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Journal of Pakistan Association of Dermatologists 2009; 19: 73-80.
Original Article
Pattern of skin disorders among adolescent
female students at Hyderabad

Doulat Rai Bajaj*, Bikha Ram Devrajani**, Rafi Ahmed Ghouri**, Bhajan Lal
Matlani*

*Department of Dermatology, Liaquat University of Medical & Health Sciences Jamshoro
**Medical unit-II, Liaquat University of Medical & Health Sciences Jamshoro
Abstract Objective To determine the pattern and severity of skin disorders among female adolescent
students at Hyderabad Sindh Pakistan.

Patients and methods This observational study was conducted at Hyderabd, Sindh,
Pakistan from August, 2007 to October, 2007. Four intermediate and degree colleges of the
Hyderabad city were randomly selected and visited. The students there were examined with
regard to the type and severity of skin disorders. The findings were recorded on a pre-
structured proforma.

Results A total of 1350 students were examined. Their ages ranged from 16-24 years. Acne
was the most common disorder seen in 59.5% of subjects followed by hair loss (59%),
pigmentary disorders (36.3%), dandruff (26.1), hirsutism (20.9%), ephelides (6.4%),
xerosis (2.9%), pruritus (2.3%), eczema (2.1%) and pityrisis versicolor (2.9%). There were
very few cases of pyoderma, tinea corporis and scabies.

Conclusion Skin disorders are common among adolescent college girls. The most
prevalent group of skin disorders at this age is cosmetic one. Their proper management at
earlier stages with education of patients is important to prevent late disfiguring
complications and psychological upset.
Key words
Skin disorders, adolescence, acne, pigmentary disorders, melasma, folliculitis, eczema.

Introduction
androgens.1,2 The androgens with growth
The female students at intermediate, degree and hormone induce rapid growth spurt, while it masters level are in their teens. This period of alone promotes growth of pubic and axillary hair, sebaceous glands and sebum production. gonadotrophic releasing hormone (GRH) from sebhorrhoea and thinning of scalp hair.3 hypothalamus stimulates pituitary gland to secrete follicle-stimulating hormone (FSH) and The ovarian development in females occurs under the action of FSH and LH. The ovary in adrenocorticotrophic hormone (ACTH) from turn secretes estrogens that results into increased pituitary stimulates adrenal cortex to secrete Address for correspondence
Dr. Doulat Rai Bajaj,
The net sum of these hormonal changes around the time of puberty is growth and development Hyderabad, Sind, Pakistan Phone: +92 300 3076504 Journal of Pakistan Association of Dermatologists 2009; 19: 73-80.
production, development of apocrine glands, duration, onset, evolution and treatment they growth of pubic and axillary hair, appearance of received for their problem. This was followed by hair in male pattern, sebhorroea, dandruff and thinning of scalp hair.4
Assessment: The examination and assessment Therefore disorders pertaining to these glandular was conducted by qualified dermatologists in a structures occur with increased frequency and separate room in the presence of chaperone. The severity at this age of life. These combined with lesions were examined meticulously for details other dermatosis resulting from constitutional and findings recorded on pre-designed proforma. The examination was confined to only those folliculitis, bacterial and parasitic infections parts allowed by subjects. The groins, chest and genital areas were not examined due to privacy concerns. No laboratory investigation was used consciousness of youths for their body and as the diagnosis was straight forward on clinical beauty is also a factor aggravating their anxiety Acne was classified on the basis of report of a The aim of present study was to investigate the consensus conference on acne classification in pattern and severity of dermatoses in adolescent Washington.5 The presence of at least four to females by dermatologist’s direct inspection in five comedones was required for the diagnosis order to understand the effect and impact of skin of acne. Those having comedones the only lesions were graded as patients with non- inflammatory acne. Adolescents with less than Patients and methods
four lesions were evaluated as participants having no acne. Inflammatory acne was ‘mild’ if This was an observational study conducted at there were few to several papules/pustules but Hyderabad city during August 2007 to October no nodules, ‘moderate’ for several to many 2007. The non-probability purposive sampling papules/ pustules and few to several nodules, method was used to carry this study. The target and ‘severe’ for numerous and/or extensive population was adolescent girls at their papules/pustules and many nodules. For the acne secondary and higher secondary education level. The reason for selection of students was easy inflammatory acne and mild inflammatory acne access and convenience. The four intermediate and degree colleges of city were selected randomly on convenient bases. These colleges Ephelides were identified by their characteristic were visited and students there were asked to appearance on sun-exposed areas as groups of consult if they have any of the skin problems. discrete, brown to yellowish, round or speckled An informed consent was obtained from all students after full explanation of the goals and Hair loss was measured by Ludwig scale.6 considerations. Students of all ages were included in study. A simple history was sought Increased pigmentation of skin over face was from them about their skin disorder regarding taken significant only when there was marked Journal of Pakistan Association of Dermatologists 2009; 19: 73-80.
difference of colour between inner aspect of arm specific age we divided patients into two groups: and the affected areas. For grading of melasma group 1 constituted subjects from 16-20 years, ‘Melasma Area and Severity Index (MASI)’ developed by Kimbrough-Green et al was Table 1 Skin Disorders in adolescent females with
number of subjects affected (n=1350).
simplified.7 It was graded as mild if less than 30% of only one area of face was slightly darker than surrounding area, moderate if 30-60% of 2- 3 areas were more darker than surrounding normal skin and severe if more than 60% of 3 or more areas were considerably darker than Scabies was recognized by the history and finding of characteristic pruritic lesions and burrows over wrists, interdigital areas, abdomen and groins. Family history of similar lesions was taken as supportive feature. Extraction of mite was not attempted because it is labour-intensive All the subjects were advised treatment for their Results:
group two from 21-24 years. It was found that grade II acne (comedones with few papules) was A total of 1350 patients were examined for any the most common type overall. Age group two of the skin disorders. Their ages ranged from 16- had more severe acne with papulo-pustular and 24 years. The majority of subjects 890 (65.9%) nodular lesions. Scars were also seen in age had one disorder only; the remainder had two or group II. Lesions of trunk were monomorphic more disorders at the same time. The most generalized hair loss reported by 796 (59%) Acne was the most common problem reported in student. On examination mild sparseness of our study (804, 59.5%) patients. Face was the scalp hair (Ludwig grade I) was noted in most of most frequent site affected (781, 97.1%) the students. The hairs were fine and came out followed by trunk (23, 2.9%). Very severe acne of scalp without pain. Only 20 (2.51%) subjects (nodulo-cystic variety) was noted in 3 patients only. To assess the type and severity of acne at frontoparietal region confirming to androgenetic Journal of Pakistan Association of Dermatologists 2009; 19: 73-80.
alopecia. Four (18%) of these had mild to Ephelides were seen chiefly on face and neck, less commonly on arms, abdomen, back and (confirmed at later visit). Associated dandruff lower limbs. They were dark brown in colour, 1- was found in 1/3rd of patients with hair loss. 3 mm in size and ranged from 5 to 15 in number. Among the 490 (36.29%) subjects complaining Dryness of skin was associated with other of increased pigmentation of facial skin 413/490 manifestations of atopy (itching, recurrent (84%) had diffuse darkening of face, neck, arms and feet. According to them pigmentation of The students presenting with generalized itching (32, 2.3%) had no cutaneous lesions or other Melasma patches (77/490, 15.7%) were found evidence of dermatoses. History and the general chiefly on malar areas of face and nose and less condition of these patients didn’t suggest any frequently over forehead, neck and chest. These were light brown in colour measuring 34cms to 45 cms indemensions. Their average duration was 2 years. Melasma was mild in 26 (33%), patients. The sites involved were face, neck and moderate in 44 (57%) and severe in 7 (10%) hands in decreasing frequency. There was history of allergy to artificial jewelry and house hold items in these patients consistent with The dandruff (352, 26.1%) was graded as severe if patients had to shampoo their scalp daily to remove the scales, moderate if at an interval of 2-3 days and mild if they did so once a week. hypopigmented type in 32 patients and slightly The majority 165 (46.9%) had moderate degree erythematous or grey coloured macules in 8 of dandruff. 133 (37.8%) participants had mild patients. The most common location was upper while 54 (16.1%) severe dandruff. It was sole back, neck, upper chest and shoulders. Pruritus complaint in 229/352 patients while it was or slight burning was present in only 10 patients. associated with hair fall (in 67), frank KOH (Potassium hydroxide) preparation could sebhorrhoic dermatitis (in 30), acne (39) and not be attempted because of non-feasibility. Folliculitis was noted over arms, legs, back and Excess growth of hair in male pattern (hirsutism) scalp. There were inflammatory erythematous complained by 282 (20.9%) patients mostly papules with or without suppuration. The lesions affected upper lips and chin (159/282), followed by mandibles, upper chest and back. Hirsutism over trunk and groins could not be confirmed by Lesions of tinea corporis were seen in 26 (1.9%) examination due to obvious reasons. Five patients. The size of lesions ranged from as patients also demonstrated other features of small as 33 cms to larger one of 710 cms. The hyperandrogenism like menstrual abnormalities sites involved were back (in 10 patients), and deepening of voice. Laboratory examination abdomen (6 patients), arms (5 patients), neck (3 revealed raised serum testosterone levels in patients) and face (2). The lesions were mildly Journal of Pakistan Association of Dermatologists 2009; 19: 73-80.
Scabies was present in 9 (6.7%) of patients. to worse the lesions by half of subjects as also Infected lesions were seen in only one patient. shown by others.12 The acne caused considerable
Vitiligo patches (8, 5.92%) were deeply white in anxiety and abstinence from studies in 10% of 2 patients. Face, lips and hands were the most the subjects. These students had severe acne. common location for these lesions. Lesions of alopecia areata (7, 5.18%) were small (2  3 Hair loss was the next common complaint. Hair cms) to medium (5  7 cms) in dimension noted loss was global in nature. The true magnitude of problem is difficult to derive from this study as the data on the hair density and thickness in our found. One patient had no hair on trunk, arms population is lacking. We understand this and legs in addition to two small patches on complaint was exaggerated by this highly conscious proportion of population. There was no apparent cause for generalized hair loss as the Discussion
significant scalp dermatosis. We consider it prevalence of cutaneous diseases in a given constitutional; or micro-deficiency of iron, population such as age, gender, race, occupation, vitamins and proteins may be the cause hair loss environmental milieu, diet etc. We sought to in these subjects.13,14 Additional cause may be
dandruff as demonstrated byet al.15
adolescent females. These individuals are prone to develop certain dermatoses with increasing Increased pigmentation was reported by 1/3rd of frequency than others because of changes in subjects in our study. This affected face, neck hormonal milieu. Among them acne, seborrhea, dandruff, increased pigmentation are well understandable. The skin type in our population known. More over these individuals are more ranges from Fitzpatrick type 3 to 5. This skin type is prone to tan on sun exposure. Being less physical well being and look. Therefore even aware of tanning effect of sun light; they indulge otherwise minor cosmetic problems compel in outdoor games and frequently resort to sun exposure during cold weather or unintentionally Acne was the dominant cutaneous disorder seen in more than half (about 60%) of total patients in subjects.16 There was no obvious evidence
our studywhich is comparable to other studies.8
suggesting some sinister cause for pigmentation Others report its prevalence from 29% to 41%.9,10 Face was the most common site
hyperthyroidism etc. The history also did not involved followed by trunk as shown in other studies.11 Mild to moderately severe acne with a
syndrome of autosomal dominant type.17
combination of comedones and inflammatory papules was the most common type of acne. However patches of pigmentation confirming to Dietary intake of eggs, milk and dairy products melasma were seen in 99 subjects. These were and sweating and hot weather was incriminated light brown in colour. The less darkening of melasma patches at this age compared to older Journal of Pakistan Association of Dermatologists 2009; 19: 73-80.
females may be because the former are still not significant systemic complaint or obvious evidence for systemic disorder. However more pregnancy.18
elaborate investigation of these subjects was not feasible in the setting therefore it was labeled as Dandruff was complained by about 1/4th of idiopathic. It was noted in 2.3% of subjects and subjects. Its prevalence is high in general is comparable to one of 2.2% in other studies.28
population.19 This was moderate in severity.
Seasonal variation with increased severity in The prevalence of vitiligo has been shown autumn and winter was reported by the subjects. 0.19% in a Chinese study.29 Vitiligo patches
The association of dandruff with hair fall, acne, were seen in 8 subjects affecting mostly face. sebhorroic dermatitis and pityriasis versicolor is understandable as propionibacterium acnes plays Hyperhidrosis causes embarrassment and is etiological roll in all these disorders. 20-23
often precipitated by anxiety and mental stress. Our subjects manifested these features. Its Growth of hair in male pattern was also the complications include pompholyx and contact bothering problem in substantial number of dermatitis.30
patients (282/1350). Its reported prevalence in complications though it was embarrassing and different studies varies from 5% to 40%.24,25
Involvement of mandibles, chest, and limbs was seen with lesser frequency. Most of the patients Other cutaneous disorders like pyoderma, had growth of fine, less pigmented hair. Only 5 folliculitis, scabies, pediculosis etc were seen patients had other features of androgenism in with less frequency in our study. The reason for form of menstrual irregularities and deepening less frequency of bacterial and parasitic of voice. Hirsutism in these patients was infection may be meticulous attention to body moderately severe.26
hygiene. Similarly eczema was less frequent because these patients are less exposed to The prevalence of atopic dermatitis varies in household allergens as their older counter parts different races and regions and ranges from less than 1% to more than 20%.27 In our study about
40 (3%) subjects complained of dryness of skin. It was evident from our study that cosmetic Among these only 12 had other features of atopy problems form the bulk of cutaneous disorders like pruritus, dust allergy, positive family history in adolescents. Females in our society are more and frequent bouts of sneezing and rhinorrhoea conscious of their cosmetic problems because of consistent with atopic dermatitis. The remainder cultural and social customs. If these are left had none of these features apart from xerosis. untreated or treated improperly, may result into The prevalence of xerosis is estimated to be grave cosmetic and psychological consequences 2.2%. 28 Use of hard soaps coupled with lesser
at later life. Therefore it is prudent to recognize tendency to moisturize their body after bath or and treat these within time. We recommend the underlying atopy may be the alternate cause of introduction of a preventive health education programs on skin diseases for adolescent population at different levels and their families In students complaining of pruritus, neither there and teachers. A periodic visit of dermatologist to was any evidence of pruritic dermatoses nor any Journal of Pakistan Association of Dermatologists 2009; 19: 73-80.
institutions would help to boost awareness 13. Rushton DH, Norris MJ, Dover R, Busuttil N. Causes of hair loss and the developments in hair
rejuvenation. Int J Cosmet Sci 2002; 24: 17–23
14. Kantor J, Jay K, Brooks D, Cotsarelis G. Acknowledgement
Decreased serum ferritin is associated with
alopecia in women: a case controlled study. J
Invest Dermatol 2001; 117 (2):435
The authors are grateful to all the students participated and cooperated in the study. Increased hair shedding may be associated with the presence of Pityrosporum References
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