Risk factors and co-morbidity of skin disorders among female schoolchildren in eastern Saudi Arabia. 

Wafa Y Al-Saeed¹, Kasim M. AL-Dawood¹, Igbal A. Bukhari² and Ahmed A. Bahnassy¹. 

¹Department of Family & Community Medicine and ²Department of Dermatology, College of Medicine, King Faisal University, Dammam, Al-Khobar, Saudi Arabia. E-mail: wyss86@hotmail.com 

Abstract. The aim of this study was to determine the risk factors of skin disorders among female schoolchildren in primary and intermediate schools in Al-khobar city, Eastern Saudi Arabia. This is a cross-sectional study conducted in Al-Khobar city during the period of January to March 2003. 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 a pre-designed structured questionnaire and clinical examination. Dandruff was negatively associated with private schools and positively associated with age, body mass index and overcrowding. The association of atopic dermatitis with family history of atopy and bronchial asthma was documented in this study. Those who were at high risk of getting acne were schoolchildren who had more baths per week and lived in villas with a high number of rooms (in other words the high socioeconomic class). Pediculosis had a negative association with a high level of father education and high socioeconomic status and a positive association with living in a flat and the number of siblings. It was concluded that sex, socioeconomic status, family history, parents’ education, home type, and overcrowding were found to be risk factors for some skin disorders. Accordingly, it is recommended that a preventive health education program for schoolchildren with different levels of skin diseases be started considering the predictive variables that increase the prevalence of these diseases. 

Key words: Prevalence, skin disorders, risk factors, Al-Khobar, Saudi Arabia. 

Factores de riesgo y co-morbilidad de enfermedades dermatológicas en niñas de edad escolar en Arabia Saudita oriental.

Resumen. El propósito de este estudio fue determinar los factores de riesgo de las enfermedades dermatológicas en escolares femeninas de escuelas primarias e intermedias en la ciudad de Al-Khobar, Arabia Saudita Oriental. Se realizó un estudio transversal en la ciudad de Al-Khobar durante el período de enero a marzo de 2003. Se estudiaron 2239 niñas en edad escolar, seleccionadas al azar de 30 escuelas primarias y preparatorias regulares, públicas y privadas. Se utilizó una técnica de muestreo al azar, estratificada de múltiple fase, con distribución proporcional. La data se colectó mediante el uso de un cuestionario estructurado pre-diseñado y evaluación clínica. La caspa estuvo asociada negativamente con las escuelas privadas y positivamente con la edad, el índice de masa corporal y el hacinamiento. Este estudio documentó la asociación de dermatitis atópica con historia familiar de atopia y asma bronquial. Las escolares que tuvieron más alto riesgo de padecer acné son aquellas que tuvieron más baños por semana y que vivían en villas con un alto número de habitaciones (en otras palabras, de la clase socioeconómica alta). La pediculosis tuvo una asociación negativa con un alto nivel de educación y alto estrato socioeconómico del padre y una asociación positiva con el habitar en un apartamento y el número de hermanos. Se concluye que el género, el estrato socioeconómico, la historia familiar, la educación de los padres, el tipo de vivienda y el hacinamiento fueron factores de riesgo para algunos desórdenes dermatológicos. En consecuencia, se recomienda que se comience un programa de educación sanitaria preventivo para escolares con diferentes grados de enfermedades dermatológicas, considerando las variables predecibles que incrementan la prevalencia de estas enfermedades. 

Palabras clave: Prevalencia, enfermedades dermatológicas, Al-Khobar, Arabia Saudita. 

Recceived: 13-03-2006. Acepted: 28-09-2006 

INTRODUCCIÓN 

The prevalence of skin diseases in any community is influenced by various risk factors. These include genetic, racial constitution, social and hygienic standards, customs and occupations. They also include the nutritional status, age structure of the community, climatic factors, state of industrialization and quality and quantity of medical care. Age is the most important factor that alters the prevalence and pattern of dermatologic disease (1). 

Poor socioeconomic environments cause high morbidity rates, particularly for infectious diseases (2). Skin diseases, especially transmissible skin diseases, are observed frequently in people living in poor socioeconomic and unhygienic conditions (3). 

Skin diseases represent one of the most frequent causes of morbidity in developing countries. The morbidity of dermatological diseases is most often presented as inability to work or as having an adverse effect on social function (1) A schoolchild can suffer from loss of concentration as a result of scratching, itching, pain, embarrassment, and loss of school days because of absence, resulting in the deterioration of school achievement. Moreover, the schoolteacher may feel uneasy by rashes or lesions on a child skin, particularly if there is a possibility of contagion (4). 

Consequently, knowledge about the prevalence of different skin conditions and associated risk factors allows for appropriate planning and the provision of care for these problems. 

To the best of the investigator’s knowledge, no studies of that nature have been conducted in the Eastern province, Saudi Arabia. The objective of this study was to determine the risk factors of skin disorders among female schoolchildren in primary and intermediate schools in Al-khobar city. 

MATERIAL AND METHODS 

This is a cross-sectional study conducted in the Al-Khobar city in the period from January to March 2003. The target population was composed of all female schoolchildren in regular public and private primary and preparatory (total number of 28,766 students). The sample size was estimated based on the proportion of schoolchildren suffering from skin disorders computed from the pilot study. A total number of 2,239 schoolchildren were included. A multi-stage stratified random sampling technique with proportional allocation was used. Skin diseases were classified according to the modified 10^th revision of the international classification of disease (ICD-10) (5). 

Self-administered designed structured questionnaires were distributed to all selected schoolchildren a few days before clinical examination, to be filled by their parents. The questionnaires were then collected on a daily basis. Informed consent for inclusion in the study was obtained from the parents by invitations accompanied by a letter explaining the purpose and details of the study. The questionnaires consisted of three parts: Schoolchildren Information, Parents Information and Family Information. 

Atopic dermatitis was defined using the U.K. Working Party diagnostic criteria for atopic dermatitis (6). Each family was classified into upper, middle and lower socioeconomic class according to the composite of father education, father’s occupation and family income (Saudi Reyal = 3.75$ (USA dollars) per month (ranking scores = 7, 3, 1 for each) (7) Level 1 (upper) = 21; level 2 (middle) = 9-20; level 3 (lower) = 3-8. 

The anthropometric measurements included were: weight, height and BMI (weight (in kg)/height (in m²). The BMI interpretation was based on the table of a standard definition for overweight and obesity in children (8) and growth chart of body mass index-for-age percentiles: girls, 2 to 20 years (CDC growth charts) (9). 

All the selected schoolchildren were examined by the investigator in a private room in daylight in the same school. All the parts of the body were exposed except the thighs and perineum. The undiagnosed cases were examined in the same school by the female consultant dermatologist. Validity of diagnosis showed McNemar test = 2, P > 0.1 and sensitivity of 100% with a specificity of 94%. Reliability of the questionnaires was examined using Cronbach’s statistic, and the alpha Coefficient was 0.8 which was considered highly reliable. 

All variables were checked for accuracy and completeness and were coded. Data was then entered into a personal computer and the Statistical Products of Service Solutions (SPSS) version 10 was used for data entry and analysis. Appropriate statistical analytical techniques were performed (Chi-squared test, Student t-test and Mann-Whitney-Wilcoxon test). EPI Info program version 6 was used to determine the odds ratio and 95% confident intervals (C.I). Multiple logistic regression was used to assess the relation between the skin diseases and other variables. All the necessary approval required were obtained from the relevant authorities before the conduct of the study. Positive skin disease cases were treated and referred to a dermatology clinic for follow up and treatment. 

RESULTS 

The response rate was 100%. The students’ ages ranged between 6 and 17 years with a mean of 10.49 ± 2.64 years. Saudis students constituted 82.4% of the study sample, while only 17.6% were non Saudi. 69.3% of students were from the primary educational level while 30.7% were from Preparatory. 

The number of students’ absent days from school ranged from 0-22 days with a mean of 3.24 ± 3.54 days. The frequency of students’ change of underwear per week ranged from 1-32 times with a mean of 6.09 ± 2.58 times, while the frequency of bathing per week ranged from 1-21 times with a mean of 4.46 ± 2.11 times. Most of the schoolchildren were first (20%) or second (20%) in order among their siblings. Almost equal percentages of the sample lived either in villas or flats, with a mean number of 5.99 ± 2.79 rooms. The mean number of siblings was 5.23 ± 2.58. The history of skin allergy was positive in 57.3% of the sample. The second and the third common positive past histories of skin diseases were dandruff and acne. Only 134 (6%) of the schoolchildren had a positive history of chronic diseases, 76 (56.7%) of whom suffered from bronchial asthma. The mean height of the sample schoolchildren was 136.85 ± 15.12 cm, while the mean weight was 37.43 ± 16.06 Kg. The mean BMI of the sample schoolchildren was 19.21 ± 5.17. 306 (13.7%) of the sample schoolchildren had family history of skin diseases and two-third of these (70.3%) had a history of skin allergy. 

Table I shows selected socio-demographic characteristics of the families of the study sample. 

TABLE I

SELECTED SOCIO-DEMOGRAPHIC CHARACTERISTICS OF THE STUDY SAMPLE FAMILIES, AL-KHOBAR AREA, 2003 

Risk factors associated with skin disorders 

I. Dermatitis, Eczema and Related Conditions: Bivariate analysis showed that there were significant statistical associations between the diagnosis of dandruff and school type (p < 0.01), educational level (p < 0.01), mother’s education (p = 0.007) and BMI (p < 0.01). It was statistically more significant among the 15-17 year-olds (0.01). Prevalence of dandruff was significantly associated with the overcrowding index of ³ 3 (p < 0.004). Table II shows the multiple logistic regression model of diagnosis of dandruff after controlling for the level of education and mother’s education. The prevalence of dandruff was negatively associated with type of school (private) and positively associated with the schoolchildren’s ages, BMI, and crowding index. 

TABLE II

THE LOGISTIC REGRESSION MODEL OF DIAGNOSIS OF DANDRUFF AMONG SCHOOLCHILDREN, AL-KHOBAR AREA, 2003 

The study showed significant statistical associations between the diagnosis of atopic dermatitis and the following variables: past history of skin allergy (p < 0.001), history of bronchial asthma (p < 0.001) and family history of skin allergy (p < 0.001). Keratosis pilaris was statistically more prevalent among the 15 ± 17 year-olds (p < 0.001), and in preparatory schools (p < 0.001). The prevalence of K. pilaris was significantly lower in underweight schoolchildren compared to normal schoolchildren (p < 0.001). Regarding Pityriasis alba the only significant variable was the father’s income. The highest percentage was found among students whose father’s income was less than 2000 Saudi Riyals. 

II. Disorders of skin appendages: Bivariate analysis showed some selected variables which were found to be statistically associated with the diagnosis of acne. The prevalence of acne was statistically higher among the 15 ± 17 year-olds (p < 0.001). Prevalence of acne was significantly associated with the overcrowding index of ³ 3 (p < 0.005). Statistically better school achievement was found among schoolchildren who did not have the diseases (p < 0.001). Table III shows the multiple logistic regression model of the diagnosis of acne after controlling for the level of education, BMI, frequency of underwear change and family income. The prevalence of acne was negatively associated with the type of school (private school), the type of home (flat) and number of siblings, while positively associated with the schoolchildren’s ages, number of rooms and frequency of bathing per week. 

TABLE III

THE LOGISTIC REGRESSION MODEL OF DIAGNOSIS OF ACNE AMONG SCHOOLCHILDREN, AL-KHOBAR AREA, 2003 

III. Transmissible Skin Diseases (infectious skin diseases): In this study sample, the most common type of transmitted skin disease was pediculosis. The distribution of cases was equal in all age groups with a mean age of 10.48 ± 2.76 years. Statistically a better school achievement was found among schoolchildren who did not have the diseases (p < 0.001). Bivariate analysis showed statistically significant association between diagnosis of pediculosis with the: school type (p < 0.001), type of home (p < 0.001), father’s education (p < 0.001), mother’s education(P < 0.001), mother’s occupation (p < 0.001), father’s income (p < 0.001), socioeconomic status (p < 0.001), number of rooms (p < 0.001), number of siblings (p < 0.003), family income (p < 0.001), and overcrowding index (p < 0.001). 

Diagnosis of Pediculosis capitis among schoolchildren with dandruff (2%) was significantly lower (5.9%) than those without dandruff (p < 0.001). Table IV shows the multiple logistic regression model of diagnosis of pediculosis after controlling for the mother’s education, mother’s occupation, father’s income and family income. The diagnosis of pediculosis was negatively associated with the type of school (private), father’s education (high education) and socioeconomic status (high class), while it was positively associated with the type of home (flat) and number of siblings. 

TABLE IV

THE LOGISTIC REGRESSION MODEL OF DIAGNOSIS OF PEDICULOSIS AMONG SCHOOLCHILDREN, AL-KHOBAR AREA, 2003 

Obesity as a risk factor for skin diseases was found to be significantly associated with dandruff, acne, xerosis, acanthosis nigricans, folliculitis, alopecia, stria and callosity. 

The skin diseases found to be statistically associated with underweight schoolchildren were: dandruff, acne, K. pilaris and insect bites, which were less prevalent among underweight schoolchildren; while herpes simplex, cheilitis, and cherry angioma were more prevalent. 

DISCUSSION 

To the best of the investigator’s knowledge, this is the first comprehensive community-based study in the region measuring the risk factors of skin disorders in children. 

The overall response rate in this study was 100%. This might be attributed to continuous follow-up, daily collection of the questionnaire and reminding the non responders by calling them at home daily. 

In a previous study (10) the overall prevalence rate of skin disorders was high (98.6%). Since accessibility to male schools is proscribed by policies of the Ministry of Education in Saudi Arabia, this study focused only on girls. The distribution of these common skin disorders showed the predominance of most of these conditions in the preparatory schools as compared to the primary schools. This result reflects the effect of age in the prevalence of skin diseases. Similar results were reported in Hong Kong schoolchildren (11). 

Dandruff in this study was more prevalent among 15-17 years old preparatory schoolchildren. Dandruff was more common among children who had low educated mothers; educated mothers tended to take care of their children’s hair and had greater awareness of hygiene, and would seek medical advice on the prevention of dandruff. 

In this study, an interesting finding was that overweight and obese schoolchildren were at a higher risk of getting dandruff than normal schoolchildren, a result that had not been reported in previous studies that considered skin disorders in obesity (12-16). No explanation has been found in the literature but it could be due to an increase risk of infection associated with obesity. Another risk factor found in this study is overcrowding, probably the result of sharing personal tools (e.g. hair comb) in big families. This supports results from Turkey (17) where dandruff was higher in schoolchildren with poor socioeconomic conditions involving high overcrowding index. 

Climate could play a role as a risk factor for atopic dermatitis which may explain why the prevalence of atopic dermatitis in this study, where the weather is very humid, was much lower than that reported in the United Status (18) and other countries (19-23).In a Japanese study the lifetime prevalence of AD amongst children aged 3 months to 12 years was 3.1% in a subtropical region of the country, compared with 19.3% in a temperate zone (24). Humidity may therefore have a role in preventing the excessive dryness of the skin. The difference in climate also affects housing conditions, such as carpeting and central heating. 

Another possible risk factor for AD is water hardness. A study conducted among primary and secondary schoolchildren in Nottinghamshire found that hard water at home seemed to increase the risk of developing AD (25). Also a study conducted in the United States showed that blacks and Asians were much more likely to visit physicians for AD than whites (26). In this study, AD was slightly higher among the primary than preparatory schoolchildren and the prevalence decreased with age from 2.7% in 6-8 years old to 2% in15-17 years old, but that result was not statistically significant. A similar finding (no differences in the prevalence of AD between the 6-7 year olds and the 12-15 years old) was reported in Singapore schoolchildren (19). This was in contrast to the expected findings of incidence decreasing with age as children went into preparatory school (20). In other words, atopic dermatitis tends to begin in childhood and clears spontaneously in adulthood (27). 

It is well known that the most significant risk factor for AD is a parental history of AD. This association is well documented in cohort and many other studies focused on the familial association of atopy (28, 29). In this study, 32.1% of atopic patients had a family history of skin allergy compared to 70% in Singapore schoolchildren (19) and 59% in North Europe (30). There was a statistical association between the presence of bronchial asthma and AD. The proportion of AD patients with asthma (10.7%) in this study was comparable to (9.5%) that reported from Singapore (19), but much lower than (46%) the reported in Italian schoolchildren (31). 

The more severe cases of atopic dermatitis can have other significant physical problems, such as growth failure (32). In this study, 13.2% of those who had AD were under weight (below 5^th percentile). The highest proportion of cases (28.3%) lay in the 50^th percentile although the result was not statistically significant. 

The evidence for a direct relationship between passive smoking and allergic sensitization is contradictory (33). This relationship was demonstrated among schoolchildren in Ostersund in northern Sweden (34). In the current study, no statistical association was found between passive smoking and AD. A similar finding was reported in Italian schoolchildren (31). 

The association between AD and environmental factors is consistent. There is a hypothesis that more crowded houses, increased family size and birth order, may possibly increase early exposure to infections. Hence, offers protection from subsequent development of eczema (35). In this study there was neither association between AD and such factors, nor between AD with the type of house and school location. A similar result was reported in Italian schoolchildren (31). 

In Western countries, the association between atopy in children and the socioeconomic class of their parents has been reported (36). A similar finding was observed in this study where 86.6% of atopic patients belonged to high and middle socioeconomic classes, but the result was not statistically significant, similar to the finding reported in Japan (37). 

Atopic dermatitis is a constitutional skin disorder which predisposes patients to interactions with other skin diseases (38). In this study, AD was found to increase the tendency to develop xerosis and Pityriasis alba and reduce the tendency for mole and acne. A similar finding was found in other studies (38, 39) on mole and acne. 

The prevalence of Keratosis pilaris (KP) in this study was more common among the 15-17 year olds schoolchildren. This study was conducted in winter; in fact, one study showed a seasonal variation in the severity of KP in 80% of patients, where 49% of them improved in summer and 47% worsened in winter (40) Keratosis pilaris was shown to be associated with multiple factors, including: BMI, dryness in the skin of the leg and atopic conditions (41). In this study, there were no statistical associations between KP patients and these variables. This is consistent with reports with the same finding (19). 

The prevalence of Pityriasis alba (PA) in this study was much lower than the reported among schoolboys in other regions in SA (42, 43). This variation in prevalence may be attributed to excessive dry skin due to over exposure to sunlight as males are more exposed to sunlight during outdoor play, or to the cold winter winds of the southern region. In this study the prevalence of PA was higher among the 6-8 years age group although the result was not statistically significant. A similar finding was reported in Romanian schoolchildren (44) where the result was statistically significant. Atopy is frequently described as a pathogenic factor in PA. In this study, 14.3% had both PA and atopic dermatitis (p < 0.01) in contrast to insignificant result in other studies (19, 38). 

Some investigators have observed that acne exacerbates in winter and improves during the summer months (45), so its prevalence in the current study might have been affected by the conduct of the study in winter. The prevalence peaked in the 15-17 years age group (66.9%), with a mean age of 13 years. Most of the studies showed age-related variations in the prevalence of acne (2, 38, 45) most probably due to the hormonal changes of adolescence. The prevalence rate of acne in the 6-12 year-olds (11.5%) in this study was however higher than that reported among schoolboys in other parts of the Kingdom (2, 38) Similar findings were reported among Swedish (39) and Australian (46) school girls aged 12 years. This supports the fact that acne appears earlier in females than in males, possibly reflecting the earlier onset of puberty (47, 48). In the current study, those who did not have the diseases had better achievement at school. This may indicate that acne may have psychological impact on school work and females were more vulnerable than males to the negative psychological impact of acne (49). Patients with acne were found to have social, psychological and emotional problems that were as marked as those reported by patients with chronic disabling asthma, epilepsy, diabetes, back pain or arthritis (50) Similar community studies in secondary school children reported a higher level of psychiatric problems (51, 52). Moreover, a study conducted in France observed that acne could affect the quality of life (53). Improvement in psychological problems and quality of life are known to be associated with an effective medical treatment for acne (54). Unfortunately, young people seem to be hesitant about seeking medical help, yet, they may consult friends and family, instead of seeking help from the appropriate source (55). 

In the current study, schoolchildren in private schools who had higher number of baths per week and lived in villas with a larger number of rooms were at higher risk of having the disease. These findings may suggest that acne could be associated with high socioeconomic class. This is supported by the higher prevalence was found among schoolchildren with high family income. A similar finding was reported in other study (17). 

Acne is a constitutional skin disorder that predisposes patients to interactions with other skin diseases (38, 39). In the present study, acne increased the tendency to develop dandruff, moles, and striae, while it reduced the tendency to develop atopic dermatitis. 

Pediculosis is a public health issue in the Middle East (56-60). The prevalence rate of pediculosis in the present study was lower than rates recorded in some developed countries (61-65). The relatively low prevalence rate of pediculosis in the current study may be attributed to the effective screening program in schools and to the free medication offered to students and their families. Another reason could be due to the timing of the study which was conducted in winter. Pediculosis is more frequent in the warmer months when the higher temperatures assist in egg laying, hatching and the spread of the infection (66). 

In the current study, the prevalence of pediculosis in schoolchildren with dandruff (2%) was lower than those without dandruff (5.9%). Therefore, the presence of dandruff appears to be protective against pediculosis. A similar finding was reported in other studies (42, 61, 67). 

The distribution of the prevalence of pediculosis in the current study was equal in all age groups which contradicts other studies (57, 64, 67, 68). The rate of infestation usually declines among older girls due to a decrease in personal contact as they grow older. 

Governmental schools had higher prevalence compared to private ones and the risk of pediculosis increased when the overcrowding index was more than 3. A similar finding was reported in other study (57). This could be explained by the fact that overcrowding in the public schools increases the chances of transmission of pediculosis. It could also due to the fact that private schools usually have medical doctors who routinely examine the students and give treatment. The current study also documents the effect of pediculosis in learning through school achievement, where those who had pediculosis statistically achieved less in school than those who did not. 

The negative association between the prevalence of pediculosis and high level of the father’s education and high socioeconomic status was expected. In a study conducted in Australia, the infestation probability in families with one child was lower than that in families with two (39.2%), three (37.3%), and four (50%) children (62). The positive association with living in a flat and families with more siblings can be explained by the overcrowding that lead ultimately to more personal contact and a greater risk of infection. There have been similar finding in other studies (56, 61). 

In conclusion age, sex, socioeconomic status, family history, parents’ education, home type, BMI and overcrowding were found to be risk factors for some skin disorders. With the presence of these risk factors the current situation in the schools need to be explored. Steps toward addressing this health problem have to be undertaken through the deep study of their causes and planning for effective prevention and better planning and provision of health services. 

A preventive health education program for schoolchildren at different levels on skin diseases has started considering the predictive variables that increase the prevalence of these diseases. A recommendation was directed to the Ministries of Planning and Social Welfare to improve the education of parents through eradication of illiteracy and the inprovement of the economical status of the families. 

ACKNOWLEDGMENT 

The authors are grateful to all female schoolchildren who participated in the study and their families. 

REFERENCES 

1. Robert SS. The Epidemiology of Cutaneous Disease. Thomas B, Fitzpatrick, Arthur Z. Eisen, ditors. Textbook of dermatology in general medicine. 5^th ed. 1999. (vol 1)         [ Links ]

2. World Health Organization. The world health report 2000. Health systems: improving performance. Geneva:World Health Organization, 2000:164-176. Available at http://w3.whosea.org/healthreport: Accessed Jan, 2004.         [ Links ]

3. Schmeller W, Dzikus A. Skin diseases in children in rural Kenya: long-term results of a dermatology project within the primary health care system. Br J Dermatol 2001; 144(1):118-124.         [ Links ]

4. Mostafa AA, Hassan AH, Bahamdan K. Skin disorders among male schoolchildren in the Asir Region, Southwestern Saudi Arabia. Ann Saudi Med 1996; 16:342-345.         [ Links ]

5. Dogra S, Kumar B. Epidemiology of skin diseases in school children: a study from northern India. Pediatr Dermatol 2003; 20(6):470-473.         [ Links ]

6. Williams HC, Forsdyke H, Boodoo G, Hay RJ, Burney PG. A protocol for recoding the sign of flexural dermatitis in children. Br J Dermatol 1995; 133:941-949.         [ Links ]

7. Al-Dawood KM. Psychosocial impact on parents of mentally retarded children in Eastern Saudia Arabia. Saud Med J 1995; 16(5):418-420.         [ Links ]

8. Cole T, Bllizzi M, Flegal K, Dietz W. Establishing a standard definition for child overweight and obesity worldwide: international survey. BMJ 2000; 320:1240-1243.         [ Links ]

9. National Center for Health Disease Control and prevention. CDC growth charts: United States; Available at: http://www. pregnancyweekly.com/topics/set2/ chart16. pdf.Accessed Jun, 2003.         [ Links ]

10. Al-Saeed WY, Al-Dawood KM, Bukhari IA, Bahnassy AA. Prevalence and pattern of skin disorders among female schoolchildren in Eastern Saudi Arabia. Saudi Med J 2006; 27: 227-234.         [ Links ]

11. Fung WK,  Lo KK. Prevalence of skin disease among school children and adolescents in a student health service center in HongKong. Pediatr Dermatol 2000; 17(6): 440-446.         [ Links ]

12. Garcia HL. Dermatological complications of obesity. Am J Clin Dermatol 2002; 3(7): 497-506.         [ Links ]

13. Garcia HL, Orozco TR, Gonzalez BJ, Villa AR, Dalman JJ, Ortiz PG. Dermatoses in 156 obese adults. Obes Res 1999; 7(3): 299-302.         [ Links ]

14. Martalo O, Pierard C, Scheen A, Pierard GE. Skin diseases and obesity. Rev Med Liege 2003; 58(2):73-76.         [ Links ]

15. Bray GA. Health hazards of obesity. Endocrinol Metab Clin North Am 1996; 25(4):907-919.         [ Links ]

16. Mousa AM, Soliman MM, Hamza MR. Obesity and skin diseases. J Egypt Public Health Assoc 1977; 52(2):65-74.         [ Links ]

17. Inanir I, Sahin MT, Gunduz K, Dinc G, Turel A, Ozturkcan S. Prevalence of skin condition in primary school children in Turkey: differences based on socioeconomic factors. Pediatr Dermatol 2002; 19(4):307-311.         [ Links ]

18. Diane L, Joseph A, Susan J, Jon M. The prevalence of atopic dermatitis in Oregon schoolchildren. J Am Acad Dermatol 2000; 43(4):649-655.         [ Links ]

19. Tay YK, Kong KH, Khoo L, Goh CL, Giam YC. The prevalence and descriptive epidemiology of atopic dermatitis in Singapore schoolchildren. Br J Dermatol 2002; 146(1): 101-106.         [ Links ]

20. Marks R, Kilkenny M, Plunkett A, Merlin K. The prevalence of common skin conditions in Australian school students: 2. Atopic dermatitis. Br J Dermatol 1999; 140: 468-473         [ Links ]

21. Dotterud LK, Odland JO, Falk ES. Atopic diseases among schoolchildren in Nikel, Russia, an Arctic area with heavy air pollution. Acta Derm Venereol 2001; 81(3):198- 201.         [ Links ]

22. Schafer T, Kramer U, Vieluf D, Abeck D, Behrendt H, Ring J. The excess of atopic eczema in East Germany is related to the intrinsic type. Br J Dermatol 2000; 143(5): 992-998.         [ Links ]

23. Esamai F, Ayaya S, Nyandiko W. Prevalence of asthma, allergic rhinitis and dermatitis in primary school children in Uasin Gishu district, Kenya. East Afr Med J 2002; 79(10):514-518.         [ Links ]

24. Agata H, Kondo N, Fukutomi O, Hayashi T, Shinoda S, Nishida T, Yomo A, Suzuki Y, Shimozawa N, Tomatsu S. Comparison of allergic diseases and specific IgE antibodies in different parts of Japan. Ann Allergy 1994; 40:447-451.         [ Links ]

25. Mar A, Marks R. The descriptive epidemiology of atopic dermatitis in the community. Aust J Dermatol 1999; 40(2):73-78.         [ Links ]

26. Janumpally SR, Feldman SR, Gupta AK, Fleischer AB. In the United States, black and Asian/Pacific islanders are more likely than whites to seek medical care for atopic dermatitis. Arch Dermatol 2002; 138:634- 637.         [ Links ]

27. Sugiura H, Umemoto N, Deguchi H, Murata Y, Tanaka K, Sawai T, Omoto M, Uchiyama M, Kiriyama T, Uehara M. Prevalence of childhood and adolescent atopic dermatitis in a Japaneese population:comparison with the disease frequency examined 20 years ago. Acta Derm Venereol 1998; 78:293-294.         [ Links ]

28. Bleiker TO, Shahidullah H, Dutton E, Graham-Brown RA. The prevalence and incidence of atopic dermatitis in a birth cohort: the importance of a family history of atopy. Arch Dermatol 2000; 136(2):274- 275.         [ Links ]

29. Matsuoka S, Nakagawa R, Nakayama H, Yamashita K, Kuroda Y. Prevalence of specific allergic diseases in school children as relatd to paternal atopy. Pediat Inter 1999; 41(1):46-51.         [ Links ]

30. Larsen FS, Diepgen T, Svensson A. The occurance of atopic dermatitis in North Europe:an international questionnaire study. J Am Acad Dermatol 1996; 34:760- 764.         [ Links ]

31. Girolomoni G, Abeni D, Masini C, Sera F, Ayala F, Belloni-Fortina A, Bonifazi E, Fabbri P, Gelmetti C, Monfrecola G, Peserico A, Seidenari S, Giannetti A. The epidemiology of atopic dermatitis in Italian schoolchildren. Allergy 2003; 584(25): 420-425.         [ Links ]

32. Edward LS. Sleep fragmentation in children with atopic dermatitis. Pediatrcs 2000; 106(2):439.         [ Links ]

33. Strachan DP, Cook DG. Health effects of passive smoking. 5. Parental smoking and allergic sensitisation in children. Thorax 1998; 53:117-123.         [ Links ]

34. Braback L, Kjellman NI, Sandin A, Bjorksten B. Atopy among schoolchildren in north and south Sweden in relation to pet ownership and early life events. Pediat Allerg Immunol 2001; 12(1):4-10.         [ Links ]

35. Bodner C, Godden D, Seaton A. Family size, childhood infections and atopic diseases. The aberdeen WHEASE group. Thorax 1998; 53(1):28-32.         [ Links ]

36. Suarez MM, Gonzalez AL, Martinez MI. Socioeconomic risk factors in the prevalence of asthma and other atopic diseases in children 6 to 7 years old in Valencia Spain. Eur J Epidemiol 1999; 15(1):35-40.         [ Links ]

37. Yura A, Shimizu T. Trends in the prevalence of atopic dermatitis in school children: longitudinal study in Osaka Prefecture, Japan, from 1985 to 1997. Br J Dermatol 2001; 145:966-973.         [ Links ]

38. Al-Khawajah MM, Al-Shammari S, Al-Mofadhi A, Al-Eisa A, Al-Kudwah A, Al-Saleh S, Al-halawani M. Spectrum of dermatological disorders in school children in Saudi Arabia, part 1; national guard school in Riyadh. J SSDDV 1997; 5(2):214-221.         [ Links ]

39. Larsson PA, Liden S. Prevalence of skin diseases among adolescents 12-16 years of age. Acta Derm Venereol 1980; 60(5):415- 423.         [ Links ]

40. Poskitt L, Wilkinson JD. Natural history of keratosis pilaris. Br J Dermatol 1994; 130(6):711-713.         [ Links ]

41. Yosipovitch G, Mevorah B, Mashiach J, Chan YH, David M. High body mass index, dry scaly leg skin and atopic conditions are highly associated with keratosis pilaris. Dermatology 2000; 201(1):34-36.         [ Links ]

42. Bahamdan K, Mahfouz A, Tallab T, Badawi IA, Al-Amari OM. Skin diseases among adolescent male boys in Abha, Saudi Arabia. Int J Dermatol 1996; 35: 405-407         [ Links ]

43. Samer Kh, Muhammad A, Fathi M, Muhammad N. Prevalence of skin disorders among male primary school children in the city of Jeddah, Saudi Arabia. Saudi Med J 1996; 17(1):56-61.         [ Links ]

44. Popescu R, Popescu CM, Williams HC, Forsea D. The Prevalence of skin Conditions in Romania Schoolchildren. Br J Dermatol 1999; 140:891-896.         [ Links ]

45. Al-Ameer AM, Al-Akloby OM. Demographic features and seasonal variations in patients with acne vulgaris in Saudi Arabia: a hospital-based study. Int J Dermatol 2002; 41(12):870-871.         [ Links ]

46. Kilkenny M, Merlin K, Plunkett A, Marks R. The prevalence of common skin conditions in Australian school students: 3. Acne vulgaris. Br J Dermatol 1998; 139: 840-845.         [ Links ]

47. Stathakis V, Kilkenny M, Marks R. Descriptive epidemiology of acne vulgaris in the community. Australas J Dermatol 1997; 38(3):115-123.         [ Links ]

48. Strasbirger VC. Acne:what every pediatrician should know about treatment. Adolescnt Med 1997; 44(6):1505-1523.         [ Links ]

49. Sebnem A, Erol O, Bema S. Anexiety, depression, and nature of acne vulgaris in adolescents. Internat J Dermatol 2000; 39(5):354-357.         [ Links ]

50. Mallon E, Newton JN, Klassen A, Stewart-Brown SL, Ryan TJ, Finlay AY. The quality of life in acne:a comparison with general medical conditions using genric questionnaires. Br J Dermatol 1999; 140: 672-676.         [ Links ]

51. Kilkenny M, Stathakis V, Hibbert ME, Patton G, Caust J, Bowes G. Acne in Victorian adolescents: associations with age, gender, puberty and psychiatric symptoms. J Paediatr Child Health 1997; 33(5):430- 433.         [ Links ]

52. Smithard, Glazebrook, Williams HC. Acne prevalence, knowledge about acne and psychological morbidity in mid-adolescence: a community-based study. Br J Dermatol 2001; 145(2):274-279.         [ Links ]

53. Poli F, Dreno B, Verschoore M. An epidemiological study of acne in female adults: result of a survey conducted in France. JEADV 2001; 15:541-545.         [ Links ]

54. Newton JN, Mallon E, Klassen A, Ryan TJ, Finlay AY. The effectiveness of acne treatment: an assessment by patient of the outcome of therapy. Br J Dermatol 1997; 137:563-567.         [ Links ]

55. Pearl A, Arrol B, Lello J. The impact of acne: a study of adolescents’attitudes, perception and knowledge. NZ Med J 1998; 1111:269-271.         [ Links ]

56. AlShahri S, Saleh Y, AlShak M, Hinadi R, Sonia A, AlMonuee E, Abdukareem E. Prevalence of pediculosis among primary female schoolchildren in Makkah, Jeddah and Hofof in Saudia Arabia. J Famil Comm Med 2000; 7(3):13-20.         [ Links ]

57. Amr ZS, Nusier MN. Pediculosis capitis in northern Jordan. Int J Dermatol 2000; 39(12):919-921.         [ Links ]

58. Saab BR, Shararah N, Makarem M. Data from a public school health project in Beirut. J Med Liban 1996; 44:663-671.         [ Links ]

59. Bharja SC, Kanwar AJ, Singh G, Belhaj MS. Pediculosis capitis in Benghazi, Libya. A school survey. Int J Dermatol 1988; 27(3):165-166.         [ Links ]

60. Morsy TA, el-Ela RG, Mawla MY, Khalaf SA. The prevalence of lice infesting students of primary, preparatory and secondary schools in Cairo, Egypt. J Egypt Soc Parasitol 2001; 31(1):43-50.         [ Links ]

61. Kokturk A, Baz K, Bugdayci R, Sasmaz T, Tursen U, Kaya TI, Ikizoglu G. The prevalence of pediculosis capitis in schoolchildren in Mersin, Turkey. Int J Dermatol 2003; 42(9):694-698.         [ Links ]

62. Richard S, Petra G, Buettner. Head lice in pupils of a primary school in Australia and implications for control. Int J Dermatol 1999; 38:285-290.         [ Links ]

63. Courtiade C, Labreze C, Frontal, Taieb A, Maleville J. Pediculosis capitis: a questionnaire survey in 4 schools of the Bordeaux Academy 1990-1991. Ann Dermatol Venereol 1993; 120:363-368.         [ Links ]

64. Downs A, Stafford K, Coles G. Factors influencing the transmission of head lice among primary school children. Br J Dermatol 1999; 141(55):56.         [ Links ]

65. Estrada JS, Morris RI. Pediculosis in a school population. J Sch Nurs 2000; 16(3):32-38.         [ Links ]

66. Mimouni D, Ankol OE, Gdalevich M, Grotto I, Davidovitch N, Zangvil E. Seasonality trends of pediculosis capitis and phthirus pubis in a young adult population: follow-up of 20 years. JEADV 2002; 16:257-259.         [ Links ]

67. Suleman M, Fatima T. Epidemiology of head lice infestation in school children at Peshawar, Pakistan. J Trop Med Hyg 1988; 91(6):323-332.         [ Links ]

68. Boyle P. Pilot study of the prevalence of head lice infestation in a population of Saudi Arabian children. Fam Pract 1987; 4(2):1.         [ Links ]

Corresponding author: Wafa Al-Saeed. Department of Family & Community Medicine, College of Medicine, King Faisal University, Dammam, AlKhobar, Saudi Arabia. E-mail: wyss86@hotmail.com