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					DERMATOSES IN OBESE FEMALE SCHOOLCHILDREN                                                                                        IN
Wafa Y. Al-Saeed, MD, FFCM (KFU), Kasim M. Al-Dawood, FFCM (KFU), DLSHTM,
Iqbal A. Bukhari, FFD (KFU), Ahmed Bahnassy, MSc, PhD (USA)
College of Medicine, King Faisal University, Dammam, Saudi Arabia

      ‫ر‬     ‫هدف الدراسة: تهدف هذه الدراسة إلى التعرف على نمط ومدى انتشار األمررا الللدةرة لردى بال رام المردار‬
                                         .‫المرحلتين االبتدائية والمتوسطة اللوات ةعانين من الوزن الزائد والسمنة بمدةنة الخ ر‬
       ‫طريقةة الدراسةةة : هرذه رراسررة ميطعيررة فرةر ر منطيررة الخ رر بالمنطيررة الشررريية ر الاتررر مررا برين ةنرراةر ومررار‬
    ‫2003م حيث شرمل الدراسرة مرا ةيرارب 2233 بال رة ترا ايتيرارهن عشروائيا مرن 02 مدرسرة حووميرة ويا،رةم مرا‬
    ‫شمل المرحلة االبتدائية والمتوسطة. فمع المعلومام المطلوبة للدراسة بعد يذ الموا ية من اللهرام المسرلولة عرن‬
                                                                   .‫برةق الاحص السرةري وييا الطول والوزن و تلة اللسا‬
    ‫نتائج الدراسة: ظهررم الدراسرة ن األمررا الللدةرة المتعليرة بالسرمنة انر الترال : يشرر الرر م حرب الشر ابم‬
    ‫فارراف الللرردم راا الشررواس األسررورم التهرراب األفربررة الشررعرةة اللر رروم م الحا،ررة (الصررل )م الخطرروب التمدرةررةم و‬
    ‫االستنتاج والتوصية: هناس مرا فلدةة توثر لدى الطال ام اللروات تعرانين مرن السرمنة والروزن الزائرد وةنصر مرن‬
    ‫يالل هذه الدراسة بال ردا ر بررامو ويائيرة وعالفيرة عرن األمررا الللدةرة المتعليرة بالسرمنة لملتمر الدراسرة علرى‬
    ‫مستوةام مختلاة تشمل األسر والمدرسة ةراعى يهرا العوامرل المسراعد علرى انتشرار السرمنة وذلر مرن اللهرام ذام‬
                                 .‫العالية الوحدام الصحيةم وزار التربية والتعليام وزار الصحة و وزار اإلعالم وغيرها‬
    ,‫الللرد, بال رام المردار , الخ رر‬     ‫الللد عند األباالم السمنة و مرا‬        ‫الكلمات المرجعية: اضطرابام الللدم مرا‬
                                                                                                 .‫المملوة العربية السعورةة‬
    Objectives: The aim of this study was to determine the most frequent skin disorders in obese
    female schoolchildren in primary and intermediate schools in the Al-Khobar area, Eastern
    Saudi Arabia.
    Methodology: This was a cross-sectional study conducted in the Al-Khobar area. It involved
    2239 female schoolchildren randomly selected from 30 regular public and private primary and
    preparatory schools. A multi-stage stratified random sampling technique with proportional
    allocation was used. Data was collected using clinical examination and anthropometric
    Result: The skin diseases that were most common in obese schoolchildren were: dandruff, acne,
    xerosis, acanthosis nigricans, folliculitis, alopecia, stria distensae (stretch marks) and callosity.
    Conclusions and recommendations: obesity is associated with specific skin disorders. Health
    education programs on skin diseases and obesity should be provided to all schoolchildren, their
    families and teachers.
    Key Words: Dermatoses, skin disorders, obese schoolchildren, Al-Khobar, Saudi Arabia.

INTRODUCTION                                       cent and that of obesity was 5.98 and 6.74 per cent
Published literature indicates a rising prevalence in boys and girls, respectively. The highest
of childhood obesity in both developed and         frequency was in the Eastern Province (27.6% and
developing countries.1,2 In a national household   13.8% for overweight and obesity in girls,
screening program study, involving 12,701          respectively).3 Overweight and obesity reported
children aged 1 to 18 years in different areas of  among adolescent females aged 12-19 years in Al-
Saudi Arabia from 1994 to 1998, the overall        Khobar, Eastern Province was 28%.4 Skin
prevalence of overweight was 10.68 and 12.7 per    diseases are reported as frequent findings in the
Correspondence to:
Dr. Wafa Y. Al-Saeed, Department of Family & Community Medicine, College of Medicine, King Faisal University, P.O. Box 2776,
Al-Khobar 31952, Saudi Arabia E-mail:

                                                                                Dermatoses in Obese Female Schoolchildren        65
obese patients. To our knowledge, there is no            classification of disease (ICD-10).8 Informed
report in the literature on the prevalence of            consent for inclusion in the study was obtained
dermatological lesions in obese schoolchildren.          from the parents by invitation accompanied by a
     A cross-sectional study of 126 female and 30        letter explaining the purpose and details of the
male obese patients aged 16 to 89 years was              study. The questionnaires consisted of information
conducted in Mexico City.5 The cutaneous                 on the schoolchildren and two questions on the
findings with statistical significance found were:       frequency of change of underwear and the number
plantar hyperkeratosis, acanthosis nigricans,            of baths taken per week. All the selected
striae, skin tags and keratosis pilaris.                 schoolchildren were examined by the investigator
     Another study, conducted in France,6 showed         in a private room during the day in the same
the following skin findings in obesity: acanthosis       school. The entire body except the thighs and
nigricans, skin tags, signs of hyperandrogeny,           perineum, was exposed. To compensate for the
striae distensae, stasis acroangiodermatitis, leg        effect on the result of some skin diseases such as
ulcers, lymphoedema and intertrigo. In a USA7            intertrigo in the obese children, the girls were
study, the skin disorders in the obese included          asked during examination if they had any
stretch marks, acanthosis nigricans, hirsutism,          complaints or lesion in those areas. The initially
intertrigo and multiple papillomas. All these            undiagnosed cases were reexamined in the same
studies were conducted on adult obese patients in        school by a female consultant dermatologist. The
hospital. To the best of           the investigator's    following anthropometric measurements were
knowledge, no study has been conducted to                included: (1) Weight: This was measured by the
investigate these conditions in schoolchildren in        interviewer, using auto-calibrated measuring
Saudi Arabia. Therefore, the aim of this study was       scale. The schoolchildren were bare-footed and
to determine the most common skin disorders              lightly clothed (school uniform). The weight was
among female schoolchildren in primary and               recorded to the nearest 100 grams. (2) Height:
intermediate schools       in Al-Khobar, Eastern         This was measured using the measuring cartoon
Saudi Arabia.                                            scale attached to the wall. Each subject was
                                                         requested to stand straight without shoes, with the
MATERIAL AND METHODS                                     heels together. Buttocks, shoulders and occiput
This was a cross-sectional study conducted in the        were made to touch the vertical wall. The height
Al-Khobar from January to March 2003. The                was measured to the nearest centimeter. (3) BMI:
target population was composed of all female             This was calculated using the formula: BMI=
schoolchildren in regular public and private             Weight (in Kg)/Height (in M2). The BMI
primary and preparatory schools (total number of         interpretation was based on the table of a standard
28766 schoolchildren). The estimated sample size         definition for overweight and obesity in children9
was based on the proportion of schoolchildren in         which does not include underweight in children
the pilot study suffering from skin diseases.            (classified as normal, overweight and obese). To
Accordingly, the final study sample size with a          include underweight growth chart of body mass
total number of 2239 schoolchildren was                  index-for-age percentiles: girls, 2 to 20 years
determined. A multi-stage stratified random              (CDC growth charts)10 was used.
sampling technique with proportional allocation               For the growth chart of body mass index-for
was used as follows:                                     age percentiles, the following established
    First; schools were sub-classified by type           percentile cut-off points were used: Underweight
(governmental/private) and educational levels            = BMI-for-age < 5th percentile; At risk of
(primary/preparatory). Using the random digits           overweight = BMI-for-age 85th percentile to <
table, ten governmental and five private schools         95th percentile; Overweight = BMI-for-age > 95th
from every educational level were selected               percentile.
yielding the desired sample size from a total of 30           All variables were checked for accuracy and
schools. A simple random sample was then used            completeness, and were coded. Data was then
to select the classes.                                   entered into a personal computer and the
    In the second stage, a systematic random             Statistical Products of Service Solutions (SPSS)
sampling technique was used to select the desired        version 10 was used for data entry and analysis.
number of schoolchildren from randomly selected          The appropriate statistical analytical techniques
classes. Skin diseases were classified according to      were performed. Frequency distribution tables
the modified 10th revision of the international          were constructed for the distribution of various

66   Journal of Family & Community Medicine 2006;13(2)
skin conditions. All the necessary approvals were              frequently than non-obese schoolchildren (mean
obtained from the relevant authorities before the              5.98 ± 2.58 sd and 4.36 ± 2.06 sd, respectively).
conduct of the study. Positive skin disease cases                  Using the standard definition,9 Table 1 shows
were treated and referred to the dermatology                   the skin conditions found to be statistically
clinic for follow up and treatment.                            associated with obesity. The skin diseases found
                                                               to be significantly more prevalent among obese
RESULT                                                         schoolchildren than children of normal weight
The mean height of the sample schoolchildren                   were acanthosis nigricans, folliculitis, and stria.
was 136.85 ± 15.12 cm, while the mean weight                       Using the same definition,9 Figure 1 shows
was 37.43 ± 16.06 Kg. The mean BMI of the                      the common skin diseases in obese
sample schoolchildren was 19.21 ± 5.17.                        schoolchildren. Using the CDC growth chart
Consequently, 11.3% of the sample school                       definition,10 Table 2 shows the skin diseases
children were found to be obese, 20% were                      found to be statistically associated with
overweight and 11% underweight.                                underweight schoolchildren. Dandruff, acne, K.
    There were significant associations between                pilaris and insect bites were less prevalent among
obesity and the frequency of underwear change                  underweight schoolchildren, while herpes
and the number of baths taken per week, (p <                   simplex, cheilitis, and cherry angioma were more
0.001). Obese schoolchildren changed their                     prevalent.
underwear (mean 6.35 ± 2.56 sd times/wk) and
took baths (mean 4.68 ± 2.19 sd baths/wk) more

Table 1: Comparison between normal and obese school children in relation to the presence of skin diseases, Al-Khobar area,
                                                                                                           Odds Ratio
Skin disorders                        Normal         Overweight & Obese               p-value
                                                                                                             95% CI
                                      No. (%)               No. (%)
Eczema/dermatitis groups                                                               0.012
   No                               1151 (70.1)            490 (29.9)                                           1.29
   Yes                               386 (64.5)            212 (35.5)                                        1.05-1.58
Skin appendages groups                                                                <0.001
   No                               1199 (71.7)            474 (28.3)                                           1.71
   Yes                               338 (59.7)            228 (40.3)                                        1.39-2.09
Miscellaneous groups                                                                  <0.001
   No                               1046 (73.4)            379 (26.6)                                           1.82
   Yes                               491 (60.3)            323 (39.7)                                        1.51-2.19
Dandruff                                                                              <0.001
   No                               1298 (70.8)            535 (29.2)                                            1.7
   Yes                               239 (58.9)            167 (41.1)                                        1.35-2.13
Acne                                                                                  <0.001
   No                               1251 (72.1)            485 (27.9)                                           1.96
   Yes                               286 (56.9)            217 (43.1)                                        1.59-2.42
Xerosis                                                                                0.015
   No                               1491 (68.3)            893 (31.7)                                           3.06
   Yes                               46 (83.6)                9 (16.4)                                       1.44-6.74
Acanthosis nigricans                                                                  <0.001
   No                               1535 (71.8)            603 (28.2)                                           1.26
   Yes                                  2 (2.0)              99 (98.0)                                       30.5-7.40
Folliculitis                                                                          <0.001
   No                               1525 (69.0)            685 (31.0)                                           3.15
   Yes                                12 (41.4)              17 (58.6)                                       1.42-7.06
Alopecia                                                                               0.022
   No                               1496 (68.3)            694 (31.7)                                           2.38
   Yes                                 41 (83.7)             8 (16.3)                                        1.06-5.52
Stria                                                                                 <0.001
   No                               1530 (70.0)            657 (30.0)                                          14.97
   Yes                                7 (13.5)              45 (86.5)                                       6.65-39.51
Callosity                                                                              0.032
   No                               1534 (68.9)            688 (31.1)                                           0.16
   Yes                                14 (50.0)              1 (50.0)                                        0.01-1.15
*Using standard definition4

                                                                           Dermatoses in Obese Female Schoolchildren   67
Table 2: Comparison between normal and underweight                                                       and obese schoolchildren. In this study, the
schoolchildren in relation to the presence of skin diseases,                                             prevalence of acne and dandruff in the obese was
Al-Khobar area, 2003
                                                                                                         30.9% and 23.8%, respectively. No studies have
Skin disorders      Normal       Underweight p-value
                                                                                                         recorded the prevalence of dandruff in obese
                    No. (%)         No. (%)                                                              people.
Dandruff                                          0.009                                                       The prevalence of acne in this study was
  No              1098 (83.3)      202 (90.2)                                                            higher than that reported in obese adults in
  Yes              220 (16.7)       22 (9.8)                                                             Mexico (25.1%)5 and Egypt (6.8%).11 This is
Acne                                              <0.001                                                 probably because acne tends to be more prevalent
  No              1046 (79.4)      205 (91.5)
  Yes              272 (20.6)       19 (8.5)                                                             in the younger age group.
K. Pilaris                                        0.025                                                       Acanthosis nigricans (AN) was a finding that
  No              1289 (97.8)      224 (100)                                                             is consistent in all studies of obese persons. It is
  Yes               29 (2.2)            0                                                                characterized by a hyperpigmented velvety
Insect bite                                       0.006
  No              1293 (98.1)      213 (95.1)
                                                                                                         cutaneous thickening affecting localized areas of
  Yes               25 (1.9)        11 (4.9)                                                             the skin in obese persons.12 AN is frequently
Herpes simplex                                    0.015                                                  associated with obesity, endocrinopathies,
  No               1318 (100)      223 (99.6)                                                            malignancy, genetic syndromes and the use of
  Yes                   0            1 (0.4)                                                             some drugs.7 AN is a reliable cutaneous marker of
Cheilitis                                         0.015
  No               1318 (100)      223 (99.6)                                                            hyperinsulinemia in obese individuals.13 High
  Yes                   0            1 (0.4)                                                             concentrations of insulin stimulates DNA
Cherry                                            0.015                                                  synthesis and cell proliferation through insulin-
angioma                                                                                                  like growth factor (IGF-1) receptors which present
  No               1318 (100)      223 (99.6)
  Yes                   0            1 (0.4)
                                                                                                         in skin keratinocytes, causing the development of
*Using the CDC growth chart definition 5
                                                                                                              AN in the present study was present was
                                                                                                         found in 14.1% of the obese schoolchildren,
          40%                                                                                            which was lower than what was reported from
                                                                                                         Brazil15 (76%), Mexico City5 (64.2%), and USA13
                23.8%                                                                                    (74%), but higher than reported in Egypt11
                                                                                                         (0.6%). The difference could be related to age
                                                                                                         group and the severity of obesity.
          10%                                                                        6.4%
                                                                                                              In this study, the prevalence of striae, which is
                                   1.3%                    2.4%            1.1%                   2%     due to skin over-extension, was low compared to
           0%                                                                                            the what was reported in obese adults in Mexico




                                                                                                         (89%)5 and among children in Taiwan16 (40%),
                                                                                                         but higher than in adult Egyptians (0.8%).11
                                             Diagnosis                                                        Folliculitis caused by excessive fat folds in an
*Using standard definition         4                                                                     obese child and favoring humidity and maceration
                                                                                                         with bacterial and fungal overgrowth was the 5th
Figure 1: The prevalence of common skin diseases in obese                                                most common skin condition (2.4%) in
schoolchildren, Al-Khobar area, 2003*                                                                    overweight and obese children in the study. This
                                                                                                         was not recorded in the Mexican or Egyptian
DISCUSSION                                                                                               studies.
The overall response rate in this study was 100%.                                                             Planter      hyperkeratosis    (callosity)     is
In the present study, the common skin findings                                                           considered a stigma of morbid obesity resulting
associated with obesity were dandruff, acne,                                                             from the effect of the pressure of excess weight.5
xerosis, acanthosis nigricans, folliculitis, alopecia,                                                   The prevalence here was 2%, which was lower
striae and callosity. Of these skin diseases, acne,                                                      than that reported among obese adults in Mexico
dandruff and acanthosis nigricans and striae                                                             (75.2%).5
represented the highest prevalence (30.9%,                                                                    The result of the study revealed an association
23.8%, 14.1% and 6.4% respectively).                                                                     between obesity and alopecia and xerosis. Since
     Acne and dandruff associated with insulin                                                           most cases of alopecia are due to trauma, it was
resistance and hyperandrogenism were the most                                                            expected to be more prevalent in obese
common skin conditions among the overweight                                                              schoolchildren as their excess weight predisposed

68   Journal of Family & Community Medicine 2006;13(2)
them to more accidents. Obese schoolchildren in          and female schoolchildren at different educational
the study changed their underwear and took baths         levels in various parts of the kingdom should be
more frequently than non-obese schoolchildren.           encouraged.
This depleted the skin's natural oils and lead to
xerosis.                                                 ACKNOWLEDGMENT
     In the present study, using the CDC growth          The authors are grateful to all female
chart with 85th and 95th percentiles as cut-off          schoolchildren who participated in the study as
points the prevalence of underweight was 11%.            well as their families.
Dandruff, acne and keratosis pilaris were
significantly less common among underweight              REFERENCES
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                                                                      Dermatoses in Obese Female Schoolchildren         69

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