1. IntroductionApproximately 9.4% of the world’s population suffers from acne vulgaris, commonly known as acne [1]. The syndrome affects 85% of both male and female teenagers and can last well into adulthood [2]. Various studies, however, estimate prevalence in teenagers ranging from 28.9% to 91% [3,4]. A survey in Jeddah, Saudi Arabia, in 2013, aiming at examining public understanding and perceptions about acne, revealed that 64.5% of the population had acne, and 28.4% of the people believed that diet plays the most critical role in acne [5]. More recently, a study conducted in Riyadh city reported 78% acne among a study group aged between 15 and 30 years, and acne was more common in women (86.1%) than in men (69.9%; p = 0.001) [6]. On the other hand, the prevalence of acne among medical students in Saudi Arabia has previously been observed to be 55%. Among them, the majority (87.2%) had a perception of hormonal imbalance in its pathogenesis [7]. Another study showed that truncal acne affected 42% of female medical students, with acne scars in 60.9% of subjects [8].Self-medication is defined as the use of non-prescribed medicines, mainly, over-the-counter (OTC) pills, to cure minor symptoms without seeking medical advice [9]. Self-medication can take several forms, such as obtaining medication without a prescription, sharing drugs with others, or using a medicine already at home [9]. Medications to treat acne and other infections are easily accessible in Saudi Arabia and can be purchased over the counter without a prescription from a medical practitioner [10]. A systematic review study mentioned that 52% of acne patients utilized some type of OTC medications at least once [6]. Cleansers were the most widely used OTC drugs [11]. In addition, a variety of factors contribute to the practice of self-medication among health care students, such as easy availability, exposure to medical settings, and pharmacological knowledge [12]. The prevalence of self-medication for acne among Pakistani medical students was 50.4% [12]. Two independent studies conducted among students of medicine and allied specialties reported that 35.8% [8] and 52.4% [11] of students practiced self-medication for acne and used OTC drugs.There are different treatment approaches for acne. For instance, the most common form is the use of plant remedies, in combination with lactic acid [13], the application of an exfoliating and cleansing treatment more commonly known as oxybrasion [14]. All these treatment approaches work effectively on the skin, including fewer skin breakouts and lower sebum levels on the skin’s surface. Furthermore, it was found that acne was more common among students and significantly associated with gender [15]. On the other hand, earlier study also reported misconceptions and false beliefs on acne about psychological problems. In addition, poor outcomes of treatment, or neglecting the condition, increases the skin sensitivity, negative feelings, and anxiety, which would negatively affect the quality of life acne patients [16,17,18,19]. Quality of life is crucial in individuals’ lives to have a balanced and healthy lifestyle [18,19].Despite the world health organization (WHO) support for self-medication for minor ailments, it warns against its drawbacks, such as unpleasant side effects and the emergence of multidrug resistance [12]. Self-medication for acne has been on the rise globally as well as locally. In addition, no study of the knowledge, attitude, and practice (KAP) of self-medication for acne among university students in Saudi Arabia has been done to date. So, our study focuses on determining the prevalence of acne and its self-medication, as well as to assessing the KAP of acne self-medication among King Saud university students in the Riyadh region of Saudi Arabia. 4. DiscussionIn our study, the prevalence of acne was observed to be 78.5%. A study of available data on the incidence of acne in the Saudi people and adolescents reveals a significant prevalence rate among the Saudi population. Menon et al. in their cross-sectional study, found the prevalence of acne to be 55.0% among university students [20]. As per previous independent studies, the prevalence of acne in the Saudi population was 64.5% and 78.0%, respectively [5,6]. Similarly, a study carried out among Saudi medical students by Alajlan et al. observed a prevalence of 55.5% [7]. Another study reported that 83.4% of female Saudi students had acne [8]. A study performed by Deyab et al. found a prevalence rate of 56.0% among students of Al Majmaah University, Saudi Arabia [21].In our survey, female students reported a significantly higher prevalence of acne than male students (66% vs. 34%). This was in comparison with a similar study done in Saudi Arabia which revealed that the prevalence of acne among male and female students was 62.5% and 51.8%, respectively [21]. The prevalence rate among high school students in Jazan province, in the south of KSA, was 71% in females compared to 60% in males [27].In our study, the face was the most common area of the body to be affected by acne, followed by the back and chest, as previously reported [6,12]. As per the study done by Allayali et al., faces were most commonly affected by acne [3].Self-medication for acne is a rampant habit among university students, especially medical students. In our study, 56.0% (244 of 432) of students suffering from acne practiced self-medication. Alshehri et al., in their study, reported that 52.4% of university students suffering from acne used OTC medications [11]. Similar to our findings, Karamata et al. observed 59.2% of students practicing self-medication for acne [28]. In this study, self-medication was found to be significantly more common among females (p = 0.001). Similar findings have been ascertained by some studies between gender and self-medication [11]. The rampant use of self-medication in females could be due to hormonal imbalance; social stress or family history [28]. A study done in Brazil showed a significant association between acne vulgaris and stress [29], linking with a study by Al Mashat et al. according to which 58.4% of individuals believed that stress aggravates acne vulgaris [5].The majority of students (38.1%) in our study used topical and oral antibiotics for acne treatment, especially topical antibiotics. In a previous study carried out in Saudi Arabia, it was reported that only 11.4% of students used topical and oral antibiotics for their acne treatment [11]. The higher frequency of topical antibiotic use in our study group hints towards the easy availability of topical antibiotics in Saudi pharmacist shops which will in the long run create havoc in society. Our study observed 22.5% of students using isotretinoin as self-medication for acne, which is close to the findings of Alanazi et al., who reported that 19.2% of the acne-affected population use isotretinoin [6]. However, as per a previous study conducted in Saudi Arabia, 44.2% of the public used isotretinoin as their first choice for mild acne, which is against recommended guidelines [30]. Nevertheless, inappropriate use of antibiotics may increase the risk of adverse effects or antimicrobial resistance even when applied topically [28]. As a result, health authorities should act decisively to put into effect the 1978 statute that the Ministry of Health passed to stop the selling of antibiotics without a prescription. Additionally, they should encourage the creation of national standards for antibiotic use and prescription that are supported by research. In order to stop the local and worldwide rise of antibiotic resistance, health awareness programs against antibiotic abuse should be launched among pharmacists, prescribers, and the general public [29].OTC acne therapies are divided into 6 main categories: cleansers, leave-on products, mechanical treatments, essential oils, vitamins, home remedies, and herbal treatments. For some patients with minor acne, OTC medications can be useful [11]. In this study, cleansers were the most common OTC treatments (44.3%). It has been established that females use self-treatment products more often than male patients, such as cleansers, acne camouflage or cover-up, and facial masks [11].In our study, the most common reason stated behind self-medication was insufficient time followed by easy accessibility and minor disease severity. According to research conducted in Pakistan, the most common reasons for self-medication were mildness of disease and easy accessibility [12]. It is conceivable that medical students in the study group have a strict and vast curriculum, so they always run out of time, and they prefer self-treatment. The students of medicine and allied branches have easy access to medicine compared to the students of other branches like social sciences, earth sciences, and mathematical sciences. Due to the mild severity of the disease and since acne is not a life-consuming disease, the seriousness to follow a treatment protocol is lacking, prompting individuals to practice self-medication. As per our survey, the most common source of information for self-medication was the social internet (31.6%). In this modern era, the internet has revolutionized the world of information technology and many previous reports back the concept of the internet revolution behind the information or knowledge source in Saudi Arabia [6,7,11,31,32]. According to few studies, the most common source of knowledge regarding the self-treatment and management of acne was friends [12,33]. Although the beneficial use of the internet cannot be denied, the rampant use of the internet for practicing medicine is illegal and is giving quacks a chance to creep into the medical profession. So, the masses in general and medical students in particular should be discouraged from using the internet for medical help and should rather be encouraged to seek knowledge from the authentic sources such as published medical literature and skilled mentors.More than half of the students had appropriate knowledge about the dosage of the drug; mode of action; adverse drug reaction; precautions for use; contraindication and associated complications, which means that the enrolled medical students had an average knowledge of self-medications. As per a few previous studies, nearly 35.0% of the students did not know the potential side effects of the self-prescribed medicines, hinting at their poor knowledge of self-medications [34,35]. Despite the little knowledge about self-medication, the attitude of our study participants was positive, which is very dangerous, as the drugs taken could not always cure the diseases but could have some deleterious health effects which might manifest later during the lifetime. In our study, 73.0% of students believe self-medication is part of self-care and 59.0% encouraged friends and family to self-medicate. Our observation is in line with the independent studies done by Tameez-Ud-Din et al. and Raikar et al. wherein almost 60.0% of students used self-medication for acne and recommended it to their friends [12,36].

Our study found that almost 70.0% of students had an attitude of reading leaflets/label instructions and expiry dates on medicines, indicating that during pharmacology and clinical training, students are trained to read the labels before using medications. This study assessed self-medication used for acne by undergraduate pharmacy. About 38% in our study used topical and oral antibiotics for acne. Even when applied topically, antibiotics may increase resistance. Therefore, it is crucial for undergraduate pharmacy students to be aware of self-medication in order to avoid negative drug reactions and antimicrobial resistance. The future of rational prescribing will be improved by awareness of self-medication and its effects. Future studies are required to fill up knowledge gaps and dispel myths about acne vulgaris among children and teenagers.

Limitations

This study has some limitations. First, this study involved only university students, and as they are often expected to be more informed, extrapolating the findings to the wider population may not be trustworthy. Second, a lack of understanding of the clinical criteria of acne may have contributed to a little lower prevalence of acne and self-medication than anticipated. Third, the design of this study was cross-sectional, and limited to a single university in Saudi Arabia, which cannot be generalized to the whole population. Therefore, extrapolating the results of this study to other areas could not give an accurate picture. Fourth, this study did not include topics like the specific, comprehensive contents, effects, and likely side effects of OTC medications.