The effect of face washing frequency on acne vulgaris patients
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Original Article
The effect of face washing frequency on acne vulgaris patients
Rini Hastuti, Etty Farida Mustifah, Imroatul Ulya, Muhammad Risman, Prasetyadi Mawardi
Department of Dermatovenerology, Medical Faculty of Sebelas Maret University,
Dr. Moewardi General Hospital, Surakarta, Indonesia
Email: rinihastuti1402@gmail.com
Abstract
Background: Patients with acne often wash their faces twice a day, but there are not many studies
supporting this practice.
Methods: A single-blind randomized clinical trial was conducted in 38 subjects, divided into three groups
based on face washing frequency (once, twice, and thrice a day). All groups used the same cleanser. The
acne vulgaris severity and the number of lesions were assessed prior to study. After eight weeks, we re-
assessed the acne severity, the number of lesions, the adverse event and patient’s self-evaluation. SPSS 17
was used to analyze the face washing frequency and the number of acne lesions.
Results: Reduction in the average number of acne lesions was found in once and twice face washing
groups, while the thrice group had increased number of acne lesions. The frequency of face washing with the
number of lesions provided significant result in group 1, but it only reduced the number of comedones
(p value = 0.041).
Conclusion: Acne patients with only comedones lesions can be advised to wash their faces once a day.
Keywords: acne vulgaris, face washing, frequency
Background most literatures simply grade the severity of acne
as mild, moderate, and severe.8
Acne vulgaris (AV) is a chronic inflammatory
disease of the pilosebaceous follicles, that is The primary goals of acne therapy are to achieve
characterized by comedones, papules, pustules, initial control, maintain therapy to prevent flares,
cysts, nodules, and occasionally scars.1 The and prevent persistent or permanent sequelae
prevalence is high in adolescents and it mostly such as scarring. An important aspect of AV
affects the face in (99%) of patients and less management that is often forgotten by physicians
frequently the trunk, back (60%), chest (15%), is to dispel any myths and misperceptions that the
shoulders and buttocks. 2,3 patients may have about the cause of their AV.9 A
survey of patient’s perception of AV showed that
The etiologic factors of acne are increased sebum they thought that acne was caused by poor skin
production, hypercornification of pilosebaceous hygiene.10
ducts, colonization of skin micro flora and
inflammation.4 Several factors known to be In order to prepare the skin to receive topical
implicated in AV include stress, menstrual period medications and to improve drug absorption, the
facial hygiene, and foods, such as fatty food, regular using of mild cleanser is an important
sweets and spices,5,6 component in effective acne management.
Routine cleansing not only increases the
Diagnosis of AV is established by physical antimicrobial activity, but it also decreases the risk
examination. The medical personnel need to of infection, removes excess sebum, and prevents
assess the severity of acne.7 Several rating scales hair follicular obstruction. 11,12
have been developed with the aim of trying to
grade the severity of the individual`s condition. No Patients with acne often mistakenly believe that
method has yet gained universal acceptance and aggressive scrubbing of their skin with soap and
water several times a day can reduce the oiliness
J Gen Proced Dermatol Venereol Indones. 2019:3(2);35-40. 35of their skin.13 The doctors usually give number of lesions including blackheads, papules,
recommendation to wash the face twice daily with pustules, and nodules was conducted. This
a mild cleanser, even though, there is not much grading system considers six locations on the face
published literature to support this practice.14 and chest/upper back (Figure 1), with a factor for
each location based roughly on surface area,
This study was conducted to determine the effect distribution, and density of pilosebaceous units.
of face washing frequency on acne vulgaris, so Each location is graded separately on a 0 to 4
that we could provide the right education to the scale, with the most severe lesion on the location
patients about the optimal face washing frequency determines the local score. The global score is a
to reduce the prevalence of acne. summation of all local scores. (Table 1).15
Methods All subjects were given the same cleanser. It is a
cleansing soap with no antiseptic nor anti-
This research is a single blind, randomized, and bacterial content, namely Primaderma® Normal
clinical trial study, conducted during the period of Skin Face Wash with composition of aqua,
November 20, 2016 until January 15, 2017 at Al sodium laureate sulfate, cocamidopropyl betaine,
Muayyad Boarding School Surakarta. A total of cocamide DEA, decyl glucoside, PEG-150
sixty subjects were recorded to participate in the distearate, PEG-12 dimethicone, sodium PCA,
beginning of the study. The inclusion criteria are phenoxyethanol, tetrasodium EDTA,
as followed: male, aged 12-18 years old, willing to methylparaben, citric acid, perfume, butylparaben,
not use other cleansing products and acne ethylparaben and propylparaben. There was no
treatments during the study, classified into mild wash out period before the study began.
and moderate acne criteria according to Global
Acne Grading System (GAGS), and willing to sign At the end of the study, at week 8, re-assessment
an informed consent. The criteria of mild and of the severity of acne, lesion count, side effects
moderate acne were based on the GAGS scoring (e.g. red, scaly, dry, stinging, hot, or itchy) and
system, in which its system can be assessed patient’s self-evaluation with history taking by
quickly and easily (Figure 1 and Table 1). asking the subjects if there was a change in the
number of acne lesions (improvement, no
Subsequently, subjects were divided into three improvement, or worsen).
groups, each consisted of twenty subjects, in
which group 1, group 2 and group 3 washed the Statistical analysis was performed to determine
face with a cleansing soap for once a day, twice a the relationship between face washing frequency
day, and thrice a day, in orderly manner. and number of acne vulgaris lesions using SPSS
with T-test and Anova test (significance level p
Prior to the study, an assessment of the degree ofTable 1. The Global Acne Grading System (GAGS) 15
Location Factor x Grading (0-4)* = Local Score
I. Forehead 2
II. Right Cheek 2
III. Left Cheek 2
IV. Nose 1
V. Chin 1
VI. Chest and upper trunk 3
*Grading: 0 = No lesion; 1 = Comedones; 2 = Papules; 3 = Pustules; 4 = Nodules
GAGS Score: 0 = Zero; 1-18 = Mild; 19-30 = Moderate; 31-38 = Severe; >39 = Very Severe
Results
Initially, sixty subjects were divided into three acne severity. While group 3 showed there was a
groups and each group consisted of twenty decrease in the number of subjects with mild acne
people. After 8 weeks, subjects who discontinued severity. On the other hand, there were more
research protocol were excluded from the study subjects with moderate acne severity.
(drop-out subjects), Meanwhile, the subjects who
did not follow the procedure properly were moved The average number of comedones, papules,
to another suitable group. Thus, the number of pustules, and nodules lesions before and after the
subjects for group 1 was nine people, group 2 was study is shown in Table 3. On group 1, there was
nineteen people and group 3 was ten people a significant reduction in the number of
(Figure 2). The average age of subjects in group comedones with p value = 0.041, meanwhile the
1 was 16 years old, group 2 was 15.4 years old, other groups did not give significant result.
and group 3 was 13.9 years old
Table 4 shows the results of the assessment of
The degree of severity of subject’s acne based on adverse event, in which most subjects felt no
GAGS before and after the study is shown in complaints. Table 5 shows the self-evaluation
Table 2. After 8 weeks of study, group 1 and 2 assessment in which most subjects felt no change
had more subjects with mild acne severity and in the number of acne lesions either before or
decreased number of subjects with moderate after the study.
Figure 2. Study Flow Chart
J Gen Proced Dermatol Venereol Indones. 2019:3(2);35-40. 37Table 2. Severity of Acne According to Global Acne Grading System (GAGS) in Each Group Before and
After Treatment
Before After
Treatment Group
Mild Moderate Mild Moderate
Group 1 (once daily) 8 1 9 -
Group 2 (twice daily) 15 4 17 2
Group 3 (thrice daily) 10 - 9 1
Table 3. Frequency of Face Washing and Average Number of Acne Lesions Before and After the Treatment
Comedones Papules Pustules Nodules
Before After Before After Before After Before After
Group 1 (once daily) 18.2 13 6.4 4.7 0.7 0.1 0.5 0
Group 2 (twice daily) 21.3 20.1 5.7 6.7 0.7 0.3 0.3 0.2
Group 3 (thrice daily) 13.3 18.4 2.7 4.6 - 0.5 0.1 0
Table 4. Adverse Event in Each Treatment Group
Itchy Dryness Scaly No Complaint
Group 1 (once daily) 3 - - 6
Group 2 (twice daily) 2 4 4 10
Group 3 (thrice daily) 4 - - 6
Total 9 4 4 22
Table 5. Self-evaluation According to Change in the Number of Acne Lesion in Each Treatment Group
Improvement No Improvement Worsen
Group 1 (once daily) 3 5 1
Group 2 (twice daily) 8 9 2
Group 3 (thrice daily) 3 5 3
Total 14 19 6
Discussion
Methods of measuring the severity of AV include
AV is a multifactorial disorder of the pilo- simple grading based on clinical examination,
sebaceous unit.16 It is a common skin disease lesion counting, and those that require
especially in adolescents and young adults.5 The complicated instruments such as photography,
prevalence of acne among adolescent was fluorescent photography, polarized light
82,9%, 17 affecting over 90% of males and 80% of photography, video microscopy, and
females in all ethnic groups.18 In this study, all measurement of sebum production. The first
selected subjects were males in order to avoid person to use a scoring system for AV was
menstrual cycle that might have influenced the Carmen Thomas of Philadelphia, by using lesion
study result. counting. In 1956, Pillsbury, Shelley and Kligman
published the earliest known grading system.
A survey of patient’s perception of AV showed After that, Burke, Cunliffe and Gibson presented
that they thought that acne was caused by poor the Leeds technique.19 Doshi et al15 introduced
skin hygiene (29%), infection (18%), and dirt as Global Acne Grading System (GAGS).
an aggravating factor (61%). Even among medical
students, 25% of them thought that poor facial In this study, inclusion criteria included mild and
hygiene was an exacerbating factor.10 This study moderate acne based on the GAGS scoring
was conducted to provide the right education to system, in which the scoring system can be
the patients about the optimal face washing assessed quickly and easily. The acne severity
frequency to reduce the prevalence of acne. was assessed by counting the number of each
lesion. The relationship between facial washing
and AV has not been clearly established. Acne
patients usually believe that lack of skin care and
J Gen Proced Dermatol Venereol Indones. 2019:3(2);35-40. 38facial dirt aggravate acne, while dermatologists Conclusion
used to believe that excessive facial washing
exacerbates acne and weakens the skin barrier There were significant results found on group 1
functions.20 (face washing for once daily) and only supported
by reduction of comedones. Most subjects had no
A study by Kairavee et al.21 concluded that complaints and in the self-evaluation assessment,
washing face with soap is one of the triggers and most subjects felt no change in the number of
can be an aggravating factor of acne. In acne lesions before and after the study. In
comparison to our study, most subjects (93%) in accordance to the results of this study, we
that study, the subjects washed their face only recommend to wash the face once daily for acne
with plain water regularly, because they had patients with comedones lesion.
experienced flares of their acne due to usage of
soaps and over time had become more
comfortable with plain water usage only. 21
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