Obsession to fairness and Topical Steroid induced acne: A situation analysis of patients presenting in dermatology clinic at a private hospital in Karachi

doi:10.21203/rs.3.rs-1343640/v1

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Research Article

Obsession to fairness and Topical Steroid induced acne: A situation analysis of patients presenting in dermatology clinic at a private hospital in Karachi

https://doi.org/10.21203/rs.3.rs-1343640/v1

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Introduction: Pakistan is a country where social and cultural factors play a crucial role in preference of fair skin complexion lead to excessive and unjustified used of topical steroids. This study aimed to determine the frequency of steroid or fairness cream induced acne and pattern of using topical steroids and fairness creams.

Methods: A cross-sectional survey was conducted from July, 2020 to Jan, 2021 in a private tertiary care hospital of Karachi. A sample of 226 patients with a positive history of topical steroids and/or fairness creams use in past 6 months, using convenient sampling technique. Information was collected about socio-demographic characteristics and use of topical steroids using a structured questionnaire. Clinical examination of facial skin was performed by a qualified dermatologist to assess presence of steroid induced acne and other cutaneous side effects related to topical steroid use. Data was analyzed using SPSS version 19.

Results: The median age of study participants was 26 years with an interquartile range of 10 years. This study found a very high frequency of acne i.e. 83.6% (n=189) followed by other side effects including hypertrichosis, facial erythema and telangiectasia The estimated median duration of using topical steroids or fairness creams or both was 6 months (IQR=4 months).The study found statistically significant differences in the reasons of using topical steroids or fairness creams on face on the basis of differences in the level of education and marital status.

Conclusion: The burden of steroid or fairness cream induced facial acne is alarmingly high among patients presenting in dermatology clinic in Karachi. Men and women in Karachi are equally obsessed with fair skin tone and use topical steroids and fairness cream without any expert advice.

acne

topical steroids

fairness cream use

Globally, fair skin color is considered as a prime beauty standard including East Asia, South Asia, Middle East and African regions.(1) Literature reports that obsession for a lighter skin tone or fair skin complexion is wide spread across the world regions and expanding more with time.(1,2) The major reason behind this obsession is increasing social and psychological pressures to meet beauty standard i.e. fair skin tone as defined under the influence of culture and media.(2,3) This worldwide obsession for fair skin has caused alarming increase the irrational use of topical steroids and fairness creams on face. (1-3) Studies conducted in India, Nepal, Saudi Arabia, and Ethiopia have reported considerable burden of irrational use of topical steroids and fairness creams to lighten the skin tone.(4-6)

The irrational use of topical corticosteroids and fairness creams may lead to many serious adverse effects on skin including acne, skin atrophy, striae, rosacea, perioral dermatitis, acne, and purpura. (7,8) While other relatively less common conditions associated with use of topical steroids on face include hypertrichosis, pigmentation alterations, delayed wound healing, and exacerbation of skin infections.(8,9) Hence, the adverse effects of topical steroids and fairness creams make their wide use a huge public health threat for the exposed populations.

Pakistan is a country where social and cultural factors play a crucial role in preference of fair skin complexion. (10) Pakistani media also plays an important role in increasing the obsession of fair skin by promoting negative self-image for dark skin as well as over rating the benefits of using fairness products. Few small scale studies conducted in hospital settings of Lahore and Lodhra and have identified considerable burden of irrational use of topical steroids and fairness creams among patients visiting dermatology clinics or OPDs and its associated adverse cutaneous effects. (11, 12) Another study conducted in 2017, among youth studying in health science in Karachi has reported lack of awareness about steroid abuse and its possible consequences. (13) Hence, this study aimed to determine the frequency of acne and other relevant side effects as well as pattern of topical steroid and fairness cream use among patients presenting with steroid and fairness cream use at dermatology OPD in a tertiary care private hospital in Karachi.

Understanding the current situation of acne and other cutaneous manifestations among patients with exposure to topical steroid use and fairness creams on face will help in generating relevant evidence for identifying the burden of this problem and implementing appropriate control and prevention measures for this important public health issue.

A cross-sectional survey was conducted from July, 2020 to Jan, 2021 in a private tertiary care hospital of Karachi. Patients of age between 10 years to 40 years, visiting Dermatology Out-Patient Department (OPD) with steroid acne or history of topical steroids and/or fairness creams on face in past 6 months, either continuously for 1 month and/or intermittently for more than 3 months were included. However, any patient with preexisting acne vulgaris or acne due to other causes or patients using systematic steroids for any skin disease or any other medical problem were excluded from the study. Moreover patients having endocrine disorders or females with polycystic ovary syndrome were also excluded from the study.

Non-probability convenient sampling was applied to select the study participants from dermatology OPD. The sample size for this study was calculated using Open Epi sample size calculator. At 5% level of significance and anticipated population proportion of 15% for topical steroid use we obtained a minimum sample size of 196. (15, 16) After adjusting for 15% non-response rate we obtained a final sample size of 226.

Data was collected using a structured questionnaire which was translated into local language i.e. “Urdu.”. Information was collected regarding, basic socio-demographic characteristics such as age, sex, marital status and education. Information regarding presence of acne on face and conditions related to abuse of topical steroids was collected by detailed clinical examination. The clinical examination was conducted by a qualified dermatologist at the time of data collection. Lesions of face were classified as inflammatory or non-inflammatory acne, erythema, telangiectasia, atrophy, hypopigmentation and hypertrichiosis, etc. Information was collected regarded use of topical steroids or fairness creams on face, duration of therapy, purpose of using topical steroids or fairness cream and source recommending use of steroids or fairness cream. Data was collected with the help of trained data collectors who were medical doctors. All the data collection and data management activities were directly supervised by the Principal Investigator (PI) herself.

Ethical considerations:

The ethical approval for this study was conducted from Ethics Review Committee of Patel Hospital Karachi. Approval was obtained from administrative authorities to collect data from patients visiting Dermatology OPD before the conduct of this study. All methods were performed according to the relevant guidelines and regulations. Written informed consent was obtained from each study participant at the time of data collection.

Data Analysis:

Data was analyzed using SPSS version 19. Descriptive statistics were calculated for socio-demographic characteristics. Chi-square test was used to assess any statistically significant differences in the frequency of acne, cutaneous side effects and use of topical steroid or fairness cream use on the basis of differences in age group, sex, marital status, and other characteristics. P-value of 0.05 or less was considered statistically significant.

A sample of 226 study participants was collected. The median age of study participants was 26 years with an interquartile range of 10 years. 19.5% (n=43) of all study participants were up to 18 years of age or younger, 30.0% (n=69) of the study participants belong to age group 19 years to 25 years and 50.5% of the participants belong to age group 26 years and above.

79.6% (n=180) of all study participants were female while 20.4% (n=46) were males. Majority of the study participants i.e. 61.1% (n=138) were single, 36.3% (n=82) were married and 2.7% (n=6) were divorced. Most of the study participants were literate with education level of more than primary education. 27.9% (n=63) of the study participants had middle to secondary level education while 61.1% (n =138) of the participants had an education level of intermediate or above. However, 11.1% (n=25) of the study participants had education level up to primary or less. More than 70% of the study participants had average monthly income of 50, 000 or less (Table: 1).

83.6% (n=189) of the study participants found to have acne while 16.4% (n =37) found to have no acne on physical examination by the dermatologist. Among all the patients with acne 23.0% (n=52) had both inflammatory as well as non-inflammatory lesions, 57.5% (n=130) had inflammatory lesions while 3.1 % (n =7) had non-inflammatory lesions (Figure:1).

Moreover, this study found that among all the patients who had inflammatory lesions papules were the most frequent lesion with a proportion of 82.4% followed by pustules, nodules and cyst. . Furthermore, among all the non-inflammatory lesions open comedones were the most common non-inflammatory lesions with followed by closed comedomes and black and white heads with proportion of 55.9%(n=33),37.2%(n=22)and 6.7%(n=7)respectively (Not shown in table).

The most common side effect of using steroids or fairness cream other than acne as identified on physical examination was telengiectasia, followed by hypertrichosis with frequency of 50.9% (n=115) and 47.8% (n=108) respectively (Figure: 2).

When enquired about facial use of topical steroids and fairness creams the study found that among all the study participants 30.1% (n = 68) of the participants reported use of topical steroids only, 57.1% (n=129) reported using fairness cream while 12.8% of the study participants were using both i.e. topical steroids as well as fairness cream on their face (Table: 2).

The estimated median duration of using topical steroids or fairness creams or both was 6 months (IQR=4 months). Among all the study participants 73.0% (n=165) were using topical steroids or fairness cream or both only for the purpose to attain a lighter skin tone or fair skin complexion. 27.0% (n=61) of the study participants reported to use topical steroids or fairness cream or both for any reason other than to attain a lighter skin tone (Table: 2).

This study observed higher frequency of acne among patients of age 18 years or less as compared to other age groups. Similarly, this study found that acne was more common among patients who were single as compared to married and divorced. Both these findings were statistically significant (p value < 0.05). However, this study no statistically significant differences in the distribution of acne on the basis of sex, education, monthly income and pattern of steroid or fairness cream use (Table:3).

This study found statistically significant differences in the reasons of using topical steroids and fairness creams on face on the basis of different socio-demographic characteristics such as level of education and marital status. However, this study didn’t find any statistically significant difference in the reason for using topical steroids and fairness creams among male and female patients or study participants. Similarly, no statistical difference was observed among the study participants on the basis of differences in average household monthly income (Table: 4).

This study is among the few studies conducted in Pakistan estimating the burden of an important and emerging health issue i.e. acne and other cutaneous side effects of using topical steroid and fairness creams. Moreover, this study also assessed the pattern of topical steroid and fairness creams use among patients presenting in a well-known private tertiary care hospital in Karachi. Hence this study provides a much needed evidence about irrational use of topical steroids and fairness creams in a megacity city with relatively better literacy rates.

This study found very high burden of inflammatory and non-inflammatory acne lesions among the study participants i.e. 83.6% Moreover, in this study acne was identified as the most common side-effect of using topical steroid or fairness cream as reported by previous studies. (15,17-19) However, the burden of acne in our study population is slightly higher than the frequency reported by previous studies conducted in similar settings. This high frequency of acne and all kind of side effects can be explained by the differences in research methodology particularly sample size and sample selection criteria.

This can be explained by biological and environmental differences in the population. In this study the burden of acne was significantly higher among study participants of age group 18 years or less. The relatively higher burden of acne among youngest age group in this study can be explained by the increased tendency and sensitivity of teens towards their outlooks leading excessive use of topical agents as well as puberty related bodily changes. Among other cutaneous side-effects identified in this study telangiectasia, hypertrichiosis and facial erythema were the most frequent observations. This finding also in line with previous evidence from the studies conducted in Pakistan and other populations with similar socio-cultural context. (11, 15-17)

This study found relatively higher frequency of fairness cream use followed by use of topical steroids alone. This finding is in contrast to previous studies conducted in similar populations and study settings. (11, 20). The higher frequency of fairness cream use in this study use can be explained by the cultural obsession for fair skin as well as strong role of media in promoting fairness products in Pakistan. (11,13) This finding is also supported by the fact that this study could not find any statistically significant difference in the frequency of men and women who were using steroids and fairness creams for the purpose to attain fairness. Similarly, this study could not find any statistically significant differences in the proportion of study participants reporting fairness as the reason for using steroids across three household income categories. Such findings indicate that in Karachi not only women but men are also equally obsessed with the desire to attain a fair skin tone. The increased desire of fair skin among men is supported with previous studies and can be explained by the strong marketing tactics of fairness product manufacturers and availability of a wide variety of male skin whitening products. (21,22)

Moreover, irrespective of the average household monthly income, the use of topical steroids and fairness products is equally prevalent and popular among people with different financial capacity. However, this study found statistically significant differences in the frequency of using topical steroids products for fairness on the basis of age, education and marital status. The study found that people of age between 20-25 years, people with higher education level and those who were single mostly reported desire for fair skin as the prime reason for using topical steroids and fairness products. These findings are well supported by the socio-cultural environment of Pakistan and other South Asian countries where skin color plays a crucial role in social acceptance and future prospects particularly for women. (1, 2, 11)

This study identified that family, friends or neighbours as the most common source for recommendation or advice regarding use of topical steroids or fairness cream. This finding is in line with previous studies conducted in Pakistan as well as Indian population due to similar socio-cultural background. (12, 20, 23, 24)

This study has few inherent limitations. First, as this study recruited study participants from one particular private tertiary care hospital in Karachi hence lacks capacity to measure the actual prevalence of topical steroid and fairness cream use in Karachi. Secondly, this study ascertained the burden of topical steroid and fairness cream induced acne and other cutaneous side effects, however, due to lack of temporality in this study we cannot rule out the other associated factors such as stress and life style factors. Moreover, the patients presenting in public sector hospitals and those going to aesthetic treatment centers (usually managed by non-medics) might be different in severity of exposure to topical agents and burden of acne as well as other related cutaneous complications. This also limits the generalizability of study findings.

Moreover, this study did not collect objective information regarding the exact amount or dose and frequency of dose for steroids or fairness creams for the total reported duration for use. While the subjective recall for total duration of topical steroid or fairness cream use might be affected by the severity of related medical complications or related health outcomes. However, despite few limitations this study provides valuable insights to develop and implement targeted control and prevention strategies or interventions for this particular population group.

The burden of acne is alarmingly high among patients presenting in dermatology out-patient department with history of topical steroid or fairness cream use. Similarly these patients are suffering from other cutaneous side-effects as a consequence of topical steroid or fairness cream use. The study conclude that young population in Karachi is obsessed with fair skin tone resulting in irrational use of topical steroids and fairness cream without any expert advice. This irrational use of topical steroids is equally prevalent in men and women irrespective of average household income. However, the irrational use of topical steroids and fairness creams is much higher among those who are single or unmarried and having education level of intermediate or above. Nevertheless, this study highlights the severe need for large scale community based research studies to estimate the actual magnitude of these issues at population level. Developing population level key interventions is crucial for a long term solution to this important public health issue while also taking in account socio-cultural and behavioral aspects of this problem.

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Table 1

Socio-demographic characteristics of skin patients with history of topical steroids or fairness cream or both presenting at dermatology clinic in a private tertiary care hospital, Karachi, Pakistan (n =226)

Variable

Frequency (n)

Percentage (%)

Median Age 26 years (IQR =10 years)

Age (in completed years)

18 years or younger

19-25 years

26 years and above

114

19.5

30.0

50.5

Sex

Male

Female

180

20.4

79.6

Marital status

Single

Married

Divorced

138

61.1

36.3

2.7

Education

Primary or less

Middle- Secondary

Intermediate and above

138

11.1

27.9

61.1

Monthly household income

20,000 PKR or less

210000-50,000

More than 50,000

129

14.2

57.1

28.8

Table 2

Pattern of topical steroids or fairness cream use on face and related characteristics of patients presenting at dermatology OPD in a private tertiary care hospital, Karachi, Pakistan (n =226)

Variable

Frequency (n)

Percentage (%)

Median duration of using topical steroid or fairness creams

6 months (IQR= 4 months)

Pattern of using fairness cream or steroid

Use fairness cream

Use Steroid

Use both (fairness cream and steroid)

129

57.1

30.1

12.8

Reason for using topical steroids

For Fairness

For any reason other than fairness

165

73.0

27.0

Use of topical steroids or fairness cream advised by

Doctor

Pharmacist

Family member/ Friends/Neighbours

Beautician

Other

103

10.3

13.7

45.6

4.4

26.1

Reason for current visit to dermatologist

Acne

Melasma

Acne with Eczema or Melasma

For fairness treatment

Fungal infection

Others *

116

51.3

14.2

11.5

2.7

6.6

13.7

Side-effects other than acne as identified on clinical examination**

Skin Atrophy

Facial Erythema

Telangiectasia

Hypertrichosis

Rosacea

Hypopigmentation

Aggravation of existing dermatosis

107

115

108

22.1

47.3

50.9

47.8

4.0

4.4

5.8

*include photosensitivity, alopecia, sunburn, Herpes stomatitis and Lichen planus

** Multiple responses possible

Table 3
Frequency distribution of acne among patients with history of steroids and fairness cream use on the basis of basic socio-demographic characteristics and pattern of use (n=226)

Variable

Acne

No acne

p-value

Age (in completed years)

18 years or younger

19-25 years

26 years and above

40(93.0)

60(87.0)

89(78.1)

3(7.0)

9(13.0)

25(21.9)

0.05

Sex

Male

Female

36(78.3)

153(85.0)

10(21.7)

27(15.0)

0.27

Marital status*

Single

Married

Divorced

125(90.6)

58(70.7)

13(9.4)

24(29.3)

6(100.0)

0.001*

Education

Primary or less

Middle-Secondary

Intermediate and above

23(92.0)

51(81.0)

115(83.3)

2(80.0)

12(19.0)

23(16.7)

0.46*

Monthly household income

20,000 PKR or less

210000-50,000

More than 50,000

24(75.0)

111)86.0)

54(83.1)

8(25.0)

18(14.0)

11(16.9)

0.36

Pattern of using fairness cream or steroid

Use fairness cream

Use Steroid

Use both (fairness cream and steroid)

109(84.5)

24(82.8)

56(82.4)

20(15.5)

5(17.2)

12(17.6)

0.87*

Purpose of use

For fairness

For any other reason

139(84.2)

50(82.0)

26(15.8)

11(18.0)

0.68

*Fisher exact test.

Table 4

Frequency distribution of steroid or fairness cream use purpose in context of basic socio-demographic characteristics of the study participants (n=226)

Variable

For Fairness

For Other Reasons

p-value

Age (in completed years)

18 years or younger

19-25 years

26 years and above

31(72.1)

59(85.5)

75(65.8)

12(27.9)

10(14.5)

39(34.2)

0.014

Sex

Male

Female

35(76.1)

130(72.2)

11(23.9)

50(27.8)

0.71

Marital status*

Single

Married

Divorced

109(79.0)

53(64.6)

03(50.0)

29(21.0)

29(35.4)

3(50.0)

0.024

Education

Primary or less

Middle-Secondary

Intermediate and above

11(44.0)

47(74.6)

107(77.5)

14(56.0)

16 (25.0)

31(22.5)

0.002

Monthly household income

20,000 PKR or less

210000-50,000

More than 50,000

24(75.0)

94(72.9)

47(72.3)

08(25.0)

35(27.1)

18(27.7)

0.95

*Fisher exact test.

No competing interests reported.

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Obsession to fairness and Topical Steroid induced acne: A situation analysis of patients presenting in dermatology clinic at a private hospital in Karachi

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