Assessment of skin care behavior and cognition of patients with acne vulgaris in China

To the Editor: Acne vulgaris (AV) is a common skin disease mainly among adolescents with varying incidences around the world, significantly affecting patients’ facial appearance, psychology, social activity, and quality of life.[1] Many factors including genetic components, environmental elements, hormone levels, treatments, diets, and skin care behavior are associated with an increased risk of AV.[2] Herein, we investigated AV patients’ skin care behavior and cognition to predisposing factors with a designed electronic questionnaire. During the period from June 1 to June 30, 2020, we collected 654 AV patients from outpatient departments from four hospitals: Shanghai Renji Hospital, Shanghai Ninth People's Hospital, Shanghai Skin Disease Hospital, and China-Japan Friendship Hospital. In addition, 465 students with AV were enrolled from four universities: Chongqing Medical University, Xi’an Jiaotong University, East China University of Science and Technology, and China-Japan Friendship School of Clinical Medicine. All participants provided written informed consent and filled in the questionnaire anonymously, 1119 validated questionnaires received for further analysis. The prevalence of AV among adolescents ranges from approximately 40% to 90%, increasingly affecting adults as well, whereas women are more frequently affected than men.[3] Of the 1119 participants, there were 798 females (71.31%) and 321 (28.69%) males. The participant age range was 11 to 69 years; the age was 28.32 ± 7.96 years, and the characteristics of AV patients in different age groups are shown in Supplementary Table 1, https://links.lww.com/CM9/A471. AV lesions typically appear on the face, which then have a negative impact on patients’ self-esteem, mood, and quality of life.[4] In this study, we observed that AV exhibited negative effects on patients’ appearance (874, 78.11%), emotion (785, 70.15%), social contact (446; 39.86%), job/study (352, 31.46%), love (301, 26.9%), and impregnability (49, 4.38%). The enrolled participants showed mild (365, 32.62%), moderate (587; 52.46%), and severe (167; 14.92%) lesions. The durations of AV were: ≤ 6 months (319, 28.51%), 6–12 months (154, 13.76%), 1–3 years (196, 17.52%), and ≥ 3 years (450, 40.21%). Though participants have a high prevalence and severity of AV, only 719 (64.25%) patients received treatment from professional dermatologists/doctors, among which 658 (58.80%) and 417 (37.27%) used topical and oral medications, respectively. Surprisingly, 783 (69.97%) patients squeezed the pimples using their hands. We categorized skin types of AV patients into five groups including oily (417, 37.27%), combination (497, 44.41%), neutral (115, 10.28%), dry (45, 4.02%), and sensitive (42, 4.02%). Previous studies have shown a highly significant association between skin types and AV;[3] we also found that there was a significant association between skin type and grade of severity in AV patients (P = 0.04; Supplementary Table 2, https://links.lww.com/CM9/A471). There were 59.16% (662) patients who thought skin care products could improve AV, and 71.85% (804) patients who thought dermocosmetics could improve the clinical manifestation of AV. During the course of AV, patients used cleansers (849, 75.87%) and moisturizers (598, 53.44%) to improve AV, but only 286 (25.56%) participants used sunscreen products, and 104 (9.29%) participants did not use any products. In addition, there was no significant association between the grade of severity in AV patients and cosmetics application (P > 0.05; Supplementary Table 3, https://links.lww.com/CM9/A471). AV patients acquired the recommendation of dermocosmetics from various resources including friends (424, 37.89%), doctors (356, 31.81%), and internet (339, 30.29%). AV patients gained care knowledge about AV mainly through doctors (774, 69.17%), followed by brand officials (505, 45.13%), Sina Weibo or Little Red Book (301, 26.90%), Zhihu (272, 24.31%), and TikTok/Kuaishou (197, 17.61%). These findings suggest that new social media would be an option for healthcare providers to distribute AV-related knowledge and care skills. In this study, we investigated the patients’ cognition to AV and found 39.50% (442) patients thought that AV would disappear naturally after adolescence. AV patients cared about disease recurrence (747, 66.76%), large pores (679, 60.68%), red spots/pigmentation/atrophic scars (621, 55.50%), and oily skin (452, 40.39%). Participants acknowledged predisposition factors to AV including familial inheritance (108, 9.65%) and environmental factors: staying up late/sleeplessness (895, 79.98%), incorrect skin care methods (602, 53.80%), mood (542, 48.44%), diet (371, 33.15%), ultraviolet light (112, 10.01%), and air quality (82, 7.33%). Notably, lowest rate of participants thought that air quality predisposes to AV, which suggests the association between AV and air pollution would be needed. In the year 2020, extended periods of mask-wearing has been necessary in regards to the COVID-19 pandemic, which has increases the flare of AV due to higher temperatures and humidity on the surface of facial skin.[5] According to our study, 73.28% (820) patients believed that long-time wearing masks would aggravate the severity of AV. The following suggestions are for AV patients: (1) wipe face with a wet towel containing moisturizing ingredients; (2) apply cleansing products and emollients containing oil control ingredients; (3) consult dermatologists for topical or oral medications if the AV lesions sustain or aggravate. Acknowledgement The authors thank all participants in this study. Additionally, the authors thank Randy Ko at the University of New Mexico School of Medicine in assisting to revise this manuscript. Funding This work was supported by a grant from the Open Research Funding of Chinese Skin Image Database (No. CSID-ORF-201922). Conflicts of interest None.