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

Objective: To determine the frequency of acne and other relevant side effects as well as the 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. Methods: A cross-sectional survey was conducted from April, 2020 to December, 2020 in a private tertiary care hospital in Karachi. In total, 226 patients with a positive history of topical steroids and/or fairness creams use in the past six months were included in the study. Information was collected about sociodemographic characteristics; topical corticosteroid uses while clinical examination of facial skin was performed by a dermatologist. Data were analyzed using SPSS version-19. Results: The median age of study participants was 26 years with an interquartile range of 10 years. This frequency of corticosteroid induced acne was highest i.e., 83.6% (n=189) followed facial erythema and telangiectasia i.e., 50.9% (n=115) 47.8% (n=108) respectively. The estimated median duration of using topical steroids or fairness creams or both was six months with an IQR of four months. The study found statistically significant differences in the reasons of using topical corticosteroids or fairness creams on the face on the basis of differences in the level of education and marital status. Conclusion: In Karachi, both, men and women are equally obsessed with fair skin tone and use topical steroids and fairness cream. The use of corticosteroid or fairness cream-induced facial acne is alarmingly high among patients presenting in a dermatology clinic in Karachi.

Hence, the adverse effects of topical corticosteroids and fairness creams make their wide use a huge public health threat for the exposed populations.][12] Hence, this study aimed to determine the frequency of acne and other relevant side effects as well as the 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 exposed to topical corticosteroid use and fairness creams on the face will help generate relevant evidence for implementing appropriate control and prevention measures.

METHODS
A cross-sectional survey was conducted from April, 2020 to December, 2020 in a private tertiary care hospital in Karachi.Patients of age between 10 years to 40 years, visiting Dermatology Out-Patient Department (OPD) with history of topical corticosteroids and/or fairness creams on the face in past six months, continuously for one month and/or intermittently for more than three months.Exclusion Criteria: However, any patient using systematic corticosteroids for any skin disease or any other medical problem was excluded from the study.
Similarly patients with preexisting acne vulgaris or acne due to other causes or using systematic corticosteroids for any skin disease or other medical problem were excluded from the study.Moreover, 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 and obtained a sample size of 226 with an anticipated population proportion of 15% for topical steroid use. 13,14he Data was collected using a structured questionnaire which was translated into the local language i.e., "Urdu".Information was collected regarding, basic socio-demographic characteristics, presence of acne on the face and conditions related to abuse of topical corticosteroids was collected by detailed clinical examination and the use of topical corticosteroids or fairness creams.Ethical Approval: The ethical approval for this study was conducted by the Ethics Review Committee of Patel Hospital Karachi with registration: No.: 79 on February 28 th 2020.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 corticosteroid or fairness cream.P-value of 0.05 or less was considered statistically significant.

RESULTS
A sample of 226 study participants was collected.The median age of study participants was 26 years Afza Naureen Ghouse et al.Papules were the most frequent inflammatory lesion with a proportion of 82.4% followed by pustules, nodules, and cysts.Open comedones were the most common non-inflammatory lesions with followed by closed comedones and black and white heads with the proportion of 55.9 % (n=33), 37.2% (n=22) and 6.7% (n=7) respectively.Among all the study participants 30.1% (n = 68) of the participants reported use of topical corticosteroids only, 57.1% (n=129) reported using fairness cream while 12.8% of the study participants were using both i.e., topical corticosteroids as well as fairness cream on their face (Table-I).
This study observed a higher frequency of acne among patients of age 18 years or less as compared to other age groups and among patients who were single as compared to married and divorced.Both these findings were statistically significant (p-value ≤0.05) (Table-II).This study found statistically significant differences in the reasons for using topical corticosteroids and fairness creams on the face on the basis of different socio-demographic characteristics such as level of education and marital status (Table-III).

DISCUSSION
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 steroids 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 much needed evidence about the irrational use of topical corticosteroids and fairness creams in a megacity with relatively better literacy rates.
This study found a very high burden of inflammatory and non-inflammatory acne lesions among the study participants i.e. 83.6%6][17] However, the burden of acne in our study population is slightly higher than the frequency reported by previous studies which can be explained by the differences in research methodology.In this study, the burden of acne was significantly higher among study participants of the age group 18 years or less.
The relatively higher burden of acne among the youngest age group in this study can be explained by the increased tendency and sensitivity of teens towards Table-III: Frequency distribution of steroid or fairness cream use purpose in context of basic socio-demographic characteristics of the study participants (n=226).their outlooks leading to excessive use of topical agents as well as puberty-related bodily changes.Literature from previous studies conducted in Pakistan also support the increased obsession for fairness among Pakistani youth and the role of local media in boosting this obsession for fairer skin. 18,19Among other cutaneous side-effects identified in this study telangiectasia, hypertrichosis and facial erythema were the most frequent observations. This study found a relatively higher frequency of fairness cream use followed by the use of topical corticosteroids alone.This finding is in contrast to previous studies conducted in similar populations that can be explained by the cultural obsession for fair skin as well as the strong role of media in promoting fairness products in Pakistan. 11,18,20Furthermore, this study couldn`t find any statistically significant differences in the use of topical corticosteroids and fairness cream use among men and women.Similarly, the desire for fairness was the main reason for using corticosteroids across three household income categories.The increased desire for fair skin among men is supported by previous studies and can be explained by the strong marketing tactics of fairness product manufacturers. 21,22owever, this study found statistically significant differences in the frequency of using topical corticosteroid products for fairness based on age, education, and marital status.The study found that people of age between 20-25 years, people with higher education levels, and those who were single mostly reported a desire for fair skin as the prime reason for using topical corticosteroids 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 prospects, particularly for women. 1,2,11he demand for fair skin has turned into an obsession because of social influence of media and endorsement of such advertisements by celebrities. 23,24his study identified that family, friends, or neighbors as the most common source for recommendation or advice regarding the use of topical corticosteroids or fairness cream.[25][26][27] Limitations: First, this study included participants from one particular private tertiary care hospital in Karachi and lacks the capacity to measure 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.Moreover, the patients presenting in public sector hospitals and those going to aesthetic treatment centers (usually managed by non-medics) might be different which further limits the generalizability of study findings.

Age (in completed years
Moreover, this study did not collect objective information regarding the exact composition or ingredients, amount or dose, and frequency of topical corticosteroids or fairness creams use for the total reported duration.The subjective recall for a 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 a few limitations this study provides valuable insights to develop and implement targeted control and prevention strategies for this particular population group.

CONCLUSION
The young population in Karachi is obsessed with fair skin tone resulting in irrational use of topical corticosteroids and fairness cream without any expert advice.This irrational use of topical corticosteroids is equally prevalent in men and women irrespective of average household income however, it is more common among single or unmarried or individuals with education level of intermediate or above.Developing population-level key interventions is crucial while taking into account the socio-cultural and behavioral aspects of this problem.

Table - I
: Socio-demographic characteristics, pattern of topical costicosteroids or fairness cream use on face and related health characteristics of skin patients with history of topical corticosteroids.

Table -
II: 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).range of 10 years (Table-I).83.6% (n=189) of the study participants were found to have acne while 16.4% (n =37) were found to have no acne on physical examination by the dermatologist.