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Knowledge, Attitude and Practice of physicians working in Primary Health Care centers towards Acne vulgaris

Acne vulgaris is an extremely common inflammatory skin disorder. This study was carried out to assess the knowledge, attitude, and practices of Primary Health Care Physicians (PHCPs) towards acne vulgaris and its management in Riyadh city.
A cross-sectional study was conducted, where 30 out of 68 Primary Health Care Centers (PHCCs) were randomly selected, representing about 44% of all PHCCs in Riyadh. All 144 physicians (76 males, 68 females) in the selected PHCCs were approached. During the months of June, July and August 2000, a self-administered anonymous confidential questionnaire was distributed, composed of 34 items including demographic data, questions related to knowledge, attitude and practice regarding acne vulgaris, measures that improve PHCPs ability in managing patients with acne vulgaris, and suggested measures to improve the PHCC to become more suitable for management of acne vulgaris. Grading of PHCPs knowledge was by using a scoring scale where each item was given a score of one for each correct answer and zero for each incorrect answer. Knowledge on acne vulgaris was categorized into poor or good based on the distribution of the scores. Those whose scores fell below one standard deviation of the mean were categorized as having poor knowledge (score of 32).
Between June and august 2000, a total of 144 (PHCPs) from 30 PHCC had responded, with a response rate of 92.4%. There were 76 males (52.8% ) and 68 females (47.2%) , with a ratio of 1.1:1. The mean age (±SD) was (42.7 years ±8.5). Only 17 were Saudis (11.8%); 2 males and 15 females. Most had no postgraduate qualifications (92.2%). The mean duration of experience in PHC was (9.7 years ± 7.34).
Acne vulgaris was regarded, correctly, as a common skin condition in Saudi Arabia by the majority of PHCPs (71.8%). Hormonal factors were considered to be the cause of acne vulgaris by 117 (81.3%) and bacterial causes (Propionibacterium acnes) by 82 (57%), 55 (38%) considered that the exact cause of acne vulgaris is still unknown, and 11 (7.6 %) were not sure.
According to the PHCPsE¼ opinion, 128 (89%) and 107 (74.3 %) believed that the common presentation of acne vulgaris are comedones (white or black heads) and pustules respectively.
Stress, cosmetics, sweating and foods were considered as factors that made acne worse by 122 (84.7%), 100 (69.4%), 76 (52.8%) respectively.
Regarding knowledge of drug groups that made acne worse, the question was open ended, and was answered by 105 (72.9%). The commonest drugs implicated were antidepressants, anti-tuberculous drugs, oral contraceptive pills, iodine, halogens, nicotine and alcohol.
Acne vulgaris was considered a curable disease in the opinion of 76.1%, and only 55 (38.2%) believed it to be a preventable disease. The majority (96.3%) thought that they could diagnose it by physical examination and (12.5%) recommended laboratory investigations.
Regarding treatment, the most common drugs mentioned were oral antibiotics (93.7%) and topical tretinoin (retin-A) (90.9%). The suggested duration of pharmacological treatment was three months (40%), six months (23.2%), three weeks (22.5%) and (7.6%) were not sure.
Regarding non-pharmacological (non-drug) therapy, the vast majority (95.8%) suggested that cleaning of the skin gently but thoroughly with soap and water, and removing all dirt or makeup are the best modalities.
The most common complication of acne vulgaris mentioned was scarring (61.1%). Psychological complications such as anxiety, depression, social isolation, and embarrassment were suggested by only a few (14.6%).
The attitudes of PHCPs when a patient with acne vulgaris presented to PHCC were variable. The majority (67.8%) would start him on drug therapy, 23.8% would refer the patient to the dermatologist, and the rest suggested counseling and using non-drug therapy modalities.
Regarding reasons that made the PHCC a suitable place for management of acne vulgaris were that the condition was easy to diagnose (71.8%), experience of PHCPs in managing such patients (60.8%), and availability of medications (53.9%). Regarding enough consultation time only 38.6% agreed. 15 (10.4%) stated other reasons such as counseling, health education and non-drug therapy modalities.
Reasons stated that PHCC was not a suitable place for management of acne vulgaris were lack of knowledge of PHCPs (6.5%), lack of medications (29.7%), problems with patient files (13.8%), lack of appointment system (15.2%), and unwillingness of patients to be treated by PHCP (23.9%). Other reasons such as lack of laboratory investigations and patients need for a dermatologist were suggested by only 8 (5.6%).
Regarding education of patients with acne vulgaris, 41.4% claimed that they educated the patients always, 26.7% often, 28.0% sometimes, 2% rarely, and only 1.4% never educated their patients.
To improve their ability in management of acne vulgaris in the PHC-setting, the majority of physicians agreed on: provision of drugs (76.8%), improving their knowledge (76.8%), improvement of the referral system (52.5%), and improvement of a communication system between the hospital and the PHCC (9.2%).
The main sources of knowledge about acne vulgaris reported were Textbooks (90.8%), medical journals (59.2%), and colleagues (36.9%).
There were differences in the score of knowledge according to the PHCPs years of experience. Those with over 15 years of experience had a significantly better knowledge than the rest.
An attempt was made to categorize knowledge into poor and good based on the distribution of the scores. Results of scoring yielded 84% with good knowledge. Apart from the years of experience (p-value=0.03), none of the other variables such as age, sex, nationality, and qualifications, had any statistically significant association with knowledge.

Editorial note:

Acne vulgaris is a very common inflammatory skin disorder, which importance stems from its negative psychological consequences, including diminished self-esteem, social withdrawal due to embarrassment, depression and unemployment.
It is encouraging that the majority of physicians in this survey were aware of the presentation of acne, however, only 14.8% were aware of its psychological and emotional impact on patients.
The exact cause of acne vulgaris is still unknown. [1,2] In this study, about 80% of PHCPs correctly related the cause of acne to hormonal changes. Androgens, poor hygiene, exposure to oils or grease and heredity are the main factors that may help in the development of acne vulgaris in the opinion of most of the physicians in this study, which is consistent with the literature.
Acne vulgaris is not a preventable or curable skin disorder, and the recurrence rate is high in young age, along with short duration of treatment. [3] In this study over 75% of PHCPs believed that acne is curable, and around 40% regarded it as preventable. This inaccurate knowledge should be addressed and modified
Fortunately, the majority of PHCPs (86%) could diagnose acne vulgaris by physical examination only, while only a small number suggested laboratory investigations, which are well known not to be required.[4]
Most patients with acne present to primary care physicians for treatment and only a small proportion are referred to a dermatologist.[3] The opinions of PHCPs regarding whether the PHCC was a suitable place for management of acne vulgaris varied.
When PHCPs were asked about measures that can improve management of acne vulgaris in the PHC-centre, over half of them suggested improving knowledge of the PHCPs by providing training courses, improving the referral system at the PHCC, maintaining the availability of drugs at the PHCC, and improving accessibility between the hospital and PHCCs.
Textbooks were reported to be the main source of knowledge for the majority of PHCPs about acne vulgaris, followed by medical journals. Only 5 physicians had received special training in dermatology.
The management of acne vulgaris should be the responsibility of the PHCC, referral being only indicated in severe or refractory cases. However, this survey showed inappropriate practice, and lack of knowledge among PHCPs towards this disease. The study should raise awareness of policy makers of the importance of continuing medical education for PHCPs in order to upgrade their knowledge and skills.
  1. Brown SK, Shalita AR. Acne vulgaris. Lancet 1998; 351: 1871-6.
  2. Preston D. The misery of acne: A look at the treatment options. Community nurse 1999; 5:13-14.
  3. Lucky AW, Biro FM, Simbartl LA, Morrison JA, Sorg NW. Predictors of severity of acne vulgaris in young adolescent girls: Results of a five-year longitudinal study. J Pediatr 1997; 13: 30-39
  4. Norman L, Sykes JR, Webrter GF. Acne: A review of optimum treatment. Drugs; 1994;48:59-69