Physical Activity and Dermatology Quality of Life: A Study During COVID-19 Pandemic in Surakarta, Indonesia

Because access to such recreational facilities is an im-portant facilitator of physical activity (PA), a lack of space and chances to move, exercise may promote sedentary behavior. During the social distancing period, an earlier study has reported a decreasing number of physical activity from 69% to 39% and its impact on the increased number of depression and anxiety during the pandemic. 6 Other published systematic review has shown that most studies report a decrease in physical activity and an increase in sedentary behavior during the lockdown in patients with various medical conditions, like type 1 and 2 diabetes. 7 A study involving nationally representative data concluded that adults in Indonesia should live more active life-ABSTRACT Context/Background: Earlier studies have shown a possible correlation between skin health and physical activity. Moreover, the COVID-19 pandemic has impacted physical activity levels due to many rea-sons. Aims/Objectives: This study aims to analyze the correlation between physical activity and dermatology quality of life during the COVID-19 pandemic. Methodology: A cross-sectional study was conducted in Surakarta, Central Java, Indonesia. This study used Dermatology Life Quality Index (DLQI) and International Physical Activity Questionnaire Short Form (IPAQ-SF) in Bahasa Indonesia to measure dermatology quality of life and physical activity. Results: A total of 207 adults participated in this study. Our study showed that females are at risk for developing a DLQI score >10 (PR: 1.23, 95% CI: 3.05-4.97). There is no significant relationship between physical activity measured in IPAQ-SF with skin-related quality of life measured by DLQI. Conclusions: A significant relationship was observed between the female sex and comorbidity with a skin condition that impairs life quality. However, this study found no significant relationship between physical activity measured in IPAQ-SF with skin-related quality of life measured in DLQI.


INTRODUCTION
The COVID-19 pandemic has been going on for about 2 years since its first recognition in China in December 2019. In April 2022, Indonesia recorded 6 million COVID-19 cases with 156,000 death cases. 1,2 The widespread pandemic has affected many sectors in a health area. 3 Governments' COVID-19 containment measures have evolved to include the shutdown of public parks, gyms, sports facilities, and clubs. Because access to such recreational facilities is an important facilitator of physical activity (PA), a lack of space and chances to move, exercise may promote sedentary behavior. 4,5 During the social distancing period, an earlier study has reported a decreasing number of physical activity from 69% to 39% and its impact on the increased number of depression and anxiety during the pandemic. 6 Other published systematic review has shown that most studies report a decrease in physical activity and an increase in sedentary behavior during the lockdown in patients with various medical conditions, like type 1 and 2 diabetes. 7 A study involving nationally representative data concluded that adults in Indonesia should live more active life-styles since more than one-third of Indonesians do not get adequate physical activity. 8 The significant decrease in physical activity during the pandemic could worsen this situation.
Nevertheless, physical activity has been widely known for its numerous health benefits and its impact on the good quality of life. Regular moderate physical exercise improves cell tolerance to oxidative stress and improves skin health. 9,10 The Maastricht Study, a cohort of type 2 DM patients, showed that higher physical activity levels increased cutaneous microvascular vasodilation. 11,12 A meta-analysis showed a clear benefit of exercise in increasing skin microvascular reactivity in a group of adults, especially the elderly and adults who were previously sedentary. 13 Another study found that exercise improves the skin's ability to retain moisture and can prevent future skin problems. 14 Physical activity might impact the quality of life, especially the dermatology quality of life in those impacted by chronic skin diseases.
Additionally, many studies have reported fewer non-COVID-19 patients visiting the hospital. In the nonemergency department, a previous study in Italy reported an 80-90% decrease in dermatology consults. 15 In Indonesia, an earlier study in Dr. Sardjito General Hospital showed a 61.2% decrease in patients visiting outpatient dermatology and venereology clinic. 16 These decreases manifest from lockdown regulation from the government, patients' hesitation to visit hospitals for non-urgent matters, and concerns of virus exposure at the health center. 16 Patients with chronic skin diseases are especially disadvantaged during the COVID-19 pandemic.
A limited number of studies reported the dermatological condition and the decrease of physical activity during COVID-19 separately, but to our knowledge, a study about the correlation between physical activity and dermatologic quality of life, especially during the COVID-19 pandemic, has yet to exist. Thus, this study aims to analyze the correlation between physical activity and dermatology quality of life during the COVID-19 pandemic.

METHODOLOGY
Study design: This cross-sectional, observational study was conducted in Surakarta, Central Java, Indonesia, from May to June 2022.

Participants:
The inclusion criteria for this study are adults aged 18-59 years old and currently living in Surakarta, Central Java, Indonesia. Participants are asked to join the study by online invitation through chat messengers and flyers.
Data collection: The data was collected through an online questionnaire in Google Forms. The study was performed in accordance with the Declaration of Helsinki principles, and all subjects provided their written informed consent before participating. De-mographic data such as sex, age, income, job, education, weight (kg), height (cm), and comorbidity were collected. Education is reported as low and high; ones are said to have a low education status when they did not or only complete high school as stated per Presidential Degree of Indonesia. 17 We use the Asia-Pacific standard for BMI classification. 18 Comorbidity is stated as having an underlying condition such as hypertension, diabetes mellitus, cancer, and autoimmune disorder.
The dermatological quality of life was measured using the Bahasa Indonesia version of the Dermatology Life Quality Index (DLQI), which was already validated. 19 DLQI, a specific instrument to measure the quality of life impacted by skin diseases, is used to measure the quality of life in this study because specific instruments focus more on the relevant domains, characteristics, or complaints about a particular disease. Disease-specific instruments are also more responsive to assessing changes in quality of life than generic instruments. 19 DLQI consists of 10 questions with a minimum score of 0 and a maximum score of 30. Different band of DLQI score indicates a change in the patient's quality of life. A score of 0-1 indicates no effect at all; 2-5 small effect; 6-10 moderate effect; 11-20 very large; and 21-30 indicates an extremely large effect on the quality of life.
Physical activity during the COVID-19 pandemic is measured using the International Physical Activity Questionnaire Short Form (IPAQ-SF) in Bahasa Indonesia. IPAQ-SF has been validated in the Indonesian population. 20 IPAQ-SF consists of 7 items. The interpretation of IPAQ-SF is aided by automatic scoring Microsoft Excel spreadsheet. 21 IPAQ-SF scores were classified into 3 categories (1-3), each for low, moderate, and high, respectively.

Statistical analysis:
Data were incorporated into a Microsoft Excel spreadsheet. The analysis was run using SPSS version 26 (IBM corp, USA) and STATA version 14 software (StataCorp, USA). Kolmogorov-Smirnov and Shapiro-Wilk tests were used to assess the normality of data. The prevalence ratio (PR) and 95% confidence interval (95% CI) were then calculated using the Poisson regression with a robust variance estimator test.

RESULTS
207 participants completed the survey. The demographic data are listed in Table 1. In short, the majority of the respondents were female (77.8%, n = 161), completed a higher education (87.0%, n = 180), and having no comorbidity (94.2%, n = 195). IPAQ scores were evenly distributed, with the moderate score being the most common (51.2%, n = 106). DLQI scores were left-skewed, typical with a score of 0-1.
The distribution of the response to the DLQI questionnaire is listed in Table 2. Almost all items consistently had a "not at all" as an answer, with question 1 being the exception. A "very much response" was the least common answer to every question. The item with the most "very much" answer was the Q2 (embarrassment and discomfort). DLQI score showed a variation in the health-related quality of life (HRQOL), with a predominance of no impact on HRQOL (43.96% were between 0-1). DLQI score with an extremely large impact on patients' HRQOL was the least common (0.97% were between 21-30). Table 3 and Picture 3, comorbidity has the most significant risk of DLQI score being >10, with PR: 9.71 (95% CI: 1.12-84.27). Another risk was fe-male sex (1.23 (95% CI: 3.05-4.97). Other variables showed an insignificant result of PR. The relationship between DLQI and IPAQ-SF showed an inconsistent result, as observed as being higher in "moderate" compared to "low" IPAQ-SF and went lowest in the "high" category of IPAQ-SF (Figure 1).
Previous studies also showed that the female sex risks developing a higher DLQI score. 22,23 The finding could be associated with the general female stereotype that shows greater interest in appearance. Thus females tend to have a worse disease-specific healthrelated quality of life than their male counterparts. 23,24 We also found that comorbidity is a significant risk factor for developing a higher DLQI score (PR: 9.71, 95% CI: 1.12-84.27). It has been long known that patients with skin disease have a lower quality of life than those who do not. 25,26 Chronic skin conditions may lead to psychological problems such as anxiety and insomnia, as well as physical distress such as pain and discomfort. 27,28 Other predictors showed no significant risk with the DLQI score >10, as stated in table 3 by their 95% CI, including the IPAQ-SF score. The association between the DLQI and IPAQ-SF was inconsistent, as it was discovered to be greater in the "moderate" IPAQ-SF category than in the "low" IPAQ-SF category and lowest in the "high" IPAQ-SF category. A previous study in South Korea on female students also found similar results. In the study, physical activity level, measured by IPAQ, has little or no effect on skin health outcomes in South Korean female college students. 29 In contrast, previous evidence showed that subjects with moderate and high physical activity have a moister skin than those with low physical activity as measured with IPAQ-SF. 14 However, it is also known that too much physical activity has a negative effect on skin health, which might explain the inconsistency in the results.   Previous findings highlighted that high-intensity exercise could lower skin hydration than before exercise. The decrease in skin hydration following physical activity is transient. It is caused by sweating, which causes swelling in the stratum corneum and thus, increases the outflow of moisturizing factors. 30 A study on skin mechanical properties found that habitual moderate-to-vigorous physical activity is a factor in influencing the mechanical properties of the skin. 31 Vierck et al. concluded that physical activity above a particular threshold causes oxidative stress in the skin, accompanied by a drop in antioxidant content. 32 In addition, a review found that physical exercise had a twofold effect on the skin. Regular moderate physical activity provided protection against oxidative damage, but endurance exercise performed without training caused oxidative stress. 10 Further research should delve deeper into the difference between populations and consider the threshold of physical activity advantageous to skin health.
It is also recommended to use other means of skin health measurements.
This study is not without limitations. As this study used convenience sampling, it might not reflect the general population. This study also used a selfadministered questionnaire, which might cause bias. A previous study reported inequivalence of the DLQI questionnaire amongst different cultures despite being validated with the local language. Skin conditions were perceived differently amongst different cultures. 33,34 These conditions might result in the study bias.

CONCLUSION
A significant relationship was observed between the female sex and having comorbidity with a skin condition that impairs life quality. However, we found no significant relationship between physical activity measured in IPAQ-SF with skin-related quality of life measured in DLQI.