Original Article

The association between blotting paper application and

severity of acne vulgaris among medical students

Ivana Beatrice Ivana Beatrice Alberta1, Melyawati Hermawan2, Soegianto Ali3

1
Faculty of Medicine, Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia
2
Department of Dermatology and Venerology, Faculty of Medicine, Atma Jaya Catholic University of
Indonesia Jakarta, Indonesia
3
Department of Biology, Faculty of Medicine, Atma Jaya Catholic University of Indonesia Jakarta, Indonesia

Email: ivanabeatricea@gmail.com

elyawati
Abstract
Background: Acne vulgaris is an inflammatory condition of the pilosebaceous glands caused by various
factors including excessive excretion of sebaceous glands. Excess sebum can be reduced using oil blotting
paper (OBP), a thin paper with microspores that absorb the oil on the face. This study was conducted to
determine the association between OBP application and sebum excretion according to the Oily Skin Self-
Assessment Scale (OSSAS) questionnaire and acne severity according to the Global Acne Grading System
(GAGS) questionnaire.
Methods: This experimental study was conducted in 2017 among 60 students aged 17–22 years at the
Faculty of Medicine, Atma Jaya Catholic University of Indonesia, recruited by purposive sampling. Data on
sebum excretion and the degree of AV severity before and after intervention were analyzed using the chi-
square test with a significant level of p < 0.05.
Results: Before intervention, 11 (18.3%) students had dry skin, 23 (38.3%) had slightly dry skin, 17 (28.4%)
had slightly oily skin, and 9 (15%) had oily skin. The prevalence of AV was 100%, with 48 (80%) students
having mild severity and the remaining having moderate severity. There was no effect of using OBP on
sebum excretion (p = 0.211); however, an improvement was noted on GAGS raw data score (p < 0.001).
Conclusion: AV is an inflammatory disease of the pilosebaceous glands, and one of the etiologies is
excessive sebum excretion, which can be reduced using OBP. This study demonstrated that OBP
application did not reduce sebum excretion statistically but could improve the severity of AV.

Keywords: GAGS, oily skin, OSSAS

Background skin microbial flora such as Propionibacterium

Acne vulgaris (AV) is a chronic skin disease
involving inflammation of the pilosebaceous
glands. This condition is a self-limiting disease and
generally does not affect the general health, but it
can leave scars on the skin and cause
1-5
psychosocial effects and economic burden. The
prevalence of AV has been reported to be 40% in
children aged 8–10 years, 90% in adolescent
males aged 13–17 years, and 80% in adolescent
6
females of the same age. A study conducted in
Palembang in 2008 reported AV prevalence up to
68.2% among the total sample. AV has a
7 to determine whether the use of OBP has an effect
multifactorial etiology, e.g., sebum; keratin plug;
acnes, Staphylococcus epidermidis, and
Pityrosporum ovale; hormones; and inflammation
mediators. The manifestations of AV are
blackheads, papules, pustules, cysts, and nodules
predominantly on the face, neck, upper arm, and
4,5,8
back.
Nowadays, teenagers generally use an oil blotting
paper (OBP) to wipe their oily face, while oil or
sebum is one of the etiologies of AV. OBP is a thin
paper or film with micropores that can absorb the
excessive oil on the face. In this study, the aim was
on sebum excretion and the severity of AV.

J Gen Proced Dermatol Venereol Indones. 2020;4(2): 66-70 66


Methods
In this experimental study, questionnaires were
used as data collection tools both at the beginning
and at the end of the study in the intervention
(using OBP) and the control (no intervention)
groups. The respondents were students of the
Faculty of Medicine, Atma Jaya Catholic University
of Indonesia, who were recruited by purposive
sampling.
As this is a categorial analytic study, we calculate
minimal sample according to this formula:
- in the table, an improvement was noted in the
𝑍𝛼 2𝑃𝑄 + 𝑍𝛽 𝑃1𝑄1 + 𝑃2𝑄2
𝑛1 = 𝑛2 =
𝑃1 − 𝑃2
We determine the value of α=5%, ᵦ=20%, Zα=1.96,
Zᵦ=0.85, P1=0.5, P2=0.85, Q1=0.5, and Q2=0.15.
We got 26 respondents for each groups and for
anticipate dropout 10%, we recruited 30
respondents for each groups in this study.
The inclusion criteria of this study were
respondents who are active students of the Faculty
of Medicine, Atma Jaya Catholic University of
Indonesia, aged 17–22 years. The exclusion
criteria were students who are under treatment or
have routine consultation with a dermatologist for
their skin health, have used acne treatment or
systemic antibiotics within 1 month prior, have a
tendency to always suffer from acne with Global
Acne Grading System (GAGS) score of > 39,
smokers, and refuse to participate in this study.
Respondents used OBP twice-daily between
09:00–11:00 AM and 13:00–15:00 PM for 30 days.
For standardization, only one sheet of
nonmedicated OBP was used for the entire face
each time. Sebum excretion was measured using
the Oily Skin Self-Assessment Scale (OSSAS)
9
questionnaire, and the degree of AV severity was
10
measured using the GAGS questionnaire. Data
were analyzed using the chi-square test with a
significant level of p < 0.05.
This study was approved by the ethical committee
of Atma Jaya Catholic University of Indonesia
(No:11/11/KEP-FKUAJ/2016). There was no
conflict of interest or any product sponsorship for
this study.
Results
This study was conducted from January to
J Gen Proced Dermatol Venereol Indones. 2020;4(2): 66-70
February 2017 on total 60 respondents.
Respondents consisted of females and males
were randomly categorized into the control and
intervention groups with 30 respondents in each
groups. The age range of the respondents was
17–22 years (mean: 19 years). The proportion of
males and females in both the control and
intervention groups was comparable (9 vs 21 in the
control group and 10 vs 20 in the intervention
group).
Table 1 shows the OSSAS and GAGS profiles of
the respondents in the control and intervention
groups before and after the intervention. As shown
OSSAS and GAGS profiles in the intervention
group. Of 14 respondents with slightly oily and oily
skin at the beginning of the intervention, only nine
respondents showed no changes in their skin post
intervention. Similarly, of six respondents with
moderate acne severity at the beginning of the
study, only one respondent had the same
moderate degree of acne severity at the end of the
study.
Despite the improvement in the OSSAS and GAGS
profiles before and after the intervention, the
difference was not statistically significant.
Therefore, we explored the improvement in the raw
scores of OSSAS and GAGS as this method would
have more statistical power in assessing the
details of the improvement. Raw score defined as
a total score from OSSAS’ or GAGS’ questionaire
before it categorized, then it compared between
before and after intervention. As shown in Table 1,
more respondents in the intervention group had
improvement in the OSSAS and GAGS scores
compared to the control group (21 vs 17 for
OSSAS score and 26 vs 13 for GAGS score).
However, only improvement on GAGS raw score is
statistically significant. The raw score changes for
OSSAS and GAGS in the intervention and control
groups are depicted in Figures 1 and 2,
respectively.
Discussion
To our knowledge, this is the first study using OBP
to determine the impact on sebum excretion and
acne severity conducted in Jakarta, Indonesia.
Furthermore, we could not find any reported
previous studies using the OSSAS questionnaire in
Indonesia.
AV is a common problem among young
adolescents in Indonesia. Due to the intensive
influence of advertisements, several young people
buy and use OBP to overcome their oily skin
67
problems; however, its effectiveness in reducing This study showed that OBP may have beneficial
sebum excretion and acne is yet to be elucidated. effects in reducing AV severity.

Table 1. Association Between the Use of Oil Blotting Paper on the Oily Skin Self-Assessment Scale
(OSSAS) (p > 0.05) and Global Acne Grading System (GAGS) (p < 0.05) Scores in the Control and
Intervention groups

Group Control Intervention Total

Dry skin 7 (23.3%) 4 (13.3%) 11 (18.3%)
Slightly Dry Skin 11 (36.7%) 12 (40.0%) 23 (38.3%)
Before
Slightly Oily Skin 8 (26.7%) 9 (30.0%) 17 (28.4%)
OSSAS

Oily Skin 4 (13.3%) 5 (16.7%) 9 (15.0%)

Dry skin 9 (30.0%) 8 (26.7%) 17 (28.4%)
Slightly Dry Skin 9 (30.0%) 13 (43.3%) 22 (36.7%)
After
Slightly Oily Skin 6 (20.0%) 6 (20.0%) 12 (20.0%)
Oily Skin 6 (20.0%) 3 (10.0%) 9 (15.0%)
Normal 0 0 0
Mild 24 (80.0%) 24 (80.0%) 48 (80.0%)
Before
Moderate 6 (20.0%) 6 (20.0%) 12 (20.0%)
GAGS

Severe 0 0 0
Normal 3 (10.0%) 3 (10.0%) 6 (10.0%)
Mild 18 (60.0%) 26 (86.0%) 44 (73.3%)
After
Moderate 9 (26.7%) 1 (3.3%) 9 (15.0%)
Severe 1 (3.3%) 0 1 (1.7%)

Before intervention
After intervention
125

100
OSSAS

75

50

25

Control Intervention
Mean raw score

Figure 1. Raw Oily Skin Self-Assessment Scale (OSSAS) Score Before and After Intervention. The
difference in the mean raw OSSAS score in the intervention group was larger than that in the control group,
J Gen Proced Dermatol Venereol Indones. 2020;4(2): 66-70 68
indicating an improvement in sebum excretion after using the blotting paper, although it was statistically not
significant (p > 0.05)
30
25
20
GAGS
15
10
Control
Mean raw score
Figure 2. Raw Global Acne Grading System (GAGS) Score Before and After Intervention. The difference in
the mean raw GAGS score in the intervention group was larger than that in the control group, indicating an
improvement in the severity of acne vulgaris after using the blotting paper (p < 0.05).
Sebum is made from the secretion of sebaceous
glands. Sebum is formed from the complete
disintegration of glandular cells into the
pilosebaceous ducts. Sebocyte is a specialized cell
that synthesizes fat and accumulates it as lipid
droplets in its cytoplasm. When sebocytes become
mature, they disintegrate and release their
contents of oily, waxy material into the follicle and
6,11
the skin surface.
In this study, we could not observe a statistically
significant effect of using OBP in improving the oily
skin problems based on the categorical data, which
is because the function of OBP is to absorb the
sebum that has been excreted into the surface of
facial skin. According to the study of Jung et al.,
sebaceous glands are laid as deep as 0.2–1 mm
below the skin surface and can be intervened by
12
413-nm blue light or 630-nm red light. However,
OBP works at the surface of the skin by absorbing
the excreted sebum and has only a temporary
J Gen Proced Dermatol Venereol Indones. 2020;4(2): 66-70
Before intervention
After intervention
Intervention
effect as it does not reach the sebaceous glands or
affect its sebum production.
Excessive sebum can result in perifollicular
inflammation and keratin plug. The keratin plug can
6
block the follicle and become the precursor of AV.
When excessive sebum is reduced using OBP, it
can decrease the formation of a new keratin plug.
When the follicle is not blocked by the keratin plug,
the growth of bacteria becomes slower due to the
reduced probability of colony formation in the
pilosebaceous follicle. Thus, the reduction of
surface oil using the OBP can improve the severity
of acne. In our study, some respondents showed
improvement in the raw GAGS scores, although it
was not significant enough to shift the respondents
to a better GAGS score category.
Our study also demonstrated a significant
improvement in the GAGS raw score but not in the
GAGS category profiles. This result indicated that
the number of our study respondents might not
69
have sufficient statistical power to identify the
improvement as being statistically significant.
However, we believe that this is the first study to
elucidate the benefit of applying OBP conducted in
Indonesia. A study with a larger number of
respondents and a longer period of intervention
might be recommended to confirm the beneficial
effect of using OBP in reducing AV severity.
Conclusion
OBP exerts a beneficial effect of improving AV
severity as indicated by the improvement in the
GAGS raw score. However, further study with a
larger sample size and assessing the impact of
other personal factors such as the frequency of
washing the face and cosmetic usage is required
to demonstrate more specific results on the effect
of using OBP in improving the severity of AV.
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