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 Table of Contents  
REVIEW ARTICLE
Year : 2017  |  Volume : 1  |  Issue : 2  |  Page : 33-36

Common misconceptions about acne vulgaris: A review of the literature


Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong

Date of Web Publication28-Jul-2017

Correspondence Address:
Rex WH Hui
Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam
Hong Kong
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CDR.CDR_16_17

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  Abstract 


Acne vulgaris (acne) is a common chronic skin disease and affects over 90% of teenagers worldwide. Despite its prevalence, acne vulgaris is shrouded in multiple misconceptions that are widespread in the general public, among acne patients, and even in health-care professionals. This article reviewed six common misconceptions about acne vulgaris: (1) acne is a trivial condition and does not require medical attention; (2) acne is a transitory disease of adolescence; (3) dietary factors cause acne; (4) acne is caused by uncleanliness; (5) acne improves rapidly upon treatment; and (6) acne can be treated by sunlight. These misconceptions span across the natural history, etiology, and treatment of acne vulgaris. The paucity of knowledge about acne has potentially severe consequences and should not be overlooked. Underestimating the severity and progression of acne may delay treatment, while misinterpreting the etiology of acne could lead to unnecessary and disruptive lifestyle changes. Unrealistic expectations about therapy will lead to dissatisfaction, which may decrease treatment compliance. Actions in public health, medical education, and research are warranted to eradicate these misconceptions about acne vulgaris.

Keywords: Acne vulgaris, community dermatology, patient misconceptions, public education


How to cite this article:
Hui RW. Common misconceptions about acne vulgaris: A review of the literature. Clin Dermatol Rev 2017;1:33-6

How to cite this URL:
Hui RW. Common misconceptions about acne vulgaris: A review of the literature. Clin Dermatol Rev [serial online] 2017 [cited 2017 Nov 24];1:33-6. Available from: http://www.cdriadvlkn.org/text.asp?2017/1/2/33/211778




  Introduction Top


Acne vulgaris (acne) is a common chronic skin condition affecting over 90% of teenagers worldwide. Acne accounts for 3.5 million annual doctor visits in the United Kingdom and up to 2.5 billion USD annual health-care expenditure in the United States.[1] Since it does not cause severe physical morbidity or mortality, acne is often dismissed as a trivial and transitory disease of adolescence. However, acne is associated with poorer quality of life [2] and may lead to psychological problems such as anxiety, depression, and suicidal ideation.[3] Despite its high prevalence and significant impact, the general public's knowledge about acne is inadequate. Misconceptions about acne are prevalent among teenagers, acne patients,[4],[5],[6],[7] medical students,[8],[9] and even doctors.[10] The natural history, etiology, and treatment of acne are all shrouded in myths. This article reviewed six common misconceptions about acne vulgaris and also explored the measures required to correct these wrong beliefs.


  Common Misconceptions About Disease Nature Top


Misconception 1: Acne vulgaris is a trivial condition and does not require medical attention

Soreness, itching, and pain are the typical symptoms of acne vulgaris. The majority of patients only have mild disease, hence patients only view acne as trivial and insignificant.[5] In a study in Saudi Arabia, 19.3% of respondents viewed acne as a cosmetic problem only, but not a medical problem.[11] However, this cannot be further from the truth. Even though the physical symptoms are usually minor, acne is highly visible and is associated with psychological conditions including anxiety and depression.[3] Acne also increases the feeling of embarrassment [12] and is associated with a poorer quality of life.[13] Using validated scales for assessment, Mallon et al. suggested that the psychological impact of acne is comparable to that of chronic asthma, epilepsy, and arthritis respectively.[2]

Neglecting the impact of acne may delay or deter patients to seek medical advice. In 78 acne patients who visited dermatologists in Canada, 74% waited for more than a year to seek medical attention, while only 7% sought help in less than three months.[14] A survey in medical students showed that over 20% of respondents did not believe in seeking dermatologists' advice for treating acne.[8] Rather than seeking medical advice, many patients may choose to seek care in beauty salons instead.

Misconception 2: Acne vulgaris is a transitory disease of adolescence

Acne vulgaris is frequently perceived as a disease for teenagers,[3],[6] and many patients believe that acne would spontaneously clear after adolescence.[5],[10] In a Croatian study, over 40% of family physicians had this misconception as well and simply reassured their patients that acne would disappear with time.[10] Indeed, the prevalence of acne is highest in teenagers [12],[13],[15] due to increased androgen secretion and sebum production. Nonetheless, acne is not limited to the youth and can persist into adulthood. In a German study, 64% of patients aged 20–29 were affected by some degree of acne, while the prevalence of acne was 43% and 24% in the 30–39 and 40–49 age groups, respectively.[16] Contrary to popular belief, acne is not unique to adolescents.


  Common Misconceptions About Etiology Top


Misconception 3: Dietary factors such as chocolate and fatty food cause acne vulgaris

Diet is frequently incriminated as a cause of acne vulgaris. In particular, chocolate and greasy food are often mentioned as the main culprits.[7],[11],[14] In an early study published in 1983, 32% of patients believed that dietary factors would precipitate acne formation and 68% specifically stated chocolate as a causal factor.[5] This misconception is prevalent in medical professionals as well, where 29% of Pakistani medical students,[8] 41% of Australian medical students,[9] and 70% of Croatian family physicians [10] listed food as the main cause of acne. Interestingly, the patients of the Croatian family physicians had better knowledge than their doctors, and only 18% of the patients had the same misconception.[10]

Chocolate as a causal factor for acne has been suggested as early as the 1960s. Yet, the studies performed in that period could not demonstrate an association between chocolate and acne.[17],[18],[19] It must be noted that those studies had small sample sizes, did not have controls, and followed up patients for short term only. Similar studies on fatty food such as pizza and fries did not show any association either.[4] In recent years, evidence has emerged to suggest a high glycemic index diet [20] and dairy products [21] to increase the risk of acne. Nonetheless, these studies should be interpreted with caution. The study on glycemic index was an ecological study comparing developing countries and Westernized societies. Confounders such as genetic factors and ecological fallacy were possible and reduce the reliability of the study. The second study on dairy products was a cross-sectional study requiring recall of dietary habits. Recall bias was likely present and temporality could not be established. Further studies are needed to investigate the effect of glycemic index and dairy products on acne. Overall, there is insufficient evidence to draw a causal relationship between diet and acne vulgaris.

Misconception 4: Acne vulgaris is caused by uncleanliness

Blackheads (open comedones) are characteristic lesions of acne vulgaris, and the dark color of blackheads is commonly perceived to be due to dirt accumulation.[5],[14] Owing to the perceived association with facial hygiene, many people, including patients [8] and medical students,[9] believe that rigorous facewashing is an effective treatment for acne.

In reality, blackheads are formed by the oxidation of open comedones and are not due to dirt accumulation. There is no evidence to suggest an association between facial cleanliness and acne. While numerous facial cleansing regimens for acne patients are marketed, the efficacy for most of these products is unclear.[22] Frequent facewashing will also remove sebum from the skin surface, leading to skin dryness and irritation. Dermatologists have suggested that irritation from frequent washing may even lead to nonadherence to topical acne treatment, resulting in a poorer clinical outcome.[6]


  Common Misconceptions About Treatment Top


Misconception 5: Acne vulgaris improves rapidly upon treatment

Patients frequently assume medical therapy to have rapid action against acne vulgaris and expect visible improvement within a few weeks.[5] In 100 surveyed patients in Croatia, 66% believed that medical therapy would provide instantaneous effect, and the condition would improve immediately after treatment initiation.[10]

In reality, acne lesions respond slowly. The currently available drugs do not prevent the formation of new lesions and time is required for the resolution of existing lesions. Exact time of treatment may vary due to the drug choice and patient's response, but a minimum of 3–4 weeks is required for visible effects.[3] Topical retinoids usually demonstrate maximal benefit after three to four months, while oral isotretinoin, a highly efficacious drug for severe acne, is typically prescribed in 16-24 week courses.[1] All in all, there is no overnight cure for acne vulgaris.

Misconception 6: Sunlight is useful in treating acne vulgaris

Sunlight is often perceived as a natural cure for acne vulgaris, and Rasmussen et al. reported that over 60% of patients may deliberately increase their outdoor activities or go tanning when having acne.[5] A study in eight hospitals in Australia revealed that 12.3% of nurses and 20.3% of doctors recommend sunlight as an acne treatment.[23]

In reality, there is insufficient evidence to support sunlight as a cure for acne. Tanning of skin may make acne look less visible, but it has no effect on acne lesions. Higher acne referral rates in winter months with less sunlight have been reported.[24],[25] However, confounders such as doctor referral patterns and ecological fallacy were not adequately controlled for in these studies.

Ultraviolet light exposure is also associated with aging of the skin and cutaneous malignancies.[6] Hence, it is not justifiable to use sunlight as an acne cure. Oral isotretinoin and tetracyclines, commonly used acne drugs, are also well known for causing photosensitivity,[22] and sunlight exposure should be reduced when taking these drugs.


  Source of Misinformation Top


Several studies assessed where patients acquired their knowledge on acne and found that the most common sources were fashion magazines and television commercials.[10],[14] While patients turn to the media for medical knowledge, it is worrying that medical students do the same too. A study in Karachi showed that the mass media, rather than academic journals or textbooks, was the most common source of acne knowledge in medical students.[8] Aside from the mass media, patients may also seek information about acne from family physicians.[14] However, is the information from family physicians reliable? By administering a knowledge-based test to family physicians and their patients, Brajac et al. concluded that the doctors and patients had similar misconceptions and had comparable performance on the test.[10] Rather than serving as a source of reliable advice, family physicians with a poor understanding of acne may contribute to the continued spread of misinformation.


  Future Directions Top


Misconceptions about the natural history, etiology, and treatment of acne vulgaris are widespread and have vast consequences. Underestimating the severity and progression of acne may delay treatment, while misinterpreting the etiology of acne could lead to unnecessary and disruptive lifestyle changes. Unrealistic expectations about therapy will lead to dissatisfaction, which may decrease treatment compliance and lead to subsequent treatment failure.[26] Interventions to correct such misconceptions are called for.

A major area requiring improvement would be the knowledge level of medical professionals. From the studies reviewed, medical students,[8],[9] nurses,[23] and doctors [23] all had suboptimal performance when tested on their knowledge of acne vulgaris. Family physicians were even shown to perform as poorly as their patients in knowledge-based tests.[10] The inadequacy of knowledge in doctors is undesirable, particularly since patients will seek advice about acne from their doctors. Improvement in medical education is warranted to ensure better management of acne patients and to avoid the dissemination of wrong information. Family physicians who commonly encounter acne patients should also receive additional training in dermatology to provide a better standard of care.

Enhanced health education to the general public is another key intervention. The literature demonstrates that knowledge of acne is not associated with the patient's demographics and background.[5] A paucity of knowledge is present in all demographic subgroups, and better health education to promote awareness is necessary. Intensive health education should also be implemented in the pubertal age group as they are at the highest risk of developing acne. When consulted by patients for acne, doctors should also spend more time for counseling and clear patients' misconceptions.

Regulatory policies on the media should be enforced as well. The public frequently receives health-related information from the mass media, and misinformation from such sources could lead to long-lasting consequences.[10],[14] Hence, regulations should be set to prevent the spread of unvalidated information through the mass media. The promotion of untested over-the-counter acne products should be banned as well.

The current evidence has described the prevalence and areas of misunderstanding about acne vulgaris. The associations between misconceptions and surrogate outcomes such as delayed treatment and poor compliance have also been reported.[26] Yet, the effect of misconceptions on patient-oriented clinical outcomes remains undetermined. Outcomes such as scarring and psychological sequel are of particular clinical significance and should be investigated by future large-scale studies.


  Conclusion Top


Six misconceptions about acne vulgaris, spanning from the disease nature, etiology, and treatment, were reviewed in this article, and they are all highly prevalent among the general public and in medical professionals. The paucity of knowledge about acne vulgaris has potentially severe consequences and should not be overlooked. Interventions in health advocacy, medical education, and research are warranted to dispel the misconceptions about acne vulgaris.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dawson AL, Dellavalle RP. Acne vulgaris. BMJ 2013;346:f2634.  Back to cited text no. 1
    
2.
Mallon E, Newton JN, Klassen A, Stewart-Brown SL, Ryan TJ, Finlay AY. The quality of life in acne: A comparison with general medical conditions using generic questionnaires. Br J Dermatol 1999;140:672-6.  Back to cited text no. 2
    
3.
Williams HC, Dellavalle RP, Garner S. Acne vulgaris. Lancet 2012;379:361-72.  Back to cited text no. 3
    
4.
Davidovici BB, Wolf R. The role of diet in acne: Facts and controversies. Clin Dermatol 2010;28:12-6.  Back to cited text no. 4
    
5.
Rasmussen JE, Smith SB. Patient concepts and misconceptions about acne. Arch Dermatol 1983;119:570-2.  Back to cited text no. 5
    
6.
Zaidi Z. Dispelling the myths and misconceptions of acne. J Pak Med Assoc 2009;59:264-5.  Back to cited text no. 6
    
7.
Suthipinittharm P, Noppakun N, Kulthanan K, Jiamton S, Rajatanavin N, Aunhachoke K, et al. Opinions and perceptions on acne: A community-based questionnaire study in Thai students. J Med Assoc Thai 2013;96:952-9.  Back to cited text no. 7
    
8.
Ali G, Mehtab K, Sheikh ZA, Ali HG, Abdel Kader S, Mansoor H, et al. Beliefs and perceptions of acne among a sample of students from Sindh Medical College, Karachi. J Pak Med Assoc 2010;60:51-4.  Back to cited text no. 8
    
9.
Green J, Sinclair RD. Perceptions of acne vulgaris in final year medical student written examination answers. Australas J Dermatol 2001;42:98-101.  Back to cited text no. 9
    
10.
Brajac I, Bilic-Zulle L, Tkalcic M, Loncarek K, Gruber F. Acne vulgaris: Myths and misconceptions among patients and family physicians. Patient Educ Couns 2004;54:21-5.  Back to cited text no. 10
    
11.
Al-Hoqail IA. Knowledge, beliefs and perception of youth toward acne vulgaris. Saudi Med J 2003;24:765-8.  Back to cited text no. 11
    
12.
Pearl A, Arroll B, Lello J, Birchall NM. The impact of acne: A study of adolescents' attitudes, perception and knowledge. N Z Med J 1998;111:269-71.  Back to cited text no. 12
    
13.
Law MP, Chuh AA, Lee A, Molinari N. Acne prevalence and beyond: Acne disability and its predictive factors among Chinese late adolescents in Hong Kong. Clin Exp Dermatol 2010;35:16-21.  Back to cited text no. 13
    
14.
Tan JK, Vasey K, Fung KY. Beliefs and perceptions of patients with acne. J Am Acad Dermatol 2001;44:439-45.  Back to cited text no. 14
    
15.
Yeung CK, Teo LH, Xiang LH, Chan HH. A community-based epidemiological study of acne vulgaris in Hong Kong adolescents. Acta Derm Venereol 2002;82:104-7.  Back to cited text no. 15
    
16.
Schäfer T, Nienhaus A, Vieluf D, Berger J, Ring J. Epidemiology of acne in the general population: The risk of smoking. Br J Dermatol 2001;145:100-4.  Back to cited text no. 16
    
17.
Fulton JE Jr., Plewig G, Kligman AM. Effect of chocolate on acne vulgaris. JAMA 1969;210:2071-4.  Back to cited text no. 17
    
18.
Grant JD, Anderson PC. Chocolate as a cause of acne: A dissenting view. Mo Med 1965;62:459-60.  Back to cited text no. 18
    
19.
Anderson PC. Foods as the cause of acne. Am Fam Physician 1971;3:102-3.  Back to cited text no. 19
    
20.
Cordain L, Lindeberg S, Hurtado M, Hill K, Eaton SB, Brand-Miller J. Acne vulgaris: A disease of Western civilization. Arch Dermatol 2002;138:1584-90.  Back to cited text no. 20
    
21.
Adebamowo CA, Spiegelman D, Danby FW, Frazier AL, Willett WC, Holmes MD. High school dietary dairy intake and teenage acne. J Am Acad Dermatol 2005;52:207-14.  Back to cited text no. 21
    
22.
Magin P, Pond D, Smith W, Watson A. A systematic review of the evidence for 'myths and misconceptions' in acne management: Diet, face-washing and sunlight. Fam Pract 2005;22:62-70.  Back to cited text no. 22
    
23.
Harrison S, Hutton L, Nowak M. An investigation of professional advice advocating therapeutic sun exposure. Aust N Z J Public Health 2002;26:108-15.  Back to cited text no. 23
    
24.
Al-Ameer AM, Al-Akloby OM. Demographic features and seasonal variations in patients with acne vulgaris in Saudi Arabia: A hospital-based study. Int J Dermatol 2002;41:870-1.  Back to cited text no. 24
    
25.
Gfesser M, Worret WI. Seasonal variations in the severity of acne vulgaris. Int J Dermatol 1996;35:116-7.  Back to cited text no. 25
    
26.
Thiboutot D, Dréno B, Layton A. Acne counseling to improve adherence. Cutis 2008;81:81-6.  Back to cited text no. 26
    




 

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Abstract
Introduction
Common Misconcep...
Common Misconcep...
Common Misconcep...
Source of Misinf...
Future Directions
Conclusion
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