Table 1: General characteristics of the medical students in the study

General characteristics		Study group  (n=251)
Age in years	<20 years	80 (32%)
	= 20 years	171 (68%)
Gender	Male	166 (66%)
	Female	85 (34%)
Residence	Albaha	200 (79.7%)
	Others	51 (20.3%)
Cumulative average of marks	<2.5	64 (25.5%)
	= 2.5	187 (74.5%)
	First	69 (27.5%)
Academic year	Second	59 (23.5%)
	Third	47 (18.7%)
	Fourth	39 (15.5%)
	Fifth	21 (8.4%)
	Sixth	16 (6.4%)

Table 2: Distribution of stressors among the medical students in the study.

Stressors	Study group (n=251)
	Yes-no (%)	No-no (%)
Academic
Extensive academic curriculum	219 (87.3%)	32 (12.7%)
Frequency of examinations	215 (85.7%)	36 (14.3%)
Fear of poor performance on examinations	194 (77.3%)	57 (22.7%)
Lack of recreation	190 (75.7%)	61 (24.3%)
Psychosocial
Loneliness	121 (48.3%)	130 (50.7%)
High parental expectations	113 (45%)	138 (55%)
Family problems	81 (32.3%)	170 (67.7%)
Financial problems	32 (12.7%)	219 (87.3%)
Environmental
Traveling between faculty and home	111 (44.2%)	140 (55.8%)
Accommodations away from home	98 (39%)	153 (61%)
Quality of food in mess hall versus home	71 (28.3%)	180 (71.7%)
Living condition in hostel versus home	57 (22.7%)	194 (77.3%)

Table 3: The relationship between levels of perceived stress and general characteristics among the studied medical students.

General characteristics		LS students (n=48)   Â	MS students (n=126)   Â	HS students  (n=77)   Â	p-value
		No (%)	No (%)	No (%)
Age in years	<20 years	17 (35%)	34 (27%)	29 (38%)	0.24
	= 20 years	31 (65%)	92 (73%)	48 (62%)
Gender	Male	41 (85%)	83 (66%)	42 (55%)	0.002*
	Female	7 (15%)	43 (34%)	35 (45%)
Residence	Albaha	38 (79%)	104 (83%)	53 (75%)	0.46
	Others	10 (21%)	22 (17%)	19 (25%)
Cumulative average of marks	<2.5	10 (21%)	29 (23%)	25 (32%)	0.23
	= 2.5	38 (79%)	97 (77%)	52 (38%)
Academic year	1st to 3rd	43 (90%)	88 (70%)	44 (57%)	0.001*
	4th to 6th	5 (10%)	38 (30%)	33 (43%)

The binary logistic regression analysis of skin symptoms after gender adjustment among HS students when compared to LS group shows that loss of hair, nail-biting, oily, waxy patches on scalp, scaly skin, itchy skin, troublesome sweating, and pimples were the most frequently significant dermatological symptoms that occurred (p<0.001). Dry/ sore rash, other rashes on the face and pulling out hair represent other significant symptoms (p<0.05). In contrast, an itchy rash and warts on the hands were insignificant (p>0.05). Diagnosed cases of acne and eczema in binary logistic regression analysis with gender adjustment among HS students in comparison with LS group were insignificant (p>0.05) (Table 5).

Discussion

Medical school has long been described as a environment with multiple stressors that can influence students’ wellbeing with increasing evidence indicating that medical students have encountered significant stress in connection with their medical education [13]. The possible stressors which affect medical students’ lifestyles include academic, psychosocial and environmental stressors [8].

In this study, academic stress and psychosocial and environmental stressors represent 70.22%, 9%, and 8.02% of stress facing the medical students in the study group, respectively. Academic stress is the key potential source of perceived stress by 80.5% among the stressed medical students.

These data are in agreement with findings reported by many researchers in universities of the United Kingdom, India, Malaysia, and Thailand also highlighted that examinations and amount of taught content throughout the academic session were perceived as stressors by students [14-18]. Moreover, academic stressor factors predicted 78% variability in perceived stress among the students of medical school [19].

An extensive academic curriculum, frequency of examination, fear of poor performances on examinations, and lack of recreation represent 87.3%, 85.7%, 77.3%, and 75.7%, respectively. Psychosocial stressors were in the second rank of stressors and include loneliness (48.3%), high parental expectations (45%), and family problems (32.3%). Financial problems represent the least amount of stress on medical students (12.7%). Environmental stressors constitute the last order and include traveling between faculty and home, accommodations away from home, quality of food, and living condition in a hostel/home.

These findings were also reported by Al Rasheed et al. [20], who demonstrated that the majority of students perceived examinations (85%) and course load (74.1%) as stressors. Additionally, Anuradha et al. [8] noted that the most important reason for increased stress among medical school students was academic stressors. Key stress-related determinants included an comprehensive college curriculum, fear of failure or poor results at tests, and lack of leisure.

Medical students were designated as a well-known model of perceived stress risk factor. High rates of psychological disorders among medical students are most likely associated with the academic, financial, and social demands placed on students by medical school environments at a time when they are included in lifestyle and career issues [7]. Academic stress in medical students is a good indicator of their psychological well-being, capacity for hard work related to rigorous curricula, regular exams, adjustment to clinical practice and the challenging necessity to obtain clinical competencies and interpersonal skills while coping with their medical studies and patients [21].

Results of this research indicate that females were correlated with the most perceived stress rates after the third academic year. These results are consistent with previous studies showing that female is especially vulnerable to stress during everyday activities and in schooling [22,23]. In addition, Bin Saif et al. [7] found that the female gender was correlated with the highest perceived stress rates during their fourth and fifth years of medical school. Additionally, Al Rasheed et al. [20] found that levels of stress increased as students progressed from preparatory year to fourth year and decreased in fifth and sixth year students. On the other hand, Schut et al. [12] recorded no significant association between academic years and the degree of stress experienced by students.

In the present study, the majority of students (50.2%) have moderate perceived stress. The HS group (30.7%) was in the second order. Finally, the LS group accounted for 19.1% of reported stress. The mean values of perceived stress for the three different levels of stress among medical students were 0.73 ± 0.07, 0.5 ± 0.05, and 0.32 ± 0.06 respectively.

These findings were supported by Schut et al. [12], who found that 109 LS, 201 MS, and 112 HS subjects were classified among 422 American college students. In addition, Stewart et al. [3] noted that there were 120 LS, 232 MS and 119 HS allocated among 471 Australian university students. Moreover, in Saudi Arabia, Bin Saif et al. [7] reported that medical students were arranged in descending manner according to the frequency in MS (48.8%), HS (25.7%), and LS (25.5%), and the mean PSQ index among medical students was for the MS group (0.5 ± 0.06), HS group (0.71 ± 0.08), and LS group (0.31 ± 0.06).

In our study, medical students experienced a number of prevalent skin symptoms. The average number of symptoms in relation to stress levels among LS, MS, and HS were 2.4, 3.7, and 5.4 respectively. Four symptoms were reported as the most frequent number of symptoms/number of all medical students based on the collected self-reported skin disorders questionnaire. A highly significant number of non-symptomatic students and a significant number had one skin symptom among LS group when compared to the other groups. Among the HS group, the difference between other groups was very significant when the number of skin symptoms was five or more.

These results were approximated to data reported by Stewart et al. [3] which demonstrated that a number of specific skin complaints were significantly correlated with perceived stress rates among the students in the study. In addition, HS students indicated that Bin Saif et al. [7] had multiple skin complaints consisting of five complaints (19.1%) followed by six and four complaints (17.6% and 12.5% respectively), more than in MS and LS classes.

The results of the present work revealed that loss of hair, pimples beside oily, waxy patches on scalp, itchy skin, and troublesome sweating were the most prevalent dermatological symptoms occurring in all students at different levels of perceived stress. Perceived stress was different in each group; in the LS group, perceived stress was between 44% and 19%, in the MS group, it was between 58% and 32%, in the HS group, it was between 83% and 45%, and in all students, perceived stress was between 63% and 33%. These results were similar to observations reported by several researchers [3,7,12].

All investigated skin symptoms were highly significant in relation to the level of stress among the medical students in the study, but an itchy rash on the hands and pulling-out hair were barely significant. On the other hand, complaining of warts was insignificant. Such results were supported by similar findings reported by Schut et al. [12], which showed that increased levels of stress are correlated with itching, hair loss, oily/waxy/flaky patches on the scalp, increased sweating, scaly skin, onychophagia, trichotillomania, and itchy hand rash.

The magnitude of skin disorders among HS students in comparison with LS group after gender adjustment showed that loss of hair, nail-biting, oily, waxy patches on scalp, scaly skin, itchy skin, troublesome sweating, and pimples was highly significant, dry/sore rash and other facial rashes, and pulling-out hair were slightly significant, whereas an itchy rash on the hands, warts, acne, and eczema were insignificant.

These results are consistent with data comparing skin conditions among HS subjects who reported statistically significantly more pruritus, dry sore rash, scaly skin, hair loss, other face rashes, itchy hand rash, hyperhidrosis and trichotillomania than LS subjects, and wart complaints were negligible (p<0.05) [3]. In addition, Bin Saif et al. [7] found that HS students suffered from substantially more oily skin, waxy patches on the scalp and/or flakey scalp (or dandruff), dry/sore rash, pimples, itchy skin , hair loss, pulling out their own hair, scaly skin, distracting sweating, nail-biting, and other forms of facial rash compared to LS category.

In comparison, Schut et al. [12] found negligible discrepancies between groups about pimples, dry/sore rash and other face rash between the two extremes of perceived levels of psychological stress. Moreover, Stewart, et al. [3] noted no significant association for pimples, onychophagia or oily, waxy patches on scalp and/or flaky scalp when comparing the HS to the LS groups. Additionally, Bin Saif et al. [7] reported itchy rashes on hands and warts as highly significant among HS students in when compared with LS subjects.

Skin examination performed in this research diagnosed eczema (14%), acne (11%), urticaria (7%), seborrheic dermatitis (1%) and vitiligo (0.5%) in all examined medical students. There was a highly significant difference between of the increased level of stress and the diagnosis of eczema and acne. A highly significant progression of previously diagnosed dermatological diseases developed after starting their medical education and was associated with the increased levels of stress.

Such results agree with evidence recorded by the authors who reported that many dermatological disorders were caused or aggravated by persistent perceived stress or correlated with certain personality characteristics [24-26]. Perceived stress was suspected in a wide variety of skin disorders, including some forms of eczema, such as atopic and seborrheic dermis. In particular, acne (23.8%) and eczema (10.2%) were the most prevalent cutaneous diagnoses among Saudi medical students, both of which represented the most common diagnoses in the HS population (31.6% and 13.2%, respectively). Seborrheic dermatitis was found only in the HS group. There were no statistically relevant variations with regard to previous skin diagnoses between HS and LS [7].

Data support these findings based on the fact that skin has the dual role of being both the target and the source of stress mediators. In many skin diseases (such as Psoriasis Vulgaris, Atopic Dermatitis, Chronic Urticaria, Viral Warts, Hair Loss, and Acne Vulgaris), this dual role has been proved with the identification of complex stress-induced networks that are expressed locally. Skin reactions to stress may provide a prognostic guide for disease severity and risk of exacerbation, depending on the amounts of locally secreted corticosteroids and other mediators affecting skin integrity, inflammation and potential healing [9].

The strengths of this study are based on the considerable number of surveyed medical students from both male and female sections with a good response rate (80.2%). Additionally, the validated questionnaire was effective for detecting the origin of stressors, perceived stress, and skin conditions. Moreover, the presence of a dermatological consultant ensured accurate student diagnoses.

It is possible to conclude that academic stress, in comparison to other stressors, constitutes the key origin of stressors affecting stressed medical students. Female students in the academic years past the third academic year were associated with significantly higher perceived stress levels. Loss of hair, pimples beside oily, waxy patches on scalp, itchy skin and troublesome sweating are the major common highly significant dermatological symptoms among all students at different levels of perceived stress. There is a substantial difference between the perceived stress and the number of five and more skin symptoms. The correlation between elevated stress levels and the diagnosis of eczema and acne is crucially relevant. A highly significant progression of previous diagnosed skin diseases developed after being medical student. Hair loss, nail-biting, oily, waxy patches on scalp, scaly skin, itchy skin, troublesome sweating, and pimples were the highly significant dermatological symptoms in highly stressed students after sex adjustment.

Conclusion

These results reveal that academic stress on medical students should be reduced via modification of the academic curriculum and decreasing the frequency of examinations in addition to creating a plan to provide psychological and environmental support. Furthermore, this work raises attention about the presence of skin disorders among medical students, which is influenced by high academic stress. Moreover, psychiatric care (drugs or psychotherapeutic methods) can also have beneficial effects on skin diseases triggered by exposure to stress.

Declarations

Conflicts of Interest

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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