Psycho-Social Determinants of Acne in Rural Community of Lahore

DOI: https://doi.org/10.53350/pjmhs22163556 ORIGINAL ARTICLE Psycho-Social Determinants of Acne in Rural Community of Lahore SYMA ARSHAD1, SADAF SAJID2, ASMA KANWAL3, MUSSAB AHMAD4, MAAZ AHMAD5, HAMNA AHMED6 1 Asstt.Prof,Community Medicine,RLMC Assoc. Prof, Forensic Medicine, RLMC Demonstrator RLMC 4 Asstt.Prof.KEMU 5 Prof. of Community Medicine,RLMC 6 Asstt Prof,Community Medicine,UOL Correspondence to: Syma Arshad 2 3 ABSTRACT Acne is a common human skin disease, characterized by areas of skin with seborrhea (scaly red skin), comedones (blackheads and whiteheads), papules (pinheads), pustules (pimples), nodules (large papules) and possibly scarring. Acne affects mostly skin with the densest population of sebaceous follicles. These areas include the face, the upper part of the chest, and the back. Objectives: To determine the association between various psycho-social factors and acne. Design:Population based Case-Control Study. Place & Duration:Galvera Village, Lahore from May 2019 to July 2019. Subjects & Methods. A population based case-control study with 1:1 case to control ratio was conducetd. A total of 100 persons (50 cases and 50 controls) were recruited in the study. Selection was made on laid down criteria from adult population living in rural community of Lahore after taking due consent. Interviews were conducted through a pretested questionnaire by a 10 membered team of group 01, 4th year MBBS students of Rashid Latif Medical College, Lahore under direct supervision of Department of Community Medicine, Rashid Latif Medical College (RLMC). Data was collected, compiled and analyzed through SPSS version 25. Results: Overall 48% were males and 52% were female in the study. Among acne cases, mostly were males(70%), above the age of 30 years (80%) and educated (88%). In bivariate analysis, Acne was found more related with aggression (OR 2.302, 95% CI=1.021-5.190), anxiety(OR 3.857, 95% CI=1.670-8.911), constipation (OR 6.143, 95% CI=2.323-16.242), depression (OR 3.019, 95% CI=1.315-6.929), dusty environment (OR 2.528, 95% CI=1.112-5.744), stress (OR 4.644, 95% CI=1.981-10.883), high fat diet (OR 3.551, 95% CI=1.541-8.181), immediate rest after dinner (OR 3.841, 95% CI=1.610-9.161), introvert personality (OR 3.407, 95% CI=1.401-8.285), irregular timings of meal (OR 8.273, 95% CI=3.357-20.388), junk food (OR 4.896 , 95% CI=2.044-11.728), lack of personal hygiene (OR 4.472, 95% CI=1.355-14.755), lack of regular intake of fruits (OR5.310, 95% CI=1.913-14.745), lack of regular intake of vegetables (OR 4.162, 95% CI=1.744-9.935), lack of regular prayers (OR 2.455, 95% CI=1.097-5.494), lack of rest after lunch (OR 2.333, 95% CI=1.027-5.300), undue late night working (OR 6.612, 95% CI=2.762-15.831), high carbohydrate diet (OR 3.622, 95% CI=1.559-8.418), dandruff (OR 2.279, 95% CI=1.017-5.108), exposure to sunlight (OR 6.000, 95% CI=2.528-14.240), habit of skin scratching (OR 8.500, 95% CI=3.412-21.177), intake of carbonated drinks (OR 3.622, 95% CI=1.559-8.418), lack of cleansing before sleep (OR 4.125, 95% CI=1.792-9.497) and less intake of water (OR 4.644, 95% CI=1.981-10.883). However after multivariate analysis while controlling all other listed risk factors, acne was found more related with constipation (OR 4.012, 95% CI=1.067-15.084)), dusty environment (OR 2.639, 95% CI=1.035-6.732)), stress (OR 3.288, 95% CI=1.022-10.580), irregular timings of meals (OR 5.809, 95% CI=1.359-24.830), undue late night working (OR 3.584, 95% CI=1.251-10.271), exposure to sunlight (OR 5.194, 95% CI=1.677-16.092), habit of skin scratching (OR 6.334, 95% CI=2.378-16.873), lack of cleansing before sleep (OR 3.109, 95% CI=1.203-8.034) and less intake of water (OR 4.518, 95% CI=1.250-16.324) Conclusion: Acne was found significantly associated with constipation, dusty environment, stress, irregular timings of meals, undue late night working, exposure to sunlight, habit of skin scratching, lack of cleansing before sleep and less intake of water. Keywords: Acne, psychological factors, social factors, urban, community INTRODUCTION Acne is a common human skin disease, characterized by areas of skin with seborrhea (scaly red skin), comedones (blackheads and whiteheads), papules (pinheads), pustules (pimples), nodules (large papules) and possibly scarring. Acne affects mostly skin with the densest population of sebaceous follicles. These areas include the face, the upper part of the chest, and the back. In the previous studies carried out regarding acne dieting1, high fat diet2, immediate rest after dinner3, irregular timings of meals4, junk food5, lack of regular intake of fruits6, lack of regular intake of vegetables7, lack of rest after lunch8, obesity9, smoking10, excessive intake of spicy food11, eating fish12, excessive intake of nuts13, excessive intake of dairy products14, excessive intake of tea15, high carbohydrate diet16, intake of chocolates17, intake of carbonated drinks18, less intake of water19, aggression20, anxiety21, depression22, emotional stress23, introvert personality24, lack of sound sleep25, lethargy26, type A personality, broken families, constipation27, family illiteracy, joint family system, lack of exercise28, lack of personal hygiene29, lack of regular prayers, peer pressure, poverty30, sedentary life style31, undue late night working32, exposure to sunlight33, dusty environment34, overcrowding in houses35, smoky environment36, dandruff37, 556 P J M H S Vol. 16, No. 03, MAR 2022 excessive use of cosmetics38, habit of skin scratching39 and lack of cleansing before sleep40were found to be associated with it. Acne is emerging as a major health issue in rural communities. Little work has been done in finding the association of various psycho-social factors with acne in rural community.So there was a dire need to conduct this study to identify various psycho-social factors associated with acne, to identify the most important predictors of acne while controlling the other factors studied, to compare the results with the already conducted studies and to make the students capable of making the community aware of the various psycho-social factors associated with acne in order to improve their health status. SUBJECTS AND METHODS A case-control study was conducted to identify various psychosocial factors associated with acne in rural community, Lahore from May 2019 to July 2019. Study population was divided into two groups. Case group included adult patients suffering from acne and were not suffering from any other major medical or surgical illness and were fulfilling the criteria laid down for acne1.The control group comprised of healthy adults who did not suffer from acne or any other major medical or surgical illness.Written consent was obtained from all selected study subjects. Data was collected Psycho-Social Determinants of Acne in Rural Community of Lahore by interviews conducted by the members of group 01 of 4th year MBBS students of Rashid Latif Medical College, Lahore using pretested and close ended questionnaire, while keeping all ethical and social considerations in mind. Data collection was supervised by the staff of Department of Community Medicine Rashid Latif Medical College, Lahore. Data entry and analysis was done by statistical software SPSS version 25 at RLMC. After describing the demographic characteristics using frequency tables, simple and multivariate logistic regression was used to calculate odds ratio and their 95% confidence intervals. RESULTS Among Acne cases mostly were males(70%), below the age of 30 years (80%) and Educated (88%). In the control group majority belonged to females (60%), below the age of 30 years (78%) and less educated (92%). See Fig.1,2,3. immediate rest after dinner (OR 3.841, 95% CI=1.610-9.161), introvert personality (OR 3.407, 95% CI=1.401-8.285), irregular timings of meal (OR 8.273, 95% CI=3.357-20.388), junk food (OR 4.896 , 95% CI=2.044-11.728), lack of personal hygiene (OR 4.472, 95% CI=1.355-14.755), lack of regular intake of fruits (OR5.310, 95% CI=1.913-14.745), lack of regular intake of vegetables (OR 4.162, 95% CI=1.744-9.935), lack of regular prayers (OR 2.455, 95% CI=1.097-5.494), lack of rest after lunch (OR 2.333, 95% CI=1.027-5.300), undue late night working (OR 6.612, 95% CI=2.762-15.831), high carbohydrate diet (OR 3.622, 95% CI=1.559-8.418), dandruff (OR 2.279, 95% CI=1.017-5.108), exposure to sunlight (OR 6.000, 95% CI=2.528-14.240), habit of skin scratching (OR 8.500, 95% CI=3.412-21.177), intake of carbonated drinks (OR 3.622, 95% CI=1.559-8.418), lack of cleansing before sleep (OR 4.125, 95% CI=1.792-9.497) and less intake of water (OR 4.644, 95% CI=1.981-10.883) whereas broken families, dieting, family illiteracy, joint family system, lack of exercise, lack of sound sleep, lethargy, obesity, overcrowding in houses, peer pressure, poverty, sedentary life style, smoking, smoky environment, excessive intake of spicy food, type A personality, eating fish, excessive intake of nuts, excessive intake of dairy products, excessive intake of tea, intake of chocolates and excessive use of cosmetics were not significantly associated with acne. Figure 1: Gender distribution Figure 3: Education distribution Figure 2: Age distribution In bivariate analysis the psychosocial factors which were found significantly associated with Acne were aggression (OR 2.302, 95% CI=1.021-5.190), anxiety(OR 3.857, 95% CI=1.6708.911), constipation (OR 6.143, 95% CI=2.323-16.242), depression (OR 3.019, 95% CI=1.315-6.929), dusty environment (OR 2.528, 95% CI=1.112-5.744), stress (OR 4.644, 95% CI=1.981-10.883), high fat diet (OR 3.551, 95% CI=1.541-8.181), Multivariate logistic regression model was used to control possible confounding effect. It was observed that there were some changes between the crude odds ratios and the adjusted odds ratios. It was observed that after controlling all the factors studied, the strongest statistically significant association was exhibited by constipation (OR 4.012, 95% CI=1.067-15.084), dusty environment (OR 2.639, 95% CI=1.035-6.732), stress (OR 3.288, 95% CI=1.022-10.580), irregular timings of meals (OR 5.809, 95% CI=1.359-24.830), undue late night working (OR 3.584, 95% CI=1.251-10.271), exposure to sunlight (OR 5.194, 95% CI=1.67716.092), habit of skin scratching (OR 6.334, 95% CI=2.37816.873), lack of cleansing before sleep (OR 3.109, 95% CI=1.2038.034) and less intake of water (OR 4.518, 95% CI=1.250-16.324). Other not significantly associated factors included aggression, anxiety, broken families, depression, dieting, family illiteracy, high fat diet, immediate rest after dinner, introvert personality, joint family system, junk food, lack of exercise, lack of personal hygiene, lack of regular intake of fruits, lack of regular intake of vegetables, lack of regular prayers, lack of rest after lunch, lack of sound sleep, lethargy, obesity, overcrowding in houses, peer pressure, poverty, sedentary life style, smoking, smoky environment, excessive intake of spicy food, type A personality, eating fish, excessive intake of nuts, excessive intake of dairy products, excessive intake of tea, high carbohydrate diet, intake of chocolates, dandruff, excessive use of cosmetics and intake of carbonate drinks. See Table P J M H S Vol. 16, No. 03, MAR 2022 557 S. Arshad, S. Sajid, A. Kanwal et al Table 1: Association of Psycho-social factors with Acne,Urban Community, Lahore Acne Bivariate Analysis Sociodemographic Factors CrudeOdd 95% CI s Case Control Lower ratio n=50 n=50 01 Dieting 50.0% 32.0% 2.125 .943 02 High fat diet 58.0% 28.0% 3.551 1.541 03 Immediate rest after dinner 52.0% 22.0% 3.841 1.610 04 Irregular timings of meals 78.0% 30.0% 8.273 3.357 05 Junk food 78.0% 42.0% 4.896 2.044 06 Lack of intake of fruits 42.0% 12.0% 5.310 1.913 07 Lack of intake of vegetables 54.0% 22.0% 4.162 1.744 08 Lack of rest after lunch 50.0% 30.0% 2.333 1.027 09 obesity 16.0% 16.0% 1.000 .343 10 smoking 12.0% 14.0% .838 .260 11 Excessive intake of spicy food 76.0% 52.0% 2.923 1.245 12 Eating fish 28.0% 50.0% .389 .170 13 Excessive intake of nuts 46.0% 50.0% .852 .388 14 Excessive intake of dairy products 12.0% 26.0% .388 .134 15 Excessive intake of tea 50.0% 50.0% 1.273 .579 16 High carbohydrate diet 74.0% 44.0% 3.622 1.559 17 Intake of chocolates 58.0% 42.0% 1.907 .862 18 Intake of carbonated drinks 74.0% 44.0% 3.622 1.559 19 Less intake of water 62.0% 26.0% 4.644 1.981 20 Aggression 52.0% 32.0% 2.302 1.021 21 Anxiety 60.0% 28.0% 3.857 1.670 22 Depression 54.0% 54.0% 3.019 1.315 23 Stress 62.0% 26.0% 4.644 1.981 24 Introvert personality 46.0% 20.0% 3.407 1.401 25 Lack of sound sleep 40.0% 34.0% 1.294 .573 26 Lethargy 62.0% 46.0% 1.915 .863 27 Type A personality 56.0% 48.0% 1.379 .628 28 Broken families 8.0% 8.0% 1.000 .236 29 Constipation 50.0% 14.0% 6.143 2.323 30 Family illiteracy 26.0% 44.0% .447 .192 31 Joint family system 46.0% 40.0% 1.278 .578 32 Lack of exercise 78.0% 60.0% 2.364 .984 33 Lack of personal hygiene 28.0% 8.0% 4.472 1.355 34 Lack of regular prayers 64.0% 64.0% 2.455 1.097 35 Peer pressure 18.0% 10.0% 1.976 .612 36 poverty 20.0% 30.0% .583 .233 37 Sedentary life style 64.0% 48.0% 1.926 .865 38 Undue late night working 72.0% 28.0% 6.612 2.762 39 Exposure to sunlight 70.0% 28.0% 6.000 2.528 40 Dusty environment 52.0% 30.0% 2.528 1.112 41 Overcrowding in houses 14.0% 24.0% .516 .184 42 Smoky environment 50.0% 34.0% 1.941 .867 43 Dandruff 66.0% 46.0% 2.279 1.017 44 Excessive use of cosmetics 40.0% 26.0% 1.897 .812 45 Habit of skin scratching 68.0% 20.0% 8.500 3.412 46 Lack of cleansing before sleep 68.0% 34.0% 4.125 1.792 DISCUSSION The determinants of acne are complex and can differ from country to county or even from one community to another. Many psychosocial factors determine the state of acne. Taking in to account the psychological factors, stress23 was found to be associated with acne which is consistent with the previous studies. On the other hand aggression20, anxiety21, depression22, introvert personality24, lack of sound sleep25, lethargy and type A personality26 were observed to have no association with acne which is contrary to previous studies. Among the environmental and social factors, undue late night working32 and exposure to sunlight33 were seen to cause acne in accordance with the former studies. However broken families, family illiteracy25, joint family system, lack of exercise28, lack of personal hygiene28, lack of regular prayer29s, peer pressure, poverty30 and sedentary life style31 were negated as causative factors of acne in current study in contrast to the former studies. On considering the physical environmental factors, dusty environment34 was shown to increase acne as is cited in the earlier studies. In contrast overcrowding in houses 35 and smoky environment36 were found to be unrelated with acne while previous 558 P J M H S Vol. 16, No. 03, MAR 2022 Upper 4.789 8.181 9.161 20.388 11.728 14.745 9.935 5.300 2.913 2.695 6.865 .892 1.868 1.122 2.795 8.418 4.220 8.418 10.883 5.190 8.911 6.929 10.883 8.285 2.921 4.250 3.029 4.241 16.242 1.039 2.825 5.677 14.755 5.494 6.380 1.463 4.290 15.831 14.240 5.744 1.443 4.346 5.108 4.431 21.177 9.497 Multivariate Analysis Adj. 95% CI Odds Lower ratio .882 .191 .758 .162 3.037 .765 5.809 1.359 1.693 .372 2.125 .333 1.624 .346 .929 .233 .922 .172 .108 .009 .598 .130 .339 .084 .366 .066 .773 .103 4.011 .735 .402 .030 2.433 .541 2.207 .455 4.518 1.250 1.928 .712 2.095 .697 1.992 .688 3.288 1.022 2.348 .829 .379 .120 1.174 .433 .547 .189 .728 .084 4.012 1.067 .349 .107 .972 .328 2.013 .613 1.345 .293 2.460 .827 1.348 .205 .543 .153 .941 .284 3.584 1.251 5.194 1.677 2.639 1.035 .322 .103 1.661 .663 1.862 .718 .889 .311 6.334 2.378 3.109 1.203 Upper 4.082 3.556 12.063 24.830 7.710 13.565 7.618 3.701 4.939 1.308 2.749 1.371 2.028 5.817 21.886 5.404 10.944 10.708 16.324 5.223 6.300 5.766 10.580 6.652 1.200 3.181 1.587 6.340 15.084 1.137 2.879 6.607 6.171 7.318 8.869 1.922 3.113 10.271 16.092 6.733 1.008 4.159 4.831 2.543 16.873 8.034 studies exhibit their definite association. Taking into account the nutritional factors irregular timings of meals 18 and less intake of water19 were found to be associated with acne which is consistent with the previous studies. On the other hand dieting1, high fat diet2, immediate rest after dinner3, junk food4, lack of regular intake of fruits6, lack of regular intake of vegetables7, lack of rest after lunch8, obesity9, smoking10, spicy food11, eating fish12, excessive intake of nuts13, excessive intake of dairy products14, excessive intake of tea15, high carbohydrate diet16, intake of chocolates17 and intake of carbonated drinks18 were observed to have no association with acne which is contrary to previous studies. In the miscellaneous group, habit of skin scatching39 and lack of cleansing before sleep40 were found to be associated with acne which is in accordance with the previous studies. However, dandruff37 and excessive use of cosmetics38 were not found to be associated with acne which is contrary to the previous studies. CONCLUSION Acne was found more in males,below the age of 30 years and educated ones. Psycho-Social Determinants of Acne in Rural Community of Lahore The determinants of acne identified included constipation, dusty environment, stress, irregular timings of meals, undue late night working, exposure to sunlight, habit of skin scratching, lack of cleansing before sleep and less intake of water while aggression, anxiety, broken families, depression, dieting, family illitracy, high fat diet, immediate rest after dinner, introvert personality, joint family system, junk food, lack of exercise, lack of personal hygiene, lack of regular intake of fruits, lack of regular intake of vegetables, lack of prayers, lack of rest after lunch, lack of sound sleep, lethargy, obesity, overcrowding in houses, peer pressure, poverty, sedentary lifestyle, smoking, smoky environment, excessive intake of spicy food, type A personality, eating fish, excessive intake of nuts, excessive intake of dairy products, excessive intake of tea, high carbohydrate diet, intake of chocolates, dandruff, excessive use of cosmetics and intake of carbonated drinks were not found to be significantly associated. Limitation of the study: As the exposure and outcome were assessed almost simultaneously in this study, temporal association between acne and factors studied could not be adequately established; which can be remedied by conducting a cohort study in a similar population. Acknowledgement: We, the group members, are thankful to the community’s co-operation for data collection, staff of computer lab at Rashid Latif Medical College, Lahore for extending nice assistance. We are extremely obliged to the staff of Community Medicine Department, Rashid Latif Medical College, Lahore for overall help, guidance, training and supervision. REFERENCES 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Durai PC, Nair DG. Acne vulgaris and quality of life among young adults in South India. Indian journal of dermatology. 2015 Jan;60(1):33. Sarkar S, Patra P, Mridha K, Ghosh SK, Mukhopadhyay A, Thakurta RG. Personality disorders and its association with anxiety and depression among patients of severe acne: A cross-sectional study from Eastern India. Indian journal of psychiatry. 2016 Oct;58(4):378. Kinsey A, Ormsbee M. The health impact of nighttime eating: old and new perspectives. Nutrients. 2015 Apr 9;7(4):2648-62. Harper JC, Gold LF, Alexis AF, Tan JK. Treating Acne in Adult Women. InSeminars in cutaneous medicine and surgery 2018 Jun 1 (Vol. 37, No. 3S, pp. S67-S70). Ginode AG, Pimparkar KM, Nawkar MS, Deshpande YN. A Survey study on Viruddha Aahar (Fast food) Consumption Amongst College Students. International Journal of Ayurvedic Medicine. 2018 Oct 7;9(3):157-66. Kumar V, Bist M. Overview on anti-acne activity of methanol extract of dried fruits of Embelia ribes. Innoriginal: International Journal Of Sciences. 2018 Jul 1:44-6. Claudel JP, Auffret N, Leccia MT, Poli F, Dréno B. Acne and nutrition: hypotheses, myths and facts. Journal of the European Academy of Dermatology and Venereology. 2018 Oct;32(10):1631-7. Ginode AG, Pimparkar KM, Nawkar MS, Deshpande YN. A Survey study on Viruddha Aahar (Fast food) Consumption Amongst College Students. International Journal of Ayurvedic Medicine. 2018 Oct 7;9(3):157-66. Neupane S, Basnet B, Sharma TD. Association Between Acne and Body Mass Index: A Hospital Based Cross Sectional Study. Nepal Journal of Dermatology, Venereology & Leprology. 2018 Mar 29;16(1):53-6. Wolkenstein P, Machovcova A, Szepietowski JC, Tennstedt D, Veraldi S, Delarue A. Acne prevalence and associations with lifestyle: a cross‐sectional online survey of adolescents/young adults in 7 European countries. Journal of the European Academy of Dermatology and Venereology. 2018 Feb;32(2):298-306. Ali F, Hasni MS, Ali SZ, Nadeem M, Khan A, Mehak T. 5. Determination of various risk factors associated with acne vulgaris infection in Quetta, Pakistan. Pure and Applied Biology (PAB). 2019 Aug 15;8(3):1919-24. Kandel S. An Evidence-based Look at the Effects of Diet on Health. Cureus. 2019 May;11(5). Khanna R, Shifrin N, Nektalova T, Goldenberg G. Diet and dermatology: Google search results for acne, psoriasis, and eczema. Cutis. 2018 Jul 1;102(44):46-8. Dréno B, Bettoli V, Araviiskaia E, Sanchez Viera M, Bouloc A. The influence of exposome on acne. Journal of the European Academy of Dermatology and Venereology. 2018 May;32(5):812-9. KI. Are Substances Found In Green Tea Effective In Reducing Inflammatory And Noninflammatory Lesion Counts In Men And Women With Acne Vulgaris?. 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 Plewig G, Melnik B, Chen W. Acne and Nutrition. InPlewig and Kligman´ s Acne and Rosacea 2019 (pp. 293-298). Springer, Cham. Gunda Praneeth Kumar TP. CORRELATION OF SERUM ZINC LEVELS WITH SEVERITY OF ACNE VULGARIS. Group. 2018 Jan 29;1(7):51. Kawase T, Kawase R, Kawase A, inventors; Japan Mode Co Ltd, assignee. Oral care composition. United States patent application US 15/568,442. 2018 May 3. Govindarajan N. A comparative study of the resurfacing effect of microdermabrasion versus glycolic acid peel in the management of acne scars. Journal of Pakistan Association of Dermatology. 2018 Dec 13;28(2):224-32. Akinboro AO, Ezejiofor OI, Olanrewaju FO, Oripelaye MM, Olabode OP, Ayodele OE, Onayemi EO. The impact of acne and facial postinflammatory hyperpigmentation on quality of life and self-esteem of newly admitted Nigerian undergraduates. Clinical, cosmetic and investigational dermatology. 2018;11:245. Dreno B, Bagatin E, Blume‐Peytavi U, Rocha M, Gollnick H. Female type of adult acne: Physiological and psychological considerations and management. JDDG: Journal der Deutschen Dermatologischen Gesellschaft. 2018 Oct;16(10):1185-94. Mikhael NW, Hamed AM, Mansour AI, Abdelrahman ES. Serum levels of brain‐derived neurotrophic factor in patients with acne vulgaris. Journal of cosmetic dermatology. 2019 Apr 13. Chowdary NK, Prabhu SS, Shenoi SD, Nayak SU. Quality of life in acne patients: A clinical and Dermatology Life Quality Index (DLQI) based crosssectional study. Journal of Pakistan Association of Dermatology. 2019 Jan 27;28(4):415-9. Gul A, Wushuer P, Rui H, Aihemaiti A, Memtily N, Talifu A. A survey and analysis of traditional Uyghur medicine abnormal body fluid type major depressive disorder with personality traits. Traditional Medicine and Modern Medicine. 2019 Mar 8;2(01):13-8. Botsali A, Kocyigit P, Uran P. The effects of isotretinoin on affective and cognitive functions are disparate in adolescent acne vulgaris patients. Journal of Dermatological Treatment. 2019 May 6:1-5. Hong G, Lee O. Three‐dimensional reconstruction of skin disease using multi‐view mobile images. Skin Research and Technology. 2019 Jan 18. Porubsky CF, Glass AB, Comeau V, Buckley C, Goodman MB, Kober MM. The Role of Probiotics in Acne and Rosacea. Probiotics: Current Knowledge and Future Prospects. 2018 Jul 4:91. DiNardo V, Conte A, Finelli F, Lotti T. Exercise and Skin. Advances in Integrative Dermatology. 2019 Jan 18:367-77. Marriott NG, Schilling MW, Gravani RB. Personal Hygiene. InPrinciples of Food Sanitation 2018 (pp. 93-108). Springer, Cham. Christina ON, Akin OM, Salisu RA, Jimoh AG, Abdurazzaq FN, Azeez IA, Aliyu K, Welcome MO, Dane S. The Effects of Sex, Physical Defect on Body, Acne on Face and Education on Depression in Nigerian University Students. Journal of Research in Medical and Dental Science. 2019 Mar;7(2):103-8. Priyanka RH, Hemanth K, Apurva M, Bakshi V, Kumar BH. Observational study on risk factors, complications and management of polycystic ovarian syndrome. Melibary YT, Alkeraye S, Alnutaifi KA, Melibary NT, Alsuwaidi MK, Algzlan HI. Occasional acne; an acne variant. Clinical, cosmetic and investigational dermatology. 2019;12:219. George RM, Sridharan R. Factors aggravating or precipitating acne in indian adults: a hospital-based study of 110 cases. Indian journal of dermatology. 2018 Jul;63(4):328. Gao M, Liu C. Integrated Chinese and Western Medicine for the Treatment of Acne Associated Blepharokeratoconjunctivitis Case 1. Journal of Clinical and Nursing Research. 2019 Jan 31;3(1). Alwan NK, Shakir SA, Waheeb HH. Epidemiology of Skin Diseases among Displaced People in Diyala Province. Journal of the Faculty of Medicine Baghdad. 2018 Apr 1;60(1):52-6. Dréno B, Bettoli V, Araviiskaia E, Sanchez Viera M, Bouloc A. The influence of exposome on acne. Journal of the European Academy of Dermatology and Venereology. 2018 May;32(5):812-9. Suvitha S, Abilasha R. General awareness about seborrheic dermatitis/dandruff among dental students–A questionnaire-based study. Drug Invention Today. 2019 May 15;11(5). Maharani A, Pratiwi W, Nauphar D. CHANGING COSMETIC BRANDS INCREASE RISK OF FREQUENCY AND DEGREE OF ACNE VULGARIS IN FEMALE UNDERGRADUATE STUDENTS. InProceedings of the International Conference on Applied Science and Health 2018 Aug 2 (No. 3, pp. 53-57). Braun N, Thomas S, Tronnier H, Heinrich U. Self-Reported Skin Changes by a Selected Number of Astronauts after Long-Duration Mission on ISS as Part of the Skin B Project. Skin pharmacology and physiology. 2019;32(1):52-7. Yu JY, Jang A, Chang BS. Comparative Analysis of skin Condition after Using Cleansing Oil and Cleansing Water for removing Facial Makeup. Medico-Legal Update. 2019;19(2):526-32. P J M H S Vol. 16, No. 03, MAR 2022 559