The Relationship between Sleep Quality and Students’ Acne Vulgaris Severity at Medical
Faculty Universitas Kristen Indonesia
Ago Harlim, Gloria Stephanie Tesalonika S
Medical Faculty, Universitas Kristen Indonesia, Jakarta
Corresponding Author: firstname.lastname@example.org
Acne vulgaris (AV) is a chronic inflammatory of the pilosebasea follicle caused by many
factors with specific symptoms and usually occurs in adolescents and young adults. Sleep quality
is one of many factors that likely affect the pathogenesis of AV. This study aimed to determine the
relationship between sleep quality and AV severity. This study was observational with cross-
sectional design conducted from October to November 2018. The sample was collected by using
purposive sampling method on medical students of Universitas Kristen Indonesia Batch 2018.
Sleep quality was defined by using the Pittsburgh Sleep Quality Index (PSQI). Acne vulgaris
severity was defined based on Lehmann criteria. Statistical analysis was performed by using
Chi-Square test (p <0.05). Result of the study is students who had mild AV 32 people (36,8%),
moderate AV 48 people (55,2%), severe AV 7 people (8%), with 69% of students experience poor
sleep quality. This study shows that there is a significant relationship between the sleep quality
and severity of AV, with Chi-Square test obtained p-value = 0.000 (p < 0.05). This study
suggested that there is a significant correlation between sleep qualities with AV severity.
Keywords: acne vulgaris, sleep quality, acne vulgaris severity
Acne vulgaris (AV) is one of the most common skin diseases that generally occurs in
adolescence, but also often continues into adulthood [1;2]. One population study in Germany
states that 64% of people aged 20-29 years and 43% of people aged 30-39 years suffer from AV
. Acne vulgaris or known as acne is a chronic skin disease that occurs due to chronic
inflammation of the pilosebaceous follicles which is characterized by blackheads, papules,
pustules, nodules, and cysts in their predilection sites, which are usually in large sebaceous
glands such as the face, chest, and back part of the above [4;5]. One factor that contributes to the
occurrence of acne vulgaris is increased sebum secretion. Sebum itself is produced by the
sebaceous glands. Sebum secretion increases due to high androgen hormone secretion . The
synthesis of androgen hormones can be suppressed by the presence of the hormone melatonin
. The hormone melatonin functions to induce sleep and can improve sleep quality .
Sleep quality is the ability of individuals to be able to stay asleep, not only reaching the
amount or duration of sleep but also to get the amount of rest that suits their needs . In this
modern era, human activity is increasingly increasing so that attention to aspects of adequate
sleep (in quantity) and quality is still lacking. This was proven by the 2013 American
International Assurance (AIA) healthy lifestyle index survey in Indonesia conducted by a global
research company, Taylor Nelson Sofrens (TNS). The survey shows that Indonesian people who
want to get sleep for 7, 8 hours apparently can only realize 6, 8 hours each day because their
activities are increasingly increasing . Acne vulgaris itself has an effect that can damage a
person's confidence because it attacks areas that are easily seen and important in one's
appearance [1; 11] The problem of acne vulgaris should not be underestimated because it harms
the psychososcopic aspects for sufferers .
Treatment can be done to overcome Acne Vulgaris, but prevention is also needed, one of
which is to improve sleep quality. Previous studies have shown that maintaining good sleep
quality where sufficient melatonin secretion can suppress the production of androgen hormones
which play a role in the emergence of acne vulgaris [13; 14] Seeing the many AV events that are
often found around us, then also research on this has never been done in the previous at the
Medical Faculty, Universitas Kristen Indonesia, then based on the above background the writer
was interested in researching the relationship of sleep quality with the severity of acne vulgaris
on the Medical Faculty, Universitas Kristen Indonesia students.
This type of research is an observational study using a cross-sectional design. The scope of the
study is Skin Health and Sex. The scope of the research location is students of the Medical
Faculty Universitas Kristen Indonesia. The time of the study was conducted from October to
November 2018. The inclusion criteria of this study were the students of the Medical Faculty
Universitas Kristen Indonesia who were willing to take part in the study, aged 18-22 years and
were having acne on their faces. The exclusion criteria for this study were research subjects who
were in the treatment of acne vulgaris at a general practitioner, dermatologist, or buying drugs at
a store/pharmacy in the last 2 weeks, and those suffering from skin diseases on the face such as
contact dermatitis, varicella, etc. other. A sampling of this study was conducted using a
purposive sampling technique. Based on the sample size formula, the minimum sample used in
this study was 61 samples. Data was collected by filling out the questionnaire The Pittsburgh
Sleep Quality Index (PSQI) by respondents. The PSQI questionnaire covers 7 components,
namely subjective sleep quality, sleep latency, sleep duration, sleep efficiency, sleep disturbance,
use of sleeping pills, and sleep dysfunction during the day. After completing the questionnaire, a
physical examination was performed to assess the presence or absence of acne vulgaris along
with its severity based on Lehmann criteria, then documentation was carried out with a Canon
G7X camera. Data analysis was performed using the Statistical Product and Service Solution
(SPSS) program 20.0 for Windows, with test results including univariate analysis using
descriptive and bivariate analysis using the Chi-Square test.
III. RESULT AND DISCUSSION
The research data was collected in October - November 2018. The number of research
subjects who met the inclusion and exclusion criteria was 87 respondents.
Table 1. Respondents’ Frequency Distribution Characteristics
Acne Vulgaris Severity Level
Based on the age frequency distribution of respondents, from 87 respondents, as many as
21 people (24.1%) were 20 years old and the least were respondents who were 22 years old
namely as many as 13 people (14.9%). Based on the gender frequency distribution of
respondents, out of 87 respondents, as many as 56 people (64.4%) were female and male as
many as 13 people (35.6%). Based on the frequency distribution of the severity of acne vulgaris,
from 87 respondents, 48 people (55.2%) suffered from a moderate degree of acne vulgaris and at
least some respondents suffered from a severe degree of Vulgaris which were 7 people (8%).
Based on the frequency distribution of sleep quality of respondents, from 87 respondents, as
many as 60 people (69%) were those of poor sleep quality and respondents who had good sleep
quality were as many as 27 people (31%).
Table 2. Cross Tabulation between Sleep Quality and Acne Vulgaris Severity
After analyzing the data using the Chi-Square test, it is showed 0,000 (p <0.05), which means
that there is a significant relationship between sleep quality and the severity of acne vulgaris at
Medical Faculty Universitas Kristen Indonesia.
In this study, 87 samples were obtained with a range of ages 18-22 years, as many as 16
people (18.4%) aged 18 years, 19 people (21.8%) aged 19 years. 21 people (24.1%) were 20
years old 18 people (20.7%) were 21 years old, and 13 people (14.9%) were 22 years old. The
results of this study are consistent with the theory which says that acne vulgaris is often found in
adolescence and can also continue into adulthood [1;15;16]. These results are also consistent
with research on population studies in Germany by Schafer T et al., That 64% of people aged 20-
29 years and 43% of people aged 30-39 years suffer from acne vulgaris [3;17].
Characteristics of research respondents based on sleep quality found as many as 60 people
(69.0%) had poor sleep quality and 27 people (31.0%) had good sleep quality. These results are
consistent with the results of research from the American International Assurance (AIA)
conducted by a global research company, Taylor Nelson Sofrens (TNS) in Indonesia in 2013,
that in this modern era, human activity is increasingly increasing so that attention to aspects of
sleep that enough (in quantity) and quality is still very lacking. The survey shows that Indonesian
people who want to get 7.8 hours of sleep can only realize 6.8 hours of sleep every day because
of their increasing activity [18;19].
Characteristics of research respondents based on the severity of acne, from 87 people found
32 people (36.8%) suffered from mild degree Vulgaris, 48 people (55.2%) suffered from
moderate degree Vulgaris, and 7 people (8%) suffered from acne vulgaris degree of weight.
Acne severity was assessed based on Lehmann's criteria. Categorized mild acne if there are
blackheads <20, or inflammatory lesions <15, or total lesions <30. Moderate acne if there are
blackheads 20 - 100, or inflammatory lesions 15 - 50, or total lesions 30 - 125. Whereas said
severe acne if there are cysts> 5 or blackheads <100, or inflammatory lesions> 50, or total
Based on the cross-tabulation between sleep quality and severity of acne vulgaris (Table 2),
out of 32 mild acne sufferers, there were 23 people (71.9%) included in the good sleep quality
category, 9 people (28.1%) included in the sleep quality category poor, 55 patients with severe
acne there were 4 people (7.3%) included in the category of good sleep quality, 51 people
(92.7%) included in the category of poor sleep quality. The results of this study stated that there
was a significant relationship between sleep quality and the severity of acne vulgaris (p = 0,000)
in 2018 students of Medical Faculty Universitas Kristen Indonesia. These results are consistent
with the study of cosmetic dermatology by Choi et al., That lack of sleep can worsen acne
vulgaris with a percentage of 66% . These results are also by existing theories. There is four
pathogenesis of acne, namely increased sebum production, hypercornification of follicles and
pilosebaceous ducts, Propionibacterium acnes colonization in follicles, and inflammatory
processes and immune responses [15; 16] reach the surface of the skin through the infundibulum.
Increased sebum production and follicular hypercornification result in the development of
microclimates and changes in the follicular environment that support the intensive growth of P.
acnes. P acnes proliferates and secretes a variety of proinflammatory products including lipases,
proteases, hyaluronidase, and chemotaxis factors. This is what triggers acne [17; 18].
Sleeping too late can cause a person to lack sleep, this can cause an increase in
inflammatory factors, a decrease in body immunity, trigger insulin resistance and increase the
stress level. Unhealthy lifestyles such as sleeping too late can affect the incidence and
exacerbation of acne. Staying up late can cause an increase in the activity of androgen hormones.
Increased activity of this hormone causes an increase in sebum production, causing the skin to
tend to be more oily and make acne easier [19; 20].
Sleep is an unconscious state that can be awakened by giving sensory stimuli or by other
stimuli. The hormone that plays the most roles in the mechanism of sleep is melatonin
[21;22;23]. Melatonin is a hormone that is synthesized and secreted by the pineal gland.
Melatonin is secreted directly into circulation and distributed throughout the body. Sleep-wake
cycle in humans follows the circadian rhythm that is regulated by the suprachiasmatic nucleus
(SCN) located in the anterior hypothalamus in the brain. SCN is often referred to as the master
circadian clock of the body because of its role in regulating all bodily functions related to
circadian rhythms including core body temperature, cardio-pulmonary function, kidney,
gastrointestinal, neurobehavioral function, and hormone secretion [24;25].
Melatonin production is very sensitive to the effect of light. Exposure to light at night, even
in a short time with low light intensity, can cause melatonin production to decrease even fully
depressed [26;27]. Experiments have been carried out using the Syrian hamster (Mesocricetus
auratus) which is given a special treatment of light, to determine the role of melatonin in the
production of cAMP and androgen biosynthesis. Melatonin through mel1a receptors found in
Leydig cells can inhibit androgen production [7;28;29]. Androgen hormone is a crucial hormone
in the pathogenesis of acne vulgaris, especially in adolescents. The term androgen means any
steroid hormone that has a masculinizing effect, including testosterone, dihydrotestosterone
(DHT), and androstenedione [30;31;32]. Androgens are mainly synthesized in testicular Leydig
cells in men. In vivo androgens affect several functions of the human sebaceous gland, including
proliferation, differentiation, and lipid synthesis [33;34]. The influence of the hormone melatonin
on the synthesis of androgen hormones, it shows that melatonin can inhibit androgen production
by decreasing the expression of Steroidogenic Acute Regulatory (StAR), P450 side-chain
cleavage (P450 SCC), 3β-Hydroxysteroid Dehydrogenase (3β-HSD), and 17β-Hydroxysteroid
Dehydrogenase (17β-HSD) which is a protein and steroidogenic enzyme that is important in the
production of cAMP and androgens .
In individuals with acne, in general, the size of sebaceous follicles and the number of lobes
per gland increases. Sebum excretion is under the control of androgen hormones. It is known that
due to androgen hormone stimulation, sebaceous glands begin to develop at the age of 7-8 years.
Androgen hormones play a role in the changes in sebocyte cells as well as follicular keratinocyte
cells, causing microcytes and blackheads to develop into inflammatory lesions. The cells of the
pilosebaceous follicle and keratinocyte have cellular mechanisms that are used to digest
androgen hormones, namely 5-a-reductase (type 1) enzymes and 3b and 7b hydroxysteroid
dehydrogenase which is found in basal cells that have not been differentiated. After the sebocyte
cells differentiate then rupture and release sebum into the pilosebaceous duct. The process of
differentiation of these sebocyte cells is triggered by androgen hormones which will bind to their
receptors in the nucleus of the sebocyte cell, and then there will be stimulation of gene
transcription and sebocyte differentiation. Increased activity of androgen hormones can increase
sebum production by the sebaceous glands [36;37]. This excess sebum production causes
imperfections and converts normal skin to oily and become nutrients for the bacterium
Propionibacterium acnes. This bacterium has lipases that convert lipids to fatty acids, and
produce proinflammatory mediators. This is what triggers acne .
Besides causing increased activity of androgen hormones, according to research by
Heiskanen et al., Poor sleep quality can increase stress . Increased proinflammatory
cytokines in the body increase the tendency to produce inflammation. Acne vulgaris is
inflammation of the pores in the skin. This inflammation is triggered due to an increase in the
number of cytokines in the body. Lack of sleep also causes insulin resistance to increase, thus
forcing the body to produce more insulin. It also causes increased sebum production and
inflammation which causes the potential for acne formation.  Stress is associated with
increased sebaceous gland work, either directly or through stimulation of the pituitary gland.
Increased sebum production is associated with an increase in free fatty acids. Free fatty acids can
trigger inflammation which is one of the basic pathogenesis of acne [4;41]. As for poor sleep
quality will cause a decrease in cortisol levels in the morning. Decreased cortisol levels that
function to regulate gluconeogenesis and distribute eosinophils, basophils, monocytes,
lymphocytes to the tissues cause increased stress and ease inflammation. Stress and
inflammation easily trigger the pathogenesis of acne vulgaris .
Increased levels of androgen hormones are the main cause of acne vulgaris, the cause of the
occurrence of acne vulgaris is multifactorial. Risk factors for acne vulgaris at puberty are
increased levels of androgen hormones, cosmetic use, stress and unhealthy lifestyles [43;44].
Other factors that can influence acne vulgaris include genetic, racial, climate and environmental
factors.4 For individuals who have acne vulgaris, it is best to avoid applying cosmetics and
sunscreens containing oil in areas with acne, clean the face with warm water and soft face cloth
(with a bar of mild soap if desired) to remove oil, if this makes the face feel oily, over-the-
counter acne cleansers or cleansers containing salicylic acid, glycolic acid or benzoyl peroxide
can help, avoid scrubs, toners and other cleansers abrasive to the skin. Avoid breaking or
extracting acne by force because this can irritate inflamed lesions and is more likely to cause
scarring. Avoid damp or hot areas and tight clothing in acne-prone areas. Follow a balanced or
low-glycemic diet combined with regular exercise, and avoid smoking . As well as to reduce
the severity of acne vulgaris, sleep quality should also be improved by taking into account the
factors that affect the quality of sleep, such as medications, lifestyle, sleep patterns, emotional
stress, the environment, physical exercise, and food and calorie intake which enters the body.
Based on the results of research on the relationship between sleep quality (X) with the
severity of acne vulgaris (Y) it can be concluded that there is a significant relationship between
the quality of sleep with the severity of acne vulgaris. For educational institutions, it is expected
to be able to add books, magazines, or journals in libraries that contain information about sleep
quality on the severity of acne vulgaris. For students of Medical Faculty Universitas Kristen
Indonesia, it is better to pay more attention to the quality of their sleep, clean their face properly,
and not break the zits by force. For further researchers, further research is needed and more in-
depth, by adding more respondents to get the possibility of better results.
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