out daily during school time over a period of 2 weeks (9 20 April 2007). The diagnosis of acne was clinical. The presence and location of comedones, inflammatory papules, pustules, nodules, and cysts were noted, and the severity of acne was assessed using the Global Acne Grading System (GAGS) developed by Doshi et al. 15 The presence of postinflammatory hyperpigmentation was noted, and its severity was graded as mild, moderate, or severe. The presence and nature of acne scars were also noted. All data were recorded in the assessment form for each participant. Data were entered into EpiInfo version (CDC, Atlanta, GA, USA, 2005) and analyzed. Differences in proportions were assessed using the chi-squared test, and P < 0.05 was considered to be significant. Results Seven hundred and sixty-eight students were randomly selected to participate in the study, and 539 completed the questionnaire, giving a response rate of 70%; 274 (50.8%) were male and 265 (49.2%) were female. The age of the participants ranged from 11 to 19 years (mean ± SD, 16.1 ± 1.9 years). Four hundred and eighteen students were available for examination. Acne prevalence Three hundred and twenty respondents (59.4%) reported they had acne on their questionnaire. The prevalence of self-reported acne was significantly higher in males (66.8%) than in females (51.7%) (P < 0.001). There was no difference in self-reported acne between those available for examination and those not examined: 242 of the 418 students examined (57.9%) and 78 of the 121 students not examined (64.5%) reported acne (P = 0.2). Three hundred and seventy-nine of the 418 students examined were found to have acne, giving an overall prevalence of 90.7% (see Table 1). Although only 61% of those who were found to have acne on examination self-reported, and therefore were aware of their acne, almost 96% of those who actually reported acne were found to have the condition. There was no difference in the prevalence of acne detected by examination between males and females (P = 0.4). There was an age-related increase in the prevalence of acne, reaching as high as 97% in late adolescence. The same trend was seen in both males and females. The majority of the students (61.4%) reported that they had suffered from acne for only 6 months or less; 26.8% had suffered from acne for more than 1 year at the time of the survey, with females having a significantly longer duration of the condition than males (29.9% vs. 25.7%) (P = 0.04). Severity of acne The severity of acne found in the students examined is shown in Table 2. Three hundred and fifty-three of the 379 students (93.1%) had mild acne (GAGS score, 1 18), but only 26 of the 379 students (6.9%) had moderate disease (GAGS score, 19 30). No student was adjudged to have severe or very severe disease (GAGS score, > 31). When mild acne was reclassified into minimal acne (GAGS score, 1 10) and mild acne (GAGS score, 11 18), more than one-half (52.8%) of students had minimal acne. Overall, there was no difference in acne severity between males and females, although boys had more severe (moderate) acne in middle adolescence than girls, and girls had more severe disease at late adolescence than boys. When asked to judge the seriousness of their acne, respondents generally overestimated the severity of the condition up to 57% thought that their condition was moderate and as many as 17% believed it to be severe. Only 26% of respondents thought that their acne was mild. There was no difference in the perception of the seriousness of acne in patients with minimal, mild, or moderate disease as assessed by the GAGS score. Mild postinflammatory Table 1 Prevalence of acne vulgaris in clinically examined Nigerian adolescents Stage of adolescence Overall Males Females Early (10 13 years) 33/43 (76.7%) 14/18 (77.8%) 19/25 (76.0%) Mid (14 16 years) 179/203 (88.2%) 77/87 (88.5%) 102/116 (87.9%) Late (17 19 years) 167/172 (97.1%) 107/110 (97.3%) 60/62 (96.8%) Overall 379/418 (90.7%) 198/215 (92.1%) 181/203 (89.2%) 2009 The International Society of Dermatology International Journal of Dermatology 2009, 48,

3 500 Tropical medicine rounds Acne vulgaris in Nigerian adolescents Yahya Table 2 Severity of acne vulgaris in clinically examined Nigerian adolescents Mild acne Moderate acne Stage of adolescence Overall Male Female Overall Male Female Early (10 13 years) 32/33 (97%) 14/14 (100%) 18/19 (94.7%) 1/33 (3.0%) 0 /14 (0.0%) 1/19 (5.3%) Middle (14 16 years) 172/179 (96.1%) 73/77 (94.8%) 99/102 (97.1%) 7/179 (3.9%) 4/77 (5.2%) 3/102 (2.9%) Late (17 19 years) 149/167 (89.2%) 98/107 (91.6%) 51/60 (85.0%) 18/167 (10.8%) 9/107 (8.4%) 9/60 (15.0%) Overall 353/379 (93.1%) 185/198 (93.4%) 168/181 (92.8%) 26/379 (6.9%) 13/198 (6.6%) 13/181 (7.2%) hyperpigmentation was detected in 32.5% of students with acne, moderate hyperpigmentation in 6.3%, and 61.2% had no pigmentation at the time of examination. Most students with acne (74.9%) had no discernible scars. Ice-pick scars were the predominant scars found (23% of students examined). Impact of acne When asked how their acne made them feel, up to 47.7% of respondents reported feeling very unhappy/sad, and only 8.4% of respondents reported that they were not worried at all. About 25% were frequently worried and 19% were occasionally worried. Dark spots were the most frequent reason for worry, being reported by about 42%. Small and large painful lesions worried 28.8% and 13% of respondents, respectively, whereas only 8.4% reported worrying about scars; 9.4% were not worried about any of the above. When asked whether their acne had any impact on their relationships or ability to make friends, most respondents (72.6% and 74.8%, respectively) answered never (see Table 3). A similar number of respondents also reported that their acne had no impact on their relationship with their family or school work. Only a small number of respondents (4.1%, 7.8%, 6.6%, and 5.5%, respectively) reported that their acne severely affected their relationship with or ability to make friends, relationship with their family, or school work. These responses were similar regardless of whether or not the study participants were examined and whether they had mild or moderate acne. Female respondents were significantly less affected in these relationships than males (P < 0.03). Belief about causes or aggravating factors for acne More than one-half of all questionnaire respondents (52.5%) cited eating too much butter or margarine as the most frequent cause of acne. Other factors thought to be responsible for causing acne are shown in Table 4. No respondent blamed blocked skin pores as a cause for acne. These responses were similar irrespective of gender, self-reporting of acne, or presence or absence of acne on examination. Eating too much fat, butter, or margarine was also the most frequently cited exacerbating factor for acne (one-third of respondents). Dirty skin and excessive heat and humidity were thought to be responsible for making acne worse by 11.7% and 5% of respondents, respectively. Other factors, such as rainy or dry season, stress, cosmetics, hair products, and sweating, were blamed by less than 4% of respondents for worsening acne. Males were more likely than females to blame dirty skin, hair Table 4 Belief about cause of acne vulgaris in questionnaire respondents What do you think causes acne? Frequency of response (%) Eating too much butter or margarine 52.5 Eating too much fatty food 37.7 Poor hygiene 26.3 Obesity/too much body oil 12 Inheritance 10.2 Infection by germs 9.8 Don t know 6 Table 3 Effect of acne on relationships with friends, family, and school work Frequency of response (%) Never Only sometimes Moderately Severely Have pimples affected your relationship with your friends? Have pimples affected your ability to make friends? Have pimples affected your relationship with your family? Have pimples affected your school work? International Journal of Dermatology 2009, 48, The International Society of Dermatology

4 Yahya Acne vulgaris in Nigerian adolescents Tropical medicine rounds 501 products, excessive heat/humidity/excessive sweating, and drugs for worsening of their acne, whereas female respondents blamed cosmetics much more frequently than males. Health-seeking behavior, practice, and beliefs about treatment Most respondents who self-reported acne (72.2%) had visited a healthcare facility concerning their condition. Males were more likely to attend than females (59.8% vs. 40.2%, P = 0.04). More than 80% of respondents had visited these facilities within 6 months of developing acne. Doctors and patent medicine store attendants were the most frequently consulted health workers, seen by 24.4% and 22.5% of respondents, respectively. Others consulted included traditional medicine practitioners (13.4%), pharmacists (13.1%), and nurses (10.3%). A medicated (antiseptic) soap was the most frequently used self-administered treatment before a health facility was visited, having been used by more than 66.3% of students who reported acne. Nixoderm, a readily available over-thecounter ointment prepared from benzoic acid 6%, salicylic acid 2.5%, and precipitated sulfur 4.6%, was used by 23.1% of respondents. Other agents used by respondents are shown in Table 5. Dudu Osun (a harsh locally made cleansing agent) and other cleansers were also frequently used by adolescents. Preparations such as benzoyl peroxide lotion and Dalacin T (clindamycin) solution were used by only approximately 2%, whereas tablets (mostly ampicillin/cloxacillin) were used by about 8% of respondents prior to seeking medical advice. Retin A (tretinoin) was not used by any respondents. Medicated soaps, nixoderm, cleansers, and aloe vera preparations were also the most common treatments claimed to have completely cleared acne in survey respondents. Males were more likely to have used nixoderm, Dudu Osun, herbal preparations, and tablets than females, and females used cleansers and cosmetics more frequently than males. The use of medicated soaps and other preparations was similar in both sexes. These were the same preparations used even after visiting healthcare facilities. Table 5 Self-administered agents used to treat acne by questionnaire respondents Agent used Frequency (%) Medicated (antiseptic) soap 66.3 Nixoderm 23.1 Aloe vera preparations 18.8 Dudu Osun soap 15 Cleansers 14.7 Cosmetic creams 11.3 Tablets (ampicillin/cloxacillin, amoxicillin, etc.) 8 Benzoyl peroxide lotion 2 Clindamycin solution (Dalacin T) 2 When asked whether acne was a curable disease, 41.9% of study participants answered yes, 33.7% answered no, and 24.4% did not know. These responses were similar, irrespective of gender, self-report of acne, or presence or absence of acne on examination. Up to 13.5% of respondents believed acne treatment was expected to last only days, whereas 28.3% believed it to last 2 4 weeks; 11% and 12.5% of respondents thought acne treatment would last 1 6 months and more than 6 months, respectively, whereas 34.6% did not know how long it would last. Discussion A high prevalence of acne vulgaris (overall 90.7%) was found in adolescents in an urban area in Nigeria. This suggests that acne vulgaris is as common in the community in Nigeria as in predominantly white adolescents in the UK, Australia, New Zealand, and France. 1 4,16 The prevalence was as high as 76.6% in early adolescence (10 13 years) and 97.1% in late adolescence (17 19 years). Amado et al. 17 have also reported a high prevalence of acne (82%) in year-olds in northern Portugal, although these rates were much lower in other studies, such as that of Kilkenny et al., 2 where acne was found in only 27.7% of year-olds. Previous reports of acne in black individuals have been hospital-based and have included mostly adults and females, and even these studies have shown that acne constitutes a large proportion of skin disease in clinics in the UK, 18 the Caribbean, 19 and the USA, 20 and is increasing in importance in Africa. 8 To our knowledge, this is the first study to examine the prevalence of acne vulgaris in black adolescents in the community. Despite the high prevalence of acne found in adolescents, many (up to 40% of respondents) were not aware of the condition and did not report any acne when asked. This may be because of the very mild (minimal) nature of their acne more than 50% of adolescents had only minimal acne (GAGS score, 1 10). Males were significantly more likely to self-report acne than females, despite the equal prevalence of the disease on examination, and, as this was also true for the use of healthcare facilities, this may be related to cultural and/or religious factors in the male-dominated, predominantly Muslim community studied. Cultural factors have also been suggested to be a probable explanation for the observed difference in the self-reporting of acne between Asian-born and Australian-born secondary school students in Australia. 21 We found that acne was as common in males as in females in all adolescent age groups, in contrast with other studies, 1 4,16,17 but was present for a significantly longer duration in females than in males, as found elsewhere. 1 4,16 Acne vulgaris was much less severe in adolescents in Nigeria than reported in other parts of the world, although its severity was similar to that of Scottish adolescents as reported by Rademaker et al. 22 Ninety-three per cent of our study participants had mild acne, whereas only 6.9% of patients 2009 The International Society of Dermatology International Journal of Dermatology 2009, 48,

5 502 Tropical medicine rounds Acne vulgaris in Nigerian adolescents Yahya had moderate acne according to the GAGS score. More than one-half of our students were adjudged to have minimal acne. No student was found to have severe or very severe acne. This is consistent with the findings by Lucky et al. 23 that white adolescent boys have significantly more inflammatory lesions than black boys at the same pubertal stage, and with Wilkins and Voohees 24 that nodulocystic acne is much less common in black than in white males. Acne severity tended to worsen with age in both males and females, but males were more likely to have more severe (moderate) acne in middle adolescence, whereas females had more severe disease than males in late adolescence. This contrasts sharply with studies in the UK, Australia, and New Zealand where severe acne is more prevalent in males than in females in late adolescence. 1 4 More studies in black adolescents in other populations are required to ascertain whether this is a general finding. Despite the mild severity of acne as assessed by an examiner, adolescents in our study generally overestimated the severity of their acne, with more than three-quarters rating their acne as moderate or severe. This is similar to the findings of Mosam et al. 25 in South Africa, where patients presenting to a tertiary dermatology outpatient clinic graded their acne more severely than it actually was on examination. This perception of seriousness was independent of the degree of severity of acne, and is probably the reason why almost one-half of our respondents (47.7%) reported feeling very unhappy/sad about their condition. Using a self-report, the General Health Questionnaire, an instrument which measures emotional distress, anxiety, depression, and social dysfunction, Mosam et al. 25 also found that, although psychologic distress occurred in more than 50% of their South African patients, it was similar in patients with mild, moderate, and severe acne. Aktan et al. 26 also reported that anxiety and depression scores were independent of the severity of acne in their Turkish high school students. As noted in other studies of acne in black patients, postinflammatory hyperpigmentation is the major cause for concern, as reported by up to 42% of our respondents despite the fact that most had comedonal acne. This may be related to the marked histologic inflammation found, even in clinically noninflammatory lesions, in some black patients with acne. 27 Scarring was a much less frequent cause for concern, reflecting the generally mild nature of acne. Despite this high prevalence of unhappiness with acne, most of our respondents reported that acne had little or no impact on their relationship with friends, family, or school work. Al Robaee 28 also recently found that acne vulgaris had no effect on relationships in most Saudi Arabian university students interviewed. Quality of life studies conducted in many countries using validated instruments, such as the Acne Disability Index (or variation thereof), have detected varying degrees of impairment in acne, ranging from little or no effect 26 to substantial morbidity. 10,11 The psychosocial impact of acne may thus be heavily influenced by cultural or other factors. Psychologic abnormalities and social dysfunction in skin disease need to be formally studied in Nigeria using validated, culture-sensitive instruments, as has been performed in other countries. Our study also looked at the beliefs, perceptions, and health-seeking behavior and practices of adolescents concerning acne. Dietary factors were believed to be the cause of acne by most (90%) respondents. As this was independent of selfreporting or the presence of acne on examination, it appears to be a general belief about acne in the community, and is probably based on folklore. Perception of diet as a cause or exacerbating factor for acne is also a worldwide, strongly held belief among patients with acne. 29 Although differences in dietary habits have been put forward as an explanation of the observed difference in prevalence in acne between some cultures, 30 and the very low prevalence of acne (4.6%) in a rural community in Ethiopia, reported by Figueroa et al., 9 compared with our study (90.7%), would seem to support this view, Magin et al., 31 in a systematic review of published reports examining the role of diet and other factors in the causation of acne, has suggested that genetic factors may be a more important explanation. He has also suggested that patients individual claims about diet in relation to their acne cannot be dismissed, as the available evidence for or against the role of diet in acne is incomplete and requires further study. Poor hygiene was cited by more than one-quarter of our respondents as a cause of acne, and is similar to other reports. 1,31 It may explain the widespread use of medicated soaps and other cleansing agents for the treatment of acne in students, although these agents are also used commonly to prevent and treat other skin diseases in Nigeria. Face washing is widespread among acne sufferers and needs to be targeted in enlightenment campaigns, as this practice has been shown to be minimally effective in the treatment of acne vulgaris. 32 Our patients did, however, use other preparations, such as nixoderm ointment (another commonly used topical treatment for skin disease in the community), cosmetics, and aloe vera preparations. The use of known active topical medications for acne, such as benzoyl peroxide, retinoids, and clindamycin, was very low, despite a large number of respondents having reported visiting a healthcare facility (72%) and, compared with other studies, 33 a relatively larger number of respondents (24.4%) having reported visiting a doctor. This suggests that awareness about the full range of effective treatments available may not be high in primary care in Nigeria. This underlies the importance of educational campaigns targeting not only the general public, but also healthcare workers. It appears from our study that adolescents were also unsure about whether or not acne could be cured and the expected duration of treatment. These are important factors to address to ensure compliance with medications and the achievement of early success for the treatment of acne, vital in preventing such complications as postinflammatory hyperpigmentation, which, International Journal of Dermatology 2009, 48, The International Society of Dermatology

6 Yahya Acne vulgaris in Nigerian adolescents Tropical medicine rounds 503 as we have identified, is a frequent cause for worry, even for patients with relatively mild acne, such as our study subjects. Costs and logistics prevented us from including secondary schools in other parts of Kaduna which have different socioeconomic characteristics from our study area. Conclusion Acne vulgaris is very common in adolescents in Kaduna, Nigeria, and is as common as reported in other parts of the world; however, it is much less severe and many adolescents are unaware of their condition. Diet was the most common factor believed to cause and exacerbate acne. Most adolescents used cleansing agents and over-the-counter preparations to treat their acne; very few used accepted effective treatments for acne despite visiting healthcare facilities. Although adolescents were as worried about their acne as elsewhere, it did not seem to interfere with their daily lives. Educational campaigns targeting adolescents and primary care providers need to be mounted to address the issues raised by our study. In addition, the psychosocial impact of acne needs to be formally studied using validated and culturally sensitive instruments, as has been performed in many countries. Acknowledgments I would like to thank Hajiya Binta (Director, Abubakar Gumi College, Kaduna, Nigeria) and other members of staff for helping with the study. References 1 Smithard A, Glazebrook C, Williams HC. Acne prevalence, knowledge about acne and psychological morbidity in midadolescence: a community-based study. Br J Dermatol 2001; 145: Kilkenny M, Merlin K, Plunkett A, et al. The prevalence of common skin conditions in Australian school students: 3. Acne vulgaris. Br J Dermatol 1998; 139: Lello J, Pearl A, Arroll B, et al. Prevalence of acne vulgaris in Auckland senior high school students. NZ Med J 1995; 108: Tan HH, Tan AWH, Barkham T, et al. Community-based study of acne vulgaris in adolescents in Singapore. Br J Dermatol 2007; 157: Goulden V, Stables GI, Cunliffe WJ. Prevalence of facial acne in adults. J Am Acad Dermatol 1999; 41: Doe PT, Asiedu A, Acheampong JW, et al. Skin diseases in Ghana and the UK. Int J Dermatol 2001; 40: Yahya H. Change in pattern of skin disease in Kaduna, north-central Nigeria. Int J Dermatol 2007; 46: Hartshorne ST. Dermatological disorders in Johannesburg, South Africa. Clin Exp Dermatol 2003; 28: Figueroa JI, Fuller LC, Abraha A, et al. The prevalence of skin disease among school children in rural Ethiopia a preliminary assessment of dermatologic needs. Pediatr Dermatol 1996; 13: Kellett SC, Gawkrodger DJ. The psychological and emotional impact of acne and the effect of treatment with isotretinoin. Br J Dermatol 1999; 140: Mallon E, Newton JN, Klassen A, et al. The quality of life in acne: a comparison with general medical conditions using a generic questionnaire. Br J Dermatol 1999; 140: Federal Republic of Nigeria Official Gazette. Legal Notice on Publication of the Details of the Breakdown of the National and State Provisional Totals 2006 Census, Vol. 94, No. 24. Lagos: Federal Republic of Nigeria, 2007: B Goodburn EA, Ross DA. A Picture of Health: A Review of Annotated Bibliography of the Health of Young People in Developing Countries, Geneva: World Health Organization/UNICEF, Tan JKL, Vasey K, Fung KY. Beliefs and perceptions of patients with acne. J Am Acad Dermatol 2001; 44: Doshi A, Zaheer A, Stiller MJ. A comparison of current acne grading systems and proposal of a novel system. Int J Dermatol 1997; 36: Daniel F, Dreno B, Poli F, et al. Epidemiological study of acne in secondary school pupils in France, autumn Ann Dermatol Venereol 2000; 127: Amado JM, Matos ME, Abreu AM, et al. The prevalence of acne in north of Portugal. J Eur Acad Dermatol Venereol 2006; 20: Child FJ, Fuller LC, Higgins EM, et al. A study of spectrum of skin disease occurring in a black population in south-east London. Br J Dermatol 1999; 141: Dunwell P, Rose A. Study of the skin disease spectrum occurring in an Afro-Caribbean population. Int J Dermatol 2003; 42: Taylor SC, Cook-Bolden F, Rahman Z, et al. Acne vulgaris in skin of color. J Am Acad Dermatol 2002; 46: S98 S Kilkenny M, Stathakis V, Hibbert ME, et al. Acne in Victorian adolescents: associations with age, gender, puberty and psychiatric symptoms. J Paediatr Child Health 1997; 33: Rademaker M, Garioch JJ, Simpson NB. Acne in school children: no longer a concern for dermatologists. Br Med J 1989; 298: Lucky AW, Biro FM, Huster GA, et al. Acne vulgaris in early adolescent boys. Correlation with pubertal maturation and age. Arch Dermatol 1991; 127: Wilkins JW, Voohees JJ. Prevalence of nodulocystic acne in white and black negro males. Arch Dermatol 1970; 10: Mosam A, Vawda NB, Gordhan AH, et al. Quality of life issues for South Africans with acne vulgaris. Clin Exp Dermatol 2005; 30: Aktan S, Ozmen E, Sanli B. Anxiety, depression and nature of acne vulgaris in adolescents. Int J Dermatol 2000; 39: Halder RM, Holmes YC, Bridgeman-Shah S, et al. A clinical pathological study of acne vulgaris in black females. J Invest Dermatol 1996; 106: The International Society of Dermatology International Journal of Dermatology 2009, 48,

7 504 Tropical medicine rounds Acne vulgaris in Nigerian adolescents Yahya 28 Al Robaee AA. Prevalence, knowledge, beliefs and psychological impact of acne in university students in central Saudi Arabia. Saudi Med J 2005; 26: Magin P, Adams J, Heading G, et al. The causes of acne: a qualitative study of patient perceptions of acne causation and their implication for acne care. Dermatol Nurs 2006; 18: Cordain L, Lindeberg S, Hurtado M, et al. Acne vulgaris. A disease of western civilization. Arch Dermatol 2002; 138: Magin P, Pond D, Smith W, et al. A systematic review of the evidence for myths and misconceptions in acne management: diet, face washing and sunlight. Fam Pract 2005; 22: Kimball A, Choi JM, Lew V. A single blinded randomized, controlled, clinical trial evaluating the effect of face washing on acne vulgaris. J Am Acad Dermatol 2005; 52(Suppl. 1): P Yeung CK, Teo LHY, Xiang LH, et al. A community-based epidemiological study of acne in Hong Kong adolescents. Acta Derm Venereol 2002; 82: Appendix Acne Pimples in Adolescents in Kaduna, Nigeria Prevalence, Severity, Beliefs, Perceptions, and Practices Questionnaire: Study No. Age Sex Class 1 Do you have pimples now, or in the last year? 2 If yes to question 1, for how long have you had the pimples for? Less than 3 months 3 6 months 7 12 months More than 1 year 3 Have you ever visited a clinic or hospital or chemist con cerning your pimples? 4 If yes to question 3, what health worker has treated your pimples? (one or more answers are allowed) Patent medicine store attendant Chemist Pharmacist Nurse Doctor Traditional medicine Other (specify) 5 How long did you have pimples for before seeing a health worker? Less than 3 months 3 6 months 7 12 months More than 1 year 6 What treatments had you tried on your own before seeing a health worker? (one or more answers are allowed) Cleansers Facial scrubs Medicated soap (tetmosol, delta, etc.) Cosmetics (e.g. shelley, clear essence, etc.) Sulfur ointment Neo medrol Dalacin T Oxy 10 or clear skin 10 Retin A cream Baycuten or betnovate or dermovate Nixoderm Whitfield s ointment Dudu Osun Aloe vera Herbs Tablets (state types) Other (specify) 7 Have you ever been completely cleared of pimples? 8 If yes to question 7, what treatments have you used that cleared the pimples? (one or more answers are allowed) Cleansers Facial scrubs Medicated soap (tetmosol, delta) Cosmetics (e.g. shelley, clear essence, etc.) Sulfur ointment Neo medrol Dalacin T Oxy 10 or clear skin 10 Retin A cream Baycuten or betnovate or dermovate Nixoderm Whitfield s ointment Dudu Osun Aloe vera Herbs Tablets (state types) Can t remember name(s) Other (specify) 9 Which of the following makes your pimples worse? (one or more answers are allowed) Dirty skin Eating too much fat or butter or margarine Eating sweets and chocolate Cosmetics Hair products Excessive heat and humidity Rainy season International Journal of Dermatology 2009, 48, The International Society of Dermatology

8 Yahya Acne vulgaris in Nigerian adolescents Tropical medicine rounds 505 Harmattan season Exercise/excessive sweating Stress Drugs (state types) Other (specify) ne of the above 10 How does your pimple make you feel? Very unhappy/sad Frequently worried Occasionally worried t worried at all 11 What makes you most unhappy or sad or worried about your pimples? Small painful lesions Large painful lesions (cysts) Dark spots Scars ne of the above Other (specify) 12 Have your pimples affected your relationship with your friends? Severely Moderately Only sometimes Never 13 Are pimples affecting your ability to make friends? Severely Moderately Only sometimes Never 14 Have your pimples affected your relationship with your family? Severely Moderately Only sometimes Never 15 Have your pimples affected your school work? Severely Moderately Only sometimes Never 16 How serious are your pimples? Mild Moderate Severe 17 Do you think pimples represent a condition that can be permanently cured (cleared never to return?) Don t know 18 How long do you expect treatment for pimples to take? Days 2 4 weeks 1 6 months More than 6 months Don t know 19 Is there any family member (brother, sister, father, mother, uncle, aunt) who has or has had pimples? 20 What do you think causes pimples? (one or more answers are allowed) Poor skin hygiene Eating too much fat Eating too much butter or margarine (Blue Band) Eating too much sweets and chocolate Obesity or too much body oil Too many body hormones Inheritance (genetics) Blocked skin pores Infection by germs Drugs Evil spirits Other (specify) Don t know 2009 The International Society of Dermatology International Journal of Dermatology 2009, 48,