Home
JournalsCollections
For Authors For Reviewers For Editorial Board Members
Article Processing Charges Open Access
Ethics Advertising Policy
Editorial Policy Resource Center
Company Information Contact Us
OPEN ACCESS

Drug Policy and Treatment Bias Due to the Hyperlipidemia Theory of Acne Vulgaris: A Hypothesis and a Methodological Proposal

  • Reza Rastmanesh1,2,3,* 
Journal of Exploratory Research in Pharmacology   2024;9(1):65-68

doi: 10.14218/JERP.2023.00059

Received:

Revised:

Accepted:

Published online:

 Author information

Citation: Rastmanesh R. Drug Policy and Treatment Bias Due to the Hyperlipidemia Theory of Acne Vulgaris: A Hypothesis and a Methodological Proposal. J Explor Res Pharmacol. 2024;9(1):65-68. doi: 10.14218/JERP.2023.00059.

Abstract

The current paradigm presumes the higher the triglyceride level, the greater the probability of acne vulgaris (AV) occurrence or severity. However, this prevailing view lacks the necessary premises required to prove causality—for which the reverse should hold true: that low TG levels are predictive of less AV occurrence or severity. A low TG concentration in patients with AV has not yet been addressed, probably because of (i) the lack of any hypothesis connecting low TG levels to AV, and (ii) a lower prevalence of hypotriglyceridemia compared to hypertriglyceridemia in societies, which may lead to missing or misdiagnosis of other types of AV. Therefore, a formal or causal position statement cannot be issued. My observations on the high prevalence of severe cases of AV in a subgroup of individuals with extremely low levels of either serum TG or TC levels (between 40–60 mg/dl) encouraged me to share this experience. I suggest that studies investigating AV calculate—retrospectively or prospectively—the odds ratio of finding AV in people with extremely low levels of TG and/or TC. I further propose that researchers investigating different therapeutic approaches and medications in patients with AV measure relevant parameters/variables (such as those described in this paper) to yield necessary data for contemporary and future trials. The prevailing view, i.e., hyperlipidemia theory, lacks the necessary premises required to prove causality and should be revisited.

Keywords

Acne vulgaris, Lipid profile, Confounding variables, Study designs, Bias, Hypotriglyceridemia

Introduction

Acne vulgaris (AV) is considered an inflammatory disorder of the pilosebaceous follicle.1 Etiologically, AV results from a hypersensitivity of the sebaceous glands to a normal circulating level of androgens, which are aggravated by inflammation and propionibacterium acnes (P. acnes).2 Different causes and risk factors of AV include medications such as lithium, steroid hormones, and anticonvulsants. Other factors linked to AV include exposure to ambient sunlight, use of headbands, backpacks, underwire brassieres, and occlusive wear such as shoulder pads. Endocrine disorders (including polycystic ovarian syndrome and even pregnancy), genetic factors,2 lifestyle factors such as smoking and high carbohydrate diets, and dairy products have also been attributed to AV.3 Previous research on etiology and risk factors of AV can be criticized because control groups were matched by only sex and age and not by other variables, such as genetics, environmental factors,4,5 congenital adrenal hyperplasia,6 dietary factors, menstrual history,7 polycystic ovary syndrome,8 insulin resistance,5,8 insulin-like growth factor-1,5 altered sex hormones,9 medications (such as oral contraceptives and anti-acne agents),10 and personal hygiene.11

Recently, many studies have reported that people with AV have higher levels of total cholesterol (TC), triglycerides (TGs), and low-density lipoprotein-cholesterol compared to healthy controls.12–14 Some have wrongly concluded that an unhealthy lipid profile is an independent risk factor for AV. This conclusion is methodologically problematic by the arguments presented below:

It is well known that AV treatment with isotretinoin (Iso) elevates TC and TG.15 This presents a confounding factor that likely mediates the pathogenesis and treatment; that is, TG levels are not a risk factor per se. Another possibility is that primary or secondary higher TC and/or TG levels may not always be risk factors for AV, but rather, these situations may at least in some cases or subtypes of affected people confer a protective effect.

There are inter-individual variances in sebocyte differentiation16 that are connected with enhanced synthesis of lipids and accumulation in the sebocytes.17 Sebocytes, the major cells within sebaceous glands, are differentiated epithelial cells that gradually accumulate lipids and eventually disrupt, releasing their content (sebum) in a secretory process called holocrine secretion.18 Furthermore, both hepatic X Receptor-α and Cyclo-oxygenase 2 (COX-2) play a role in the pathogenesis of AV through their effects on cellular proliferation, inflammation, and lipid synthesis.19 There are again significant inter-individual differences in terms of hepatic X Receptor-α expression.20 Several other nuclear receptors are implicated in the regulation of growth and differentiation of sebaceous glands. For instance, the androgen receptor is highly activated by androgens, such as dehydroepiandrosterone, androstenedione, and testosterone, which are known to stimulate sebum secretion in human skin.21 Both estrogen receptor-α and -β are reported to be widely expressed in the sebaceous glands; nevertheless, estrogen locally antagonizes the effects of androgens within the sebaceous glands by regulating a set of genes that inversely impact growth and/or lipid production in sebaceous glands.22 In addition to the aforementioned variables, peroxisome proliferator-activated receptor γ gene expression, retinoic acid receptors, and retinoid X receptors play major roles in the differentiation of sebocytes.23

It was recently shown that activation of hepatic X Receptor-α induces lipid synthesis in sebocytes that parallels the induction of sterol regulatory-binding protein-1 and peroxisome proliferator-activated receptors.24 Inter-individual variability in the aforementioned factors further complicates the results and impacts the current understanding of the pathogenesis of AV and its treatment; overall, despite intra-individual variability, generally a similar treatment regimen is administered for patients with AV.

The unnecessary use of lipid-lowering agents in AV patients is well documented.25 There are reports of side effects such as the significant elevation of the plasma level of homocysteine26 and folic acid27 after Iso treatment. In terms of adverse effects, one study recently reported that there is a significant negative correlation between the severity of AV before treatment and the level of 25 hydroxy vitamin D, whereas after, Iso therapy serum levels of 25 hydroxy vitamin D were significantly increased.28

Methods

I extensively searched various medical databases for studies that reported the existence of AV in people with low TG and/or TC. Articles in English came from databases including Google Scholar, Web of Science, OT search, CINAHL, Medline, PubMed, OT Direct, Pedro, SID, ProQuest, Up to Date, OVID Medline, and Cochrane. English keywords included “low cholesterolemia”, “low triglyceridemia”, hypocholesterolemia, hypotriglyceridemia, dyslipidemia, “weight loss”, “low-glycemic diet”, “risk/benefit analysis”, acne, and “acne vulgaris”. The search was performed with no time limits and I found no published report in the English literature of such an observation. My observations on the high prevalence of severe cases of AV in a subgroup of individuals with extremely low levels of either serum TG or TC (between 40–60 mg/dl) encouraged me to share this experience. The data were collected from August 2011 to March 2023. Table 1 indicates that the incidence of acne vulgaris in subjects with hypocholesterolemia and/or hypotriglyceridemia is not only non-negligible but unexpectedly considerable.

Table 1

Clinical characteristics of subjects

Subjects, n = 960
P value
Subjects with hypercholesterolemia and/or hypertriglyceridemia (n = 762)Subjects with hypocholesterolemia and/or hypotriglyceridemia (n = 198)
Age* (years)25.6 ± 4.526.7 ± 5.5NS
Triglycerides* (mg/dl)311 ± 3449 ± 11<0.0001
Cholesterol* (mg/dl)307 ± 10148 ± 8.5<0.0001
Acne vulgaris (AV)**AV (+) (n = 711)AV (+) (n = 167)<0.0001
AV (−) (n = 51)AV (−) (n = 31)

Results and discussion

Results of weight loss trials employing two preliminary low-glycemic diets29 and other medications such as combined metformin and rosiglitazone30 show this to be an effective AV treatment. At the same time, there have been many other well-conducted clinical trials that have failed to have any beneficial effect on AV such as trials on exercise with and without metformin,31 a combination of metformin and oral contraceptives,32 gastric bypass surgery,33 and clinical trials with low glycemic index carbohydrates.34 Furthermore, the design of the aforementioned randomized clinical trials on the claimed beneficial effects of low-glycemic diets29 has been criticized35 for neglecting other aspects of the diet such as omega-3 fatty acids36 and dietary fiber,36 which have been shown to have strong therapeutic effects on AV. To the best of the author’s knowledge, no clinical trials are available regarding the detrimental effects of lipid-lowering agents as an ancillary treatment for AV—most likely for ethical reasons. Such a lack of evidence limits our ability to make a causal claim that higher serum lipids directly mediate the pathogenesis of AV. Here, one may conjecture that other factors such as inter-individual genetic and hormonal variability may have led to artifact results.

Based on the above, it would be misleading to describe AV as a skin disease that is solely associated with hypertriglyceridemia, and while superficially valid, such a description ignores the many component dimensions of AV; thus this view should be revisited. This short paper is not intended to be an all-inclusive overview of the etiology and treatment of AV. Rather, to come to a better understanding of how an altered lipid profile might affect AV, I suggest that future studies investigating such relationships should take all these considerations and variables into account.

Also, to come to a better understanding of how different dietary patterns and/or treatments affect AV, the possible interaction or modification effect between the above-mentioned confounding variables as well as other factors such as the role of cosmetics use and personal hygiene should be concomitantly considered in future studies, possibly facilitating the discovery of more suitable treatments for the management of this skin disease.

A precise and correct risk attribution is necessary to ensure the best therapeutic approach and eventually decision-making process for each patient. A risk/benefit analysis of AV treatment has never been carried out or at least reported) before, and it is unclear whether any beneficial anti-AV effect of standard treatments prevails over their adverse effect.

Limitations

There are limitations in my data analysis: I was not able to calculate adjusted OR due to missing data. Since many other variables can influence AV and its severity (such as waist circumference, waist-to-hip ratio, dehydroepiandrosterone, dehydroepiandrosterone sulfate, total testosterone, sex hormone-binding globulin, insulin resistance, free androgen index, follicle-stimulating hormone, luteinizing hormone, fasting glucose, or a homeostasis model assessment of insulin resistance), it would be wise to account for these important factors.

Abbreviations

AV: 

acne vulgaris

TC: 

total cholesterol

TG: 

triglyceride

Declarations

Acknowledgement

None.

Data sharing statement

No additional data are available.

Funding

This research received no specific grant from any funding agency, commercial or not-for-profit sectors.

Conflict of interest

The author declares no competing interests.

References

  1. Sutaria AH, Masood S, Saleh HM, Schlessinger J. Acne Vulgaris. [Updated 2023 Aug 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459173/ View Article PubMed/NCBI
  2. Motosko CC, Zakhem GA, Pomeranz MK, Hazen A. Acne: a side-effect of masculinizing hormonal therapy in transgender patients. Br J Dermatol 2019;180(1):26-30 View Article PubMed/NCBI
  3. Schnopp C, Mempel M. Acne vulgaris in children and adolescents. Minerva Pediatr 2011;63(4):293-304 View Article PubMed/NCBI
  4. Bataille V, Snieder H, MacGregor AJ, Sasieni P, Spector TD. The influence of genetics and environmental factors in the pathogenesis of acne: a twin study of acne in women. J Invest Dermatol 2002;119(6):1317-1322 View Article PubMed/NCBI
  5. Melnik BC, Zouboulis CC. Potential role of FoxO1 and mTORC1 in the pathogenesis of Western diet-induced acne. Exp Dermatol 2013;22(5):311-315 View Article PubMed/NCBI
  6. Speiser PW, Knochenhauer ES, Dewailly D, Fruzzetti F, Marcondes JA, Azziz R. A multicenter study of women with nonclassical congenital adrenal hyperplasia: relationship between genotype and phenotype. Mol Genet Metab 2000;71(3):527-534 View Article PubMed/NCBI
  7. Di Landro A, Cazzaniga S, Parazzini F, Ingordo V, Cusano F, Atzori L, et al. Family history, body mass index, selected dietary factors, menstrual history, and risk of moderate to severe acne in adolescents and young adults. J Am Acad Dermatol 2012;67(6):1129-1135 View Article PubMed/NCBI
  8. Alemzadeh R, Kansra AR. New adolescent polycystic ovary syndrome perspectives. Minerva Pediatr 2011;63(1):35-47 View Article PubMed/NCBI
  9. Farrell A, Alaghband-Zadeh J, Carter G, Newson RB, Cream JJ. Do some men with acne vulgaris have raised levels of LH?. Clin Endocrinol (Oxf) 1999;50(3):393-7 View Article PubMed/NCBI
  10. Rosen MP, Breitkopf DM, Nagamani M. A randomized controlled trial of second- versus third-generation oral contraceptives in the treatment of acne vulgaris. Am J Obstet Gynecol 2003;188(5):1158-1160 View Article PubMed/NCBI
  11. Conforti C, Giuffrida R, Fadda S, Fai A, Romita P, Zalaudek I, et al. Topical dermocosmetics and acne vulgaris. Dermatol Ther 2021;34(1):e14436 View Article PubMed/NCBI
  12. Jiang H, Li CY, Zhou L, Lu B, Lin Y, Huang X, et al. Acne patients frequently associated with abnormal plasma lipid profile. J Dermatol 2015;42(3):296-299 View Article PubMed/NCBI
  13. Romańska-Gocka K, Woźniak M, Kaczmarek-Skamira E, Zegarska B. Abnormal plasma lipids profile in women with post-adolescent acne. Postepy Dermatol Alergol 2018;35(6):605-608 View Article PubMed/NCBI
  14. Sobhan M, Seif Rabiei MA, Amerifar M. Correlation Between Lipid Profile and Acne Vulgaris. Clin Cosmet Investig Dermatol 2020;13:67-71 View Article PubMed/NCBI
  15. Karadag AS, Tutal E, Ertugrul DT, Akin KO. Effect of isotretinoin treatment on plasma holotranscobalamin, vitamin B12, folic acid, and homocysteine levels: non-controlled study. Int J Dermatol 2011;50(12):1564-1569 View Article PubMed/NCBI
  16. Paraskevaidis A, Drakoulis N, Roots I, Orfanos CE, Zouboulis CC. Polymorphisms in the human cytochrome P-450 1A1 gene (CYP1A1) as a factor for developing acne. Dermatology 1998;196(1):171-175 View Article PubMed/NCBI
  17. Downie MM, Sanders DA, Maier LM, Stock DM, Kealey T. Peroxisome proliferator-activated receptor and farnesoid X receptor ligands differentially regulate sebaceous differentiation in human sebaceous gland organ cultures in vitro. Br J Dermatol 2004;151(4):766-775 View Article PubMed/NCBI
  18. Schneider MR, Zouboulis CC. Primary sebocytes and sebaceous gland cell lines for studying sebaceous lipogenesis and sebaceous gland diseases. Exp Dermatol 2018;27(5):484-488 View Article PubMed/NCBI
  19. Bakry OA, El Farargy SM, El Kady NNED, Dawy HFA. Immunohistochemical Expression of Cyclo-oxygenase 2 and Liver X Receptor-α in Acne Vulgaris. J Clin Diagn Res 2017;11(9):WC01-WC07 View Article PubMed/NCBI
  20. Smith G, Ibbotson SH, Comrie MM, Dawe RS, Bryden A, Ferguson J, et al. Regulation of cutaneous drug-metabolizing enzymes and cytoprotective gene expression by topical drugs in human skin in vivo. Br J Dermatol 2006;155(2):275-281 View Article PubMed/NCBI
  21. Chen W, Thiboutot D, Zouboulis CC. Cutaneous androgen metabolism: basic research and clinical perspectives. J Invest Dermatol 2002;119(5):992-1007 View Article PubMed/NCBI
  22. Zouboulis CC, Chen WC, Thornton MJ, Qin K, Rosenfield R. Sexual hormones in human skin. Horm Metab Res 2007;39(2):85-95 View Article PubMed/NCBI
  23. Sertznig P, Seifert M, Tilgen W, Reichrath J. Peroxisome proliferator-activated receptors (PPARs) and the human skin: importance of PPARs in skin physiology and dermatologic diseases. Am J Clin Dermatol 2008;9(1):15-31 View Article PubMed/NCBI
  24. Hong I, Lee MH, Na TY, Zouboulis CC, Lee MO. LXRalpha enhances lipid synthesis in SZ95 sebocytes. J Invest Dermatol 2008;128(5):1266-1272 View Article PubMed/NCBI
  25. Ahmadvand A, Yazdanfar A, Yasrebifar F, Mohammadi Y, Mahjub R, Mehrpooya M. Evaluating the Effects of Oral and Topical Simvastatin in the Treatment of Acne Vulgaris: A Double-blind, Randomized, Placebo-controlled Clinical Trial. Curr Clin Pharmacol 2018;13(4):279-283 View Article PubMed/NCBI
  26. Polat M, Lenk N, Bingöl S, Oztaş P, Ilhan MN, Artüz F, et al. Plasma homocysteine level is elevated in patients on isotretinoin therapy for cystic acne: a prospective controlled study. J Dermatolog Treat 2008;19(4):229-232 View Article PubMed/NCBI
  27. Kim HJ, Lee SM, Lee JS, Lee SY, Chung EH, Cho MK, et al. Homocysteine, folic acid, and vitamin B12 levels in patients on isotretinoin therapy for acne vulgaris: A meta-analysis. J Cosmet Dermatol 2020;19(3):736-745 View Article PubMed/NCBI
  28. El-Hamd MA, El Taieb MA, Ibrahim HM, Aly SS. Vitamin D levels in acne vulgaris patients treated with oral isotretinoin. J Cosmet Dermatol 2019;18(1):16-20 View Article PubMed/NCBI
  29. Smith RN, Mann NJ, Braue A, Mäkeläinen H, Varigos GA. The effect of a high-protein, low glycemic-load diet versus a conventional, high glycemic-load diet on biochemical parameters associated with acne vulgaris: a randomized, investigator-masked, controlled trial. J Am Acad Dermatol 2007;57(2):247-256 View Article PubMed/NCBI
  30. Li Y, Tan J, Wang Q, Duan C, Hu Y, Huang W. Comparing the individual effects of metformin and rosiglitazone and their combination in obese women with polycystic ovary syndrome: a randomized controlled trial. Fertil Steril 2020;113(1):197-204 View Article PubMed/NCBI
  31. Tiwari N, Pasrija S, Jain S. Randomised controlled trial to study the efficacy of exercise with and without metformin on women with polycystic ovary syndrome. Eur J Obstet Gynecol Reprod Biol 2019;234:149-154 View Article PubMed/NCBI
  32. Altinok ML, Ravn P, Andersen M, Glintborg D. Effect of 12-month treatment with metformin and/or oral contraceptives on health-related quality of life in polycystic ovary syndrome. Gynecol Endocrinol 2018;34(10):859-863 View Article PubMed/NCBI
  33. Legro RS, Dodson WC, Gnatuk CL, Estes SJ, Kunselman AR, Meadows JW, et al. Effects of gastric bypass surgery on female reproductive function. J Clin Endocrinol Metab 2012;97(12):4540-4548 View Article PubMed/NCBI
  34. Reynolds RC, Lee S, Choi JY, Atkinson FS, Stockmann KS, Petocz P, et al. Effect of the glycemic index of carbohydrates on Acne vulgaris. Nutrients 2010;2(10):1060-1072 View Article PubMed/NCBI
  35. Logan AC. Omega-3 fatty acids and acne. Arch Dermatol 2003;139(7):941-942 View Article PubMed/NCBI
  36. Logan AC. Dietary fat, fiber, and acne vulgaris. J Am Acad Dermatol 2007;57(6):1092-1093 View Article PubMed/NCBI