Journal of Cosmetics, Dermatological Sciences and Applications, 2013, 3, 26-29
Published Online November 2013 (http://www.scirp.org/journal/jcdsa)
http://dx.doi.org/10.4236/jcdsa.2013.33A2006
Open Access JCDSA
Acne Flares among University Female Students: The Role
of Perceived Factors
Amal A. Kokandi
Rabegh College of Medicine, King Abdulaziz University, Jeddah, KSA.
Received September 18th, 2013; revised October 15th, 2013; accepted October 23rd, 2013
Copyright © 2013 Amal A. Kokandi. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Objectives: Acne is a common skin disease especially in adolescents and young adults. Several pathogenetic factors are
implicated in causing the disease. Typically acne flares and remits in its course. Several factors can cause flares. The
aim of this study was to assess the perceived factors of acne flares and the idea of sun creams causing skin darkening.
Methods: A questionnaire study of the perceived factors in causing acne flares was studied in university female stu-
dents. These included food, stress, hygiene and menstrual periods. In addition, the effect of sun creams on causing skin
darkening was asked. Results: Food was implicated by 43.2% of patients. Stress and menstrual periods were thought to
exacerbate acne by more than 70% of patients while 80% of patients did not think bad hygiene worsened acne. 40% of
patients thought the use of sun creams cause skin darkening. Conclusion: More controlled studies are needed to explore
the effect of food on acne. Dermatologists need to explain the benefit of using sun creams especially to acne patients
while using standard treatments.
Keywords: Acne; Precipitating Factors; Food; Sun Creams
1. Introduction
Acne is a common skin disease especially in adolescents
and young adults [1]. Several pathogenetic factors are
implicated in causing the disease. Typically acne flares
and remits in its course. Many factors were previously
implicated in causing acne and acne flares. These factors
include food as precipitating agent, stress, menstrual pe-
riods, facial hygiene and marital status [2-4]. Data from
our region are scarce.
Most of the patients will be prescribed one of the reti-
noid creams. These creams are known to make the user
photosensitive [5] necessitating the avoidance of sun and
the use of sun protecting creams. Some adults are reluc-
tant to use sun creams because of the belief that sun
creams cause skin darkening.
In this study perceived factors in causing acne flares
were studied. These included food, stress, hygiene and
menstrual periods. In addition, to the question about sun
creams if they cause skin darkening or not was asked.
2. Methods
Subjects: Female students attending King Abdulaziz uni-
versity medical administration dermatology clinic (fe-
male section) with acne complaints.
Procedure: Verbal informed consent was obtained
from all patients and they were assured that their partici-
pations were voluntary and their responses were anony-
mous and confidential.
A medical history was taken in addition to the acne-
related complaint. An assessment of acne was made us-
ing the global acne grading system or GAGS [6]. GAGS
considers six locations on the face and chest/upper back,
with a factor for each location based roughly on surface
area, distribution, and density of pilosebaceous units. The
severity was graded as mild if the score was 1 - 18, mod-
erate with scores from 19 to 30, severe with scores from
31 to 38, and as very severe if the score is more than 38.
A questionnaire was filled by the investigator by ask-
ing the patients about their opinion and to reply by yes or
no or do not know. They were asked if they think that
food worsens their acne, and if yes which food they think
most does, if acne is worsened by bad hygiene, if acne
worsened by stress, if acne is affected by the menstrual
period, if acne is affected (worsened or improved by
marriage) and if using sun protecting creams cause skin

Acne Flares among University Female Students: The Role of Perceived Factors 27
darkening. This questioned was added because most of
acne treatment modalities necessitate the use of sun pro-
tection cream and some patients were reluctant to use
them. The study protocol was approved by local research
ethics committee.
Analysis: The statistical analysis was performed using
the SPSS software version 16.0.
3. Results
A total of 125 responses were collected. Age of patients
ranged from 16 - 39 years (mean 22.2, SD 3.96). Severity
ranged from 5 - 37 (mean ± SD, 15.54 ± 5.21). Disease
duration ranged from 0.3 - 20 years (mean ± SD, 5.7 ±
3.18 years). The responses to the questions are summa-
rized in Table 1 and Figure 1.
Acne was implicated to be worsened by certain food
by 43.2% of patients. While 49.6% of patients did not
think food was worsening their acne. The main food im-
plicated in worsening acne was chocolate (66.7% of pa-
tients agreeing food is causing acne), followed by fatty
food and chili (31.5% and 20.4% respectively). Less
commonly nuts, fizzy drinks and other food items were
implicated. A list of food items implicated in worsening
acne is presented in Table 2 and Figure 2. Eighty per-
cent of acne patients thought that bad hygiene does not
affect or worsen acne. Stress and menstrual period were
thought be affecting acne flares by 72.8% and 78.4% of
patients respectively. Marriage was thought to be affect-
ing acne by 34.4% of patients, while 28.8% thought that
it does not have a role. Regarding the sunscreen use, 40%
of patients thought that it causes skin darkening and only
27.2% of patients did not think it causes skin darkening.
4. Discussion
Acne is one of the most common complaints in adoles-
cents and early adulthood. Several beliefs still exist re-
garding the cause and the precipitating factors of acne. In
this study some of the factors thought to be related to
acne flares were studied in university female students. In
addition to the question about the concept of sun creams
causing skin darkening was asked.
Food is still debatable issue especially in relation to
acne. The earliest studies performed to declare the effect
of food, namely, chocolates, milk and roasted nuts were
small, uncontrolled and for short periods only [7,8].
Food with high glycemic load are implicated in wors-
ening acne in addition to milk and dairy products [9,10].
Soft drinks were considered the most aggravating food
item by Pakistani students [11]. On the other hand some
food is thought to improve or protect against acne like
fish oil [12] and Mediterranean food [13,14]. In this
study more than 40% accused food of worsening acne.
Interestingly, chocolate followed by fatty food were the
Table 1. Summary of responses of acne patients to the ques-
tions.
Yes (%) No (%) Do not
know (%)
Is acne worsened by food? 54 (43.2) 62 (49.6)9 (7.2)
Is acne precipitated by
bad hygiene? 22 (17.6) 100 (80)3 (2.4)
Is acne worsened by stress? 91 (72.8) 30 (24) 4 (3.2)
Is acne affected by the period?98 (78.4) 24 (19.2)3 (2.4)
Does marriage affect acne
in anyway? 43 (34.4) 36 (28.8)46 (36.8)
Does sunscreen use cause
skin tanning? 50 (40) 34 (27.2)41 (32.8)
% the percentage of responses out of total responses (125).
% the percentage of responses out of total responses (125).
Figure 1. Summary of responses of acne patients to the
questions.
Table 2. Types of food implicated in worsening acne.
Food Number of cases Percentage
chocolate 36 66.7
fatty food 17 31.5
chili 11 20.4
nuts 8 14.8
fizzy drinks 5 9.3
chips 3 5.6
sweets 2 3.7
dairy products 1 1.9
aubergiene 1 1.9
eggs 1 1.9
bananas 1 1.9
fish 1 1.9
caffiene 1 1.9
pastries 1 1.9
iron deficiency 1 1.9
The percentage is the percentage implicating the food out of total cases
implicating food as a causative agent for acne flare (54).
Open Access JCDSA

Acne Flares among University Female Students: The Role of Perceived Factors
28
The percentage is the percentage implicating the food out of total cases
implicating food as a causative agent for acne flare (54).
Figure 2. Food items implicated in worsening acne.
most culprits. There is still a need for more controlled
studies regarding the effect of food on acne.
Sometimes the stigma of cleanlessness is feared by
some acne patients [2,4]. In some societies still poor hy-
giene is thought to be a cause of acne [15], or acne to be
relieved by frequent face washing [11]. In this study 80%
of patients thought that bad hygiene does not worsen
acne but still 17.6% of patients thought bad hygiene is a
factor. Acne is known to cause a significant psychologi-
cal burden on patients. The effect of feeling guilty about
worsening it by bad hygiene may cause an added nega-
tive effect on patients.
Stress was reported to be aggravating factor of acne
[15,16]. In this study more than 70% of patients thought
acne was worsened by stress. Similar results were re-
ported by previous studies in different societies [17,18].
Stress seems to be a factor in our society too.
Acne is known to be associated with the polycystic
ovarian syndrome and affecting their quality of life [18].
Period irregularity is one of PCO manifestations and
higher testosterone level than normal subjects are mani-
festations too. More than 78% of patients in this study
claimed that acne flared in relation to the menstrual pe-
riod. This might be explained by hormonal variation
throughout the menstrual cycle. Only 34.4% of patients
thought that acne is related to the marital state. Appar-
ently there is not a link between marital state or sexual
activity, and acne flares.
Most acne patients will be prescribed topical or sys-
temic treatment that will cause them photosensitive. This
necessitates the use of sun protecting creams. There is a
misconception of sun creams causing darkening of skin.
This concept might came from the fact that some sun
cream users are feeling sun safe and exposing themselves
to the sun for longer times. The other explanation might
be that some sun cream users are not applying the creams
in enough amounts or not renewing the application as
needed. In this study 40% of patients thought that sun
protecting creams cause skin darkening and only 27.2%
think that it does not. This might warrant dermatologist
to explain the benefit of using sun protecting creams to
avoid sun burning or unwanted facial tanning especially
for patients on treatments with photosensitizing agents.
The counseling should be individualized [19].
5. Conclusion
More than 40% of acne patients think that food is a
causative factor and more than 70% of patients think that
stress and menstrual period is an exacerbating factor.
More research is needed in regard to food as causative or
precipitating acne lesions. Counseling regarding the use
of sun protecting creams should be part of the clinical
management of acne patients especially if they will be on
treatments specially retinoids.
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