Common dermatologic diseases among students at a tertiary

ARTICLE ORIGINAL/ ORIGINAL ARTICLE
COMMON DERMATOLOGIC DISEASES AMONG STUDENTS
AT A TERTIARY CARE CENTER IN LEBANON
http://www.lebanesemedicaljournal.org/articles/58-4/original3.pdf
Joe A. KHATTAR 1 , Ghassan N. HAMADEH 1 , Amal C. RAHI 2 , Umayya M. MUSHARRAFIEH 1
Khattar JA, Hamadeh GN, Rahi AC, Musharrafieh UM.
Common dermatologic diseases among students at a tertiary
care center in Lebanon. J Med Liban 2010 ; 58 (4) : 195-198.
ABSTRACT : There are few publications on prevalence
of skin diseases in Lebanon.
OBJECTIVES : To find the prevalence of dermatologic
diseases among students seen at the university health
services of the American University of Beirut.
PATIENTS & METHODS : Medical charts were retrospectively
reviewed. Chi-square tests were used to
assess any significant difference between male and
female prevalence amongst all types of skin diseases
met; p-value < 0.05 was considered significant.
RESULTS : 2903 visits were reviewed, ages ranged
from 16 to 33 years old, of whom 1688 were females
(58.15%) and 1215 were males (41.85%). Acne vulgaris
was the most prevalent, followed by hair problems and
contact dermatitis. Acne vulgaris and hair problems
were significantly higher among females, and verruca
among males (p < 0.001 in all).
CONCLUSIONS : Dermatologists must be aware of
the psychological effects of skin diseases on their patients.
Acne, hair problems, and contact dermatitis are
the most common diseases seen. Patients seem to be
more concerned about diseases that affect their image
in society.
INTRODUCTION
Skin diseases account for 6-7% of all patient visits to
primary care clinics [1-2]. The incidence of skin disease is
affected by geographic, socioeconomic, genetic, ethnic
and environmental factors [3]. Skin diseases can place a
heavy emotional and psychological burden on patients
that may be far worse than the physical impact [4].
Most available statistics on skin diseases in developing
countries based on hospital studies do not necessarily
reflect the true spectrum in the community.
The purpose of this study was to perform a chart
review at the American University of Beirut (AUB) health
From the 1 University Health Services, Department of Family
Medicine, 2 Department of Pediatrics, Faculty of Medicine,
American University of Beirut Medical Center, Beirut, Lebanon.
Correspondence: Joe A. Khattar, MD. American University
of Beirut Medical Center. Bliss Street. P.O.Box: 11-0236.
Beirut. Lebanon.
Tel.: +961 3 300 121 Fax: +961 1 370 802
e-mail: jk00@aub.edu.lb
Khattar JA, Hamadeh GN, Rahi AC, Musharrafieh UM. Maladies
dermatologiques observées chez les étudiants dans un centre
de soins universitaire au Liban. J Med Liban 2010 ; 58 (4) : 195-198.
RÉSUMÉ : Il existe peu de publications sur la prévalence
des maladies de peau au Liban.
OBJECTIFS : Étudier la prévalence des maladies
cutanées chez les étudiants examinés au service de la
santé universitaire de l’Université américaine de Beyrouth
(AUB).
PATIENTS & MÉTHODES : Les dossiers médicaux ont
été étudiés rétrospectivement. Le test Chi-square a été
utilisé pour évaluer l’existence d’une différence significative
dans la prévalence masculine et féminine parmi
les maladies rencontrées. La valeur p < 0,05 a été
considérée comme significative.
RÉSULTATS : Un total de 2903 consultations a été
étudié. Elles concernaient 1688 femmes (58,15%) et
1215 hommes (41,85%), l’âge des patients variant
entre 16 et 33 ans. L’acné était la pathologie la plus
prévalente, suivie par les problèmes capillaires et les
eczémas de contact. L’acné et les problèmes capillaires
chez les femmes et les verrues chez les hommes étaient
significativement plus élevés (p < 0,001).
CONCLUSIONS : Les dermatologues doivent être conscients
de tous les effets psychologiques des affections
cutanées les plus souvent observées chez les étudiants :
acné, problèmes capillaires et eczémas de contact. Les
patients semblent être plus concernés par les maladies
qui affectent leur image dans la société.
services, in order to determine the rate of dermatologic
visits accounted from all visits among university students
and to assess the prevalence of dermatologic diseases.
MATERIALS AND METHODS
Following the approval of the Institutional Review Board,
medical records of students presenting for dermatologic
complaints to the University Health Service (UHS) at the
American University of Beirut were reviewed and analyzed
over a one-year period (July 2005 to June 2006).
The UHS is an ambulatory clinic and offers services to all
students who are enrolled in the hospital insurance plan of
the AUB and these constitute 71% of all students, and to
personnel with a total of 16,000 people. Patients attending
the UHS clinic come from both rural and urban areas
of Lebanon. The diseases were coded according to the
9 th version of the international classification of diseases
(ICD-9) published by the World Health Organization
Lebanese Medical Journal 2010 • Volume 58 (4) 195

in 1977 [5]. In this classification health conditions are
assigned to categories and given codes that are up to
six characters long. Data on participant demographics
including gender and age, in addition to clinical diagnosis
incorporating the type of skin disease encountered were
collected. Data were reported as number (percentages).
Chi-square test [6] was used to assess any significant difference
between male and female prevalence amongst all
types of skin diseases met. P-value < 0.05 was considered
significant.
RESULTS
A total of 10,786 student visits were recorded at the UHS
during the study period, of which 2903 were related to dermatologic
consults accounting for 27.36%, of whom 1688
were females (58.15%) and 1215 were males (41.85%).
The most commonly encountered dermatologic diseases
are shown in table I.
Acne vulgaris and hair problems were significantly
more in females than males (p < 0.0001). However, no significant
differences were encountered in contact dermatitis
(p = 0.5) and bacterial infections (p = 0.05) respectively.
Verruca vulgaris was significantly more prevalent in males
(p < 0.0001).
Other dermatoses accounting for less than one percent
each, included diseases like: aphthosis (0.41%), angioma
(0.17%), dermatofibroma (0.17%), erythema multiforme
(0.07%), freckles (0.024%), ganglion (0.34%), geographic
tongue (0.14%), intertrigo (0.48%), keloid (0.14%), keratois
pilaris (1%), knukle pads (0.03%), lichen planus
(0.03%), melasma (0.1%), milia (0.65%), miliaria (0.2%),
molluscum contagiosum (0.79%), pilomatricoma (0.03%),
petechiae (0.07%), pitted keratolysis (0.07%), pityriasis
alba (1%), sychosis barbae (0.48%), scars (0.55%), Schamberg’s
(0.01%), seborrheic keratosis (0.03%), striae (0.2%),
and vitiligo (0.07%).
Ages ranged from 16 to 33 years, as seen in table II
there was no significant difference among females and
males as to the age of presentation in all diseases seen.
TABLE I
THE MOST COMMON SKIN DISEASES ENCOUNTERED ACCORDING TO GENDER
DIAGNOSIS Females Males F:M Total number (%) p-value
N =1688 N =1215 N = 2903
Acne vulgaris 500 (30%) 17 (14%) 3:1 671 (23%) < 0.0001
Hair problems 205 (12%) 64 (5%) 3.2:1 269 (9.26) < 0.0001
Idiopathic hirsutism 134 (8%) 0 (0%) – 134 < 0.0001-
Androgenetic alopecia 28 (2%) 7 (0.6%) 1:4 35 0.073
Alopecia areata 17 (1%) 1 (0.1%) 1:17 18 0.02
Ingrown hair 2 (0.1%) 8 (0.7%) 4:1 10 0.104
Telogen effluvium 0 (0%) 8 (0.7%) – 8 – 0.012
Trichotillomania 2 (0.1%) 0 (0%) – 2 – 0.72
Pseudopellade of Brocq 1 (0.06%) 0 (0%) – 1 – 0.87
Other 61
Contact Dermatitis 164 (9.7%) 98 (8%) 1.7:1 262 (9.02) 0.5
Bacterial infections 121 (7.2%) 122 (10%) 1:1 243 (8.37) 0.05
Verruca vulgaris 80 (4.7%) 146 (12%) 1:1.8 226 (7.78) < 0.0001
Dermatophytosis 27 (1.6%) 97 (8%) 1:3.6 124 (4.27) < 0.0001
Tinea versicolor 39 (2.3%) 64 (5.3%) 1:1.6 103 (3.54) 0.0004
Nail problems 48 (2.9%) 47 (3.9%) 1:1 95 (3.27) 0.5
Insect bites 58 (3.4%) 23 (2%) 2.5:1 81 (2.79) 0.1
Melanocytic nevi 48 (2.8%) 28 (2.3%) 1.7:1 76 (2.61) 0.84
Seborrheic dermatitis 20 (1.2%) 37 (3%) 1:1.85 57 (1.96) 0.005
Urticaria 35 (2.1%) 17 (1.4%) 2:1 52 (1.79) 0.2
Bruising trauma 19 (1.1%) 22 (1.8%) 1:1.1 41 (1.41) 0.5
Dry skin 22 (1.3%) 13 (1%) 1.7:1 35 (1.20) 0.96
Burns 25 (1.5%) 9 (0.7%) 2.8:1 34 (1.17) 0.34
Skin tags 15 (0.9%) 14 (1.1%) 1:1 29 (0.99) 0.9
Pityriasis rosea 20 (1.2%) 9 (0.7%) 2.2:1 29 (0.99) 0.7
Herpes simplex 14 (0.8%) 14 (1.2%) 1:1 28 (0.96) 0.86
Corns 18 (1%) 8 (0.7%) 2.2:1 26 (0.89) 0.76
Lipomas 13 (0.8%) 12 (1%) 1:1 25 (0.86) 0.95
196 Lebanese Medical Journal 2010 • Volume 58 (4) J.A. KHATTAR et al. – Skin diseases among university students

DISCUSSION
In this study, a retrospective chart review, acne vulgaris
was the most frequent complaint similar to most developed
countries [4] as Sweden (38% in females vs. 35% in
males), and higher than Afro-Caribbean 16.4% [3], Iran
9.8% [7], and Egypt 5.37% [8]. Acne tends to be more
severe and increases gradually in males probably due to
hormonal factors [9]. However, our review revealed that
acne is about two times more prevalent in females. This
could be attributed to more attendance to dermatology
clinics for issues of body image and external appearance.
The clinical implications of the present study revealed that
since acne is a disfiguring disease, it should not be looked
at as trivial [10], as it may seriously affect the patient’s life
[11]. Screening adolescents for acne may be of great importance
especially in view of the wide armamentarium of
therapy available.
The high frequency of contact dermatitis in females
may be attributed to their use of cosmetics as mentioned
in other studies [12]. Hand contact dermatitis is also
known to be more common in women [13]. Contact dermatitis
rate was lower than in other countries where it
reached 24.5% [7, 14].
Of significance is the high rate of cases of increased
facial or body hair where 74% had normal hormonal profile
(idiopathic hirsutism) [15] posing the question of
whether it is really cost effective to screen all patients presenting
with increased facial/body hair.
TABLE II
THE MOST COMMON SKIN DISEASES ENCOUNTERED
ACCORDING TO AGE
Females Males p
Mean age (SD)
Acne vulgaris 22 (2.64) 21.9 (2.60) 0.67
Hair problems 21.97 (2.6) 22.02 (2.67) 0.89
Contact dermatitis 22.02 (2.64) 22 (2.53) 0.95
Bacterial infection 22 (2.66) 21.99 (2.65) 0.98
Verruca vulgaris 21.94 (2.57) 22 (2.62) 0.87
Dermatophytosis 22 (2.62) 22 (2.64) 1.00
Tinea versicolor 21.88 (2.46) 22 (2.66) 0.82
Nail problems 21.81 (2.48) 22 (2.64) 0.72
Insect bites 21.88 (2.58) 21.93 (2.57) 0.94
Melanocytic nevi 22.0 (2.62) 22.07 (2.64) 0.91
Seborrheic dermatitis 22.05 (2.53) 22.0 (2.64) 0.94
Urticaria 21.91 (2.46) 21.97 (2.46) 0.93
Bruising trauma 22 (2.34) 22.28 (2.34) 0.70
Dry skin 21.9 (2.45) 22 (2.5) 0.90
Burns 21.84 (2.47) 21.9 (2.45) 0.95
Skin tags 21.84 (2.43) 22 (2.45) 0.84
Pityriasis rosea 21.84 (2.48) 22 (2.33) 0.87
Herpes simplex 22.2 (2.54) 22.18 (2.3) 0.98
Corns 21.17 (2.38) 21.95 (2.32) 0.44
Lipomas 22.17 (2.39) 21.9 (2.43) 0.78
Androgenetic alopecia accounted for 47% of all hairloss
problems and 13% of all hair problems. This is a very
high rate when compared to other studies [9, 16]. Studies
have shown that 72% of adolescents with androgenetic
alopecia have family history with either one or two parents
involved [17].
Hair loss can psychologically affect the balding individual
and can influence others’ perceptions of him.
Adolescents are invariably sensitive regarding their external
features, and thus may be easily withdrawn psychologically
and avoid social activities due to androgenetic
alopecia, and this tends to affect girls more than boys [18].
Thus, defining and addressing the patient’s expectations
regarding therapy and outcome, and tackling their
reactions to possible altered appearance in the future may
need to be discussed. In this study the frequency of hair
problems (9.26%) was noted to be higher than a previous
study (5.89%) conducted on the same age group [19].
Bacterial skin infections had similar rates to some
developing countries like Ethiopia 8% [20], Egypt 10.1%
[21], Tanna Vanuata 12% [22], lower rates in Tanzania
3% [23] and Mexico 6% [24]. It is important to mention
that our study population consisted of students attending a
private university in an urban setting. This could make it
difficult to fairly compare with the previous cited references
conducted mainly in rural areas.
Verruca vulgaris accounted for 7.78%, this was higher
than reports from Denmark 2.5% [25], and from Iran
3.5%. Herpes simplex infections accounted for only
0.96%.
Other infections like fungal (dermatophytosis 4.27%,
and tinea versicolor 3.54%) had relatively high rates. This
could be explained by the periods of high humidity (50-
80%) and elevated temperatures reaching up to 35°C,
although the general climate in Lebanon is moderate. In
the USA, tinea versicolor accounted only for 0.85% [26],
whereas in northern Malawi it reached 17.9% [27].
In a previous Lebanese study similar results were
reported “the most frequent skin diseases remain fungal
infections, acne, and eczema” [28]. The profile of dermatologic
diseases in students seen at UHS is very close to
that in developed countries. Moreover, the profile in
Lebanon appears to be different from the Middle Eastern
and Arab countries; in particular some endemic diseases
such as tinea capitis, leprosy and leishmaniasis are either
rare or absent [19, 28]. Despite the fact that Lebanon is a
developing country, the country is technically-overequipped
with advanced medical technologies and a high
level of tertiary care expenditure including those related
directly to dermatology, and beauty is no longer looked at
as a luxury but an adaptation to a new life that people
want.
The high standard of living among our studied UHS-
AUB students suggested no association of nutritional
deficiency presenting as skin diseases.
One possible limitation of our student population is
that it may not be representative of all socioeconomic
groups in Lebanon because of the relative high rate of aca-
J.A. KHATTAR et al. – Skin diseases among university students Lebanese Medical Journal 2010 • Volume 58 (4) 197

demic fees at the American University of Beirut. Another
limitation is the lack on some demographic information
concerning the region from which patients come. Thus,
the need for further studies from a broader socioeconomic
spectrum is recommended.
CONCLUSION
Among students seen at UHS, skin diseases related to
external appearance seem to head the list of dermatologic
complaints and we anticipate an increase in number of
adolescents seeking dermatologic centers in the future.
Dermatologists as well as other physicians treating such
diseases should be familiar with the signs, symptoms, and
possible psychological and social consequences of these
diseases.
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