Correlation between Duration of Sun Exposure and Scalp Seborrheic

Dermatitis Severity Score in the Dermatovenereology Clinic,

Dr. Cipto Mangunkusumo General Hospital

Khaula Latifah Ramadhani Sahidah

Triana Agustin

Faculty of Medicine, Universitas Indonesia, Salemba Raya 6, Jakarta 10430, Indonesia

Departement of Dermatology and Venereology, Dr. Cipto Mangunkusumo Hospital, Faculty of Medicine, Universitas

Indonesia, Salemba Raya 6, Jakarta 10430, Indonesia

Keywords: Duration of sun exposure, scalp seborrheic dermatitis severity score

Abstract: Seborrheic dermatitis is a chronic inflammatory skin condition characterized by scaling and pruritus in

seborrheic areas. One of the influencing factors of seborrheic dermatitis severity is sun exposure. However,

the role of sun exposure in the pathogenesis of seborrheic dermatitis is still controversial. Several studies

showed sunlight can assist the improvement of seborrheic dermatitis, while other studies found sunlight can

provoke exacerbation of symptoms. This study aims to investigate the correlation between duration of sun

exposure and scalp seborrheic dermatitis severity score. We included 87 subjects with seborrheic dermatitis

in the dermatology and venereology outpatient clinic, dr Cipto Mangunkusumo General Hospital, Jakarta,

Indonesia. The severity score of seborrheic dermatitis on the scalp was measured using the modified

Seborrheic Dermatitis Area Severity Index (SDASI), and data on duration of sun exposure were obtained

using questionnaires. The average of sun exposure duration is 120 minutes (0-660), and the average of SDASI

score was 2.25 (0.25-21.00). Spearman correlation test revealed a significant (p=0.002) yet weak (r=0.322)

negative correlation between the duration of sun exposure and scalp seborrheic dermatitis severity score.

1 INTRODUCTION

Seborrheic dermatitis is a chronic inflammatory skin

condition characterized by scaling and pruritus in

seborrheic areas, estimated to occur in 1-3% of the

world population (Borda et al, 2015). In Indonesia,

the prevalence of seborrheic dermatitis in the 12-20

years old population is 26.5% (Cheong et al, 2016).

The mildest form of seborrheic dermatitis is

commonly called dandruff (Borda et al, 2015).

Dandruff is a chronic condition associated with

pruritus and scaling of the scalp (Borda et al, 2015)

(Mohamed et al, 2014). The prevalence of dandruff is

estimated to be 50% worldwide (Borda et al, 2015).

Despite its non-life threatening nature, dandruff and

seborrheic dermatitis can negatively affect quality of

life. Currently, the etiopathogenesis of seborrheic

dermatitis is unclear. Three main factors are known to

be associated with the disease, which are sebaceous

glands secretions, Malassezia colonization, and

individual susceptibilities such as skin condition,

immune responses, neurogenic factors, nutritional

factors, genetic factors, and the presence of other

medical conditions (Borda et al, 2015) (Collins et al,

2012).

In addition to the three factors, weather and

climate are also known to affect seborrheic

dermatitis. In countries with temperate climate and

four seasons, seborrheic dermatitis generally worsens

in the winter and autumn, and improves in the

summer (Mohamed et al, 2014).

These changes are

believed to be caused by low sun exposure, which is

a risk factor of seborrheic dermatitis (Goldberg et al,

2013). On the contrary, several studies reported sun

exposure as a non-microbial factor which causes

dandruff and exacerbation of seborrheic dermatitis

(Cheong et al, 2016) (Mohamed et al, 2014).

Ultraviolet radiation is thought to cause hyperplasia

of sebaceous glands and changes in the skin surface’s

lipid composition, leading to disturbances in skin’s

defenses (Akitomo et al, 2017). Thus, the role of

sunlight in the pathogenesis of seborrheic dermatitis

is controversial. This study aims to investigate the

correlation between duration of sun exposure and

132

Sahidah, K. and Agustin, T.

Correlation between Duration of Sun Exposure and Scalp Seborrheic Dermatitis Severity Score in the Dermatovenereology Clinic, Dr. Cipto Mangunkusumo General Hospital.

DOI: 10.5220/0008152401320135

In Proceedings of the 23rd Regional Conference of Dermatology (RCD 2018), pages 132-135

ISBN: 978-989-758-494-7

scalp seborrheic dermatitis severity score in dr Cipto

Mangunkusumo General Hospital’s dermatology and

venereology outpatient clinic. The results of this

study are hoped to add to the evidence regarding

factors associated with seborrheic dermatitis, and can

be considered in preventing or treating the disease.

2 METHODS

This study is a cross-sectional study conducted in the

dermatology and venereology outpatient clinic in dr

Cipto Mangunkusumo General Hospital, Jakarta,

Indonesia, from April to July 2017. Through

consecutive sampling, 87 subjects were recruited

according to the inclusion and exclusion criteria. We

investigated two variables, which are the duration of

sun exposure and the severity score of scalp

seborrheic dermatitis. Duration of sun exposure was

defined as the average duration of sun exposure

experienced by the subjects on a daily basis; the data

was obtained from the patient profile and

characteristics questionnaire in the clinic. The

severity score of scalp seborrheic dermatitis is a

measurement of scalp seborrheic dermatitis through

clinical observation by a dermatovenereologist, using

a modified seborrheic dermatitis area severity index

(SDASI). The measurement was performed by

dividing the scalp area into four quadrants. Erythema,

scaling, and papules were measured, and scored with

0 (absent), 1 (mild), 2 (moderate), and 3 (severe). The

size of lesions in each quadrant was scored 1-4 (1: 1-

25%, 2: 26-50%, 3: 51-75%, 4: 76-100%). The score

of each quadrant was added and divided by 4 to obtain

the final severity score of scalp seborrheic dermatitis.

The final score was classified as mild (1-9), moderate

(10-26), and severe (≥27). The data collected were

analyzed using SPSS 20.0 with univariate and

bivariate analysis to investigate inter-variable

correlation. The collected data had abnormal

distribution, and the Spearmann correlation was used.

3 RESULTS

The median age of the subjects was 29.25 years old.

The majority of the subjects were female (61.4%),

work as office workers (48.2%), and had mild

seborrheic dermatitis (89.7%). Univariate analysis

showed both variables had abnormal distribution on

the Kolmogorov-Smirnov test. The median sun

exposure duration was 120 minutes with a minimum

value of 0 minutes and a maximum value of 660

minutes. For the seborrheic dermatitis severity score

variable, the median was 2.25 with a minimum of

0.35 and a maximum of 21. Bivariate analysis using

the Spearmann test revealed p=0.002 and r=-0.322,

which showed a weak negative correlation between

the two variables.

4 DISCUSSION

Our study found the median of sun exposure duration

in the subjects was 120 minutes. This finding is in line

with a study conducted by W&S Market in Southeast

Asian countries, which found Indonesians spend an

average of 1-2 hours outdoors, exposed to direct

sunlight. Vietnamese people spend 1-2 hours

outdoors as well, while Thai people only spend 30

minutes to an hour (W&S Market Research, 2016).

Sunlight contains ultraviolet rays, which can have

both positive and negative effects on human health. A

study by Setiati reported the intensity of ultraviolet

rays in Jakarta and Bekasi, Indonesia, reach their peak

at 11 a.m. to 2 p.m., and decrease until 4 p.m (Setiati,

2016). Most of humans’ ultraviolet exposure is from

sunlight, which can vary depending on someone’s

outdoor activities such as sunbathing, recreational

activities, or outdoor work. The majority of our study

subjects were office workers who mostly spend their

time indoors.

The median of sun exposure duration in our study

is the same in both male and female subjects (120

minutes). According to Koster and Al-Ghamdi, sun

exposure in males was generally higher compared to

females (Koster et al, 2017). A study in Sweden

reported duration of sun exposure may be affected by

age, level of education, and skin type. Furthermore, a

study by Haluza identified the factors that affect

levels of sun exposure, which include age, social and

professional factors, routine exercise, skin type,

sunscreen use, sunburn occurrence, and motivation to

tan the skin (Haluza et al 2016).

The seborrheic dermatitis severity score measured

using modified SDASI can be classified as mild (1-

9), moderate (10-26), and severe (≥27). From the

collected data, we found the average seborrheic

dermatitis severity score in this study was 2.25. Most

of the subjects were categorized as mild (89.7%),

10.3% was categorized as moderate, and none of the

subjects was categorized as severe. Based on sex, no

significant difference was found between the average

severity score in male subjects (2.25) and female

subjects (2.375). Our findings are consistent with

findings from a study by Olina, which reported no

significant relationship between sex and seborrheic

Correlation between Duration of Sun Exposure and Scalp Seborrheic Dermatitis Severity Score in the Dermatovenereology Clinic, Dr. Cipto

Mangunkusumo General Hospital

133

dermatitis severity score measured with Seborrheic

Area Severity Index (SASI) (Olina et al, 2015). In

contrast, Park’s study observed male sex, duration of

disease of more than 7 years, and history of acne

vulgaris as the influencing factors of scalp seborrheic

dermatitis occurrence (Park et al, 2016).

Bivariate analysis showed a significant

relationship between duration of sun exposure to

seborrheic dermatitis severity score (p<0.05), with a

correlation coefficient of -0.322, showing an

inversely proportional relationship where longer

duration of sun exposure is related to lower

seborrheic dermatitis severity score. Nevertheless, a

coefficient of 0.322 shows a weak correlation. The

role of sunlight, including ultraviolet rays, in

seborrheic dermatitis is still controversial. Currently,

no other studies have investigated the direct

relationship between duration of sun exposure and

seborrheic dermatitis severity score. The factors

associated with seborrheic dermatitis which have

been extensively studied include Malassezia,

sebaceous glands activity, and skin defenses.

The findings of this study are corroborated by

previous studies on the effect of ultraviolet irradiation

on Malassezia or Pityrosporum ovale fungi. Mayser

and Pape’s study showed UVA and UVB irradiation

had significant inhibitive effects on Malassezia

growth (Masyer et al, 1998).

Their findings became

the foundation of using UVB phototherapy as a

treatment method for seborrheic dermatitis,

especially for patients with large or recalcitrant

lesions, although this modality has not been proven

by randomized trials (Naldi, 2009). Moreover,

Mayser and Pape’s findings on sun exposure’s effect

on sebaceous glands, skin condition, skin temperature

changes, and sweat production were not consistent

with the results of other previous works. The effects

of ultraviolet irradiation on sebaceous glands and

sebum production have been extensively studied.

Akimoto conducted a study on the sebocytes of

guinea pigs, and found increased cell proliferation

and sebum production after UVB irradiation (Setiati,

2006). On the contrary, Lee’s study on human

sebocytes found irradiation with UVB, UVA, and

other components of sunlight did not cause significant

increase nor decrease in sebum production (Lee et al,

2015). Although seborrheic dermatitis occurrence is

strongly associated with sebaceous glands activity,

excessive sebum production is not an independent

etiological factor of seborrheic dermatitis (Collins et

al, 2012) (Goldberg et al, 2013). In general,

seborrheic dermatitis develops due to changes in lipid

compositions on the skin surface, providing favorable

conditions for the colonization of certain

microorganisms. Excessive sun exposure and

ultraviolet irradiation are believed to disturb the

skin’s defenses, supporting the development of

seborrheic dermatitis (Akitomo et al, 2003).

Akimoto’s study highlighted how ultraviolet rays can

oxidize squalane, a form of lipid found on the skin

surface, to squalane peroxidase which can irritate the

skin and disturb its defenses (W&S Market Research,

2016).

A few limitations may influence the results of our

study, such as the use of sun exposure duration as the

sole indicator of sun exposure. According to Koster,

in order to measure sun exposure, thorough

observation of objective and subjective factors is

needed. In addition to duration, observations of the

time of exposure, ultraviolet ray intensity, exposed

body parts, and sun protection habits should be

made.

Furthermore, the subjects in our study mostly

had mild seborrheic dermatitis, and none of the

subjects had severe seborrheic dermatitis, thus the

conclusion on the relationship between sunlight and

seborrheic dermatitis based on the findings of this

study should be interpreted with caution. Thus, an

important component to include in future

investigations is an equal distribution of different

levels of seborrheic dermatitis severity. Our study did

not include other factors aside from the duration of

sun exposure as variables, which lead to the

possibility of our results being affected by other

confounding factors, due to seborrheic dermatitis’

multifactorial nature. This limitation suggests an

opportunity for future multivariate research to study

the various factors that can influence the severity of

scalp seborrheic dermatitis.

5 CONCLUSION

The evidence from the current study suggests a

significant negative correlation, albeit weak, between

the duration of sun exposure and scalp seborrheic

dermatitis severity score. Our study was limited by

the large amount of subjects (89.7%) with mild

seborrheic dermatitis, thus further investigations

including all levels of seborrheic dermatitis severity

are needed.

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Mangunkusumo General Hospital

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