Correlation between Lipid Profile, Sebum Excretion Levels and

Severity of Acne Vulgaris in Non-obese Patients

Artini Wijayanti Islami

, Wresti Indriatmi

, Lis Surachmiati Suseno

, Evita Halim Effendi

Department of Dermatology and Venereology Faculty of Medicine, Universitas Indonesia /

Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia

Keywords: acne vulgaris, lipid profile, sebum

Abstract: Acne vulgaris is a common chronic skin disease involving blockage and inflammation of pilosebaceous

units. Previous studies about lipid profile in acne patients showed variable results. Lipid profile was

considered affecting sebum production. The aim of this study is to identify the correlation between lipid

profile, sebum excretion levels and acne severity. This study also determines the correlation between lipid

profile and sebum excretion levels. The study was conducted at Dr. Cipto Mangunkusumo General Hospital

(RSCM) in Jakarta. This was a cross-sectional study with total of 30 non-obese AV patients. The subjects

were divided into 3 groups based on the severity of AV. Total cholesterol, triglycerides, LDL, HDL serum

and sebum excretion levels were measured. The results revealed significant correlation between sebum

excretion levels and severity of acne vulgaris (r = 0,6689, p = 0,0001). There was no correlation between

total cholesterol, LDL, triglycerides, HDL and acne severity. Lipid profile had no correlation with sebum

excretion levels. The results of this study have proven that lipid profile does not affect the severity of acne

and sebum excretion levels. While increased sebum secretion will increase acne severity.

1 INTRODUCTION

Acne vulgaris (AV) is a very common skin

condition found worldwide, especially in teenagers

and young adults. The development of AV is

multifactorial, and a high-fat diet is considered by

the public as an associated factor supporting AV

occurrence. Several studies reported that AV is

exacerbated by the consumption of foods with high

glycemic index and dairy products. Consumption of

foods with high levels of fat and high glycemic

index can affect sebum production, thus fat is

speculated to play a role in AV pathogenesis (Veith

and Silverberg, 2011).

The correlation between lipid profile and sebum

synthesis in sebaceous glands is continously to be of

interest. Sebum contains triglycerides (40-60%),

wax esters (19-26%), squalene (11-15%),

cholesterol, and cholesterol esters. The activity of

sebaceous glands is influenced by circulating

androgen in the blood. Sebaceous glands are also

considered to express low density lipoprotein (LDL)

receptors, which act in the uptake of circulating

lipoprotein in the blood (Toruan et al., 2017). In

other words, sebaceous glands are able to

autonomously synthesize lipids, express the

androgen and lipogenesis enzymes receptors, which

lead us to hypothesize about the relationship

between lipid profile and sebum excretion.

Several studies reported the correlation between

AV and lipid profile with variable results. Bakry et

al (Bakry et al., 2014) in India investigated the

relationship between total lipid levels with AV

severity, and revealed significantly higher levels of

total cholesterol and LDL in AV patients compared

to non-AV group. El-Akawi et al (El-Akawi et al.,

2007). reported different findings regarding lipid

profile and AV, where they found low HDL levels

and significantly increased triglycerides and LDL in

AV patients compared to non-AV group. In

Indonesia, Budiani (Budiani, 2013) studied lipid

profile and AV severity, and found increased

triglyceride levels and lower HDL levels in patients

with severe AV compared to patients with mild AV.

Currently, the role of lipid profile in AV is unclear.

Several studies have shown a correlation between

sebum levels on AV, but there is no data available

on the relationship between lipid profile, sebum

levels, and AV.

150

Islami, A., Indriatmi, W., Suseno, L. and Effendi, E.

Correlation between Lipid Proﬁle, Sebum Excretion Levels and Severity of Acne Vulgaris in Non-obese Patients.

DOI: 10.5220/0008152801500154

In Proceedings of the 23rd Regional Conference of Dermatology (RCD 2018), pages 150-154

ISBN: 978-989-758-494-7

2 METHODS

This cross-sectional study was conducted in

September 2017 at Dermatology and Venereology

Outpatient Clinic, Dr. Cipto Mangunkusumo

National General Hospital (RSCM). Subjects were

consecutively sampled according to the inclusion

and exclusion criteria, through interviews and

physical examinations. The inclusion criteria were

AV patients, male or female, aged 18-40 years, with

normal or overweight body mass index (BMI). The

exclusion criteria were active smokers, regular

alcohol consumers, patients with diabetes mellitus

and any symptomps of clinical hyperandrogenism,

as well as patients under medications affecting blood

lipid levels, oral corticosteroids within the last 1

month, oral retinoids within the last 4 months, and

topical retinoids within the last 2 weeks.

The subjects were classified into three groups

based on the Lehmann criteria: mild AV, moderate

AV, and severe AV. During the subjects’ first visit,

informed consent was obtained and the AV lesions

were documented. Before the next visit, the subjects

were asked to fast for 9-12 hours before undergoing

tests for blood lipid levels and the subjects were

asked not to wash their face within 4 hours before

facial sebum levels measurement. Lipid profile test

for total cholesterol, LDL, triglyceride, and HDL

was performed in the Clinical Pathology Laboratory,

RSCM. Sebum excretion measurement was

performed in the Dermatology & Venereology

Outpatient Clinic, using Sebumeter (Courage-

Khazaka Electronic, Koln, Germany) on 5 areas of

the face (forehead, nose, chin, left cheek and right

cheek), with temperature of 22-24

C and humidity

of 40-50%. Afterwards, the mean facial sebum

excretion (MFSE) was measured. The data were

documented in the subjects’ records. Subjects were

informed of the lipid profile results through text

message and the subjects were advised to consult an

internist if dyslipidemia was present.

3 RESULTS

From 69 new patients with AV visited outpatient

clinic in September 2017, 30 subjects who met the

inclusion and exclusion criteria were enrolled in this

study. The subjects’ characteristics are described in

Table 1.

Table 1: Characteristics distribution of study subjects of correlation between lipid profile, sebum excretion levels and

severity of acne vulgaris in non-obese patients study in RSCM, September 2017.

Notes: AV= Acne vulgaris, n = numbers of study subjects; N = total of study subjects.



Charasteristics Mild AV Moderate AV Severe AV TOTAL

n % n % n % N %

Gender

Men

Women

Education

High school

Bachelor

66.7

33.3

Occupation

Unemployed

Employee

Body mass index

(BMI)

Normal

Overweight

100

86.7

13.3

Correlation between Lipid Proﬁle, Sebum Excretion Levels and Severity of Acne Vulgaris in Non-obese Patients

151

Table 2: Correlation between lipid profile, sebum excretion levels and severity of acne vulgaris in non-obese patients study

in RSCM, September 2017.

Variable

Severity of AV

Mild AV

n=10

Moderate AV

n=10

Severe AV

n=10

p value

Total Cholesterols

(mg/dl)

178.5

(SD 38)

188.6

(SD 3.7)

179.1

(SD 24.9)

-0.0519 0.785

LDL

(mg/dl)

119.30

(SD 34.7)

128.60

(SD 35.6)

119,90

(SB 26.1)

-0.0401 0.833

Triglycerides

(mg/dl)

(38-106)

66.9

(45-104)

(41-156)

0.1723 0.363

HDL

(mg/dl)

50.5

(SD 10.5)

51.6

(SD 8.8)

49,1

(SB 9.2)

-0.0496 0.795

Sebum excretion

(μg/cm

)

89.64

(SD 31.1)

166.58

(SD45.4)

176

(SB 37.9)

0.6698

0.0001*

Notes; n = numbers of study subjects; mg/dl = miligram per deciliter; μg/cm

= microgram per centimeter

square; SD = Standard deviation; *Spearman test; r= coefficient of correlation, statistically significant if p<0.05

There was no significant correlation between

lipid profile and severity of AV as shown in table 2.

Nevertheless, we found a moderate positive

correlation between sebum excretion levels and

severity of AV (table 2). We also obtained the

correlation between sebum excretion levels and lipid

profile in this study. There were no statistically

significant correlations between total cholesterol (r =

0.1245, p = 0.51), triglycerides (r = 0.2468, p =

0.19), LDL (r = 0.1145, p = 0.55), HDL (r = -01391,

p = 0.46) and sebum excretion levels. However,

there was no previous study regarding this subject.

4 DISCUSSION

No significant correlation between lipid profile and

severity of AV was found in this study. A similar

study by Budiani (Budiani, 2013)

in 2013 reported

significant positive correlation between triglyceride

and severity of acne. Budiani (Budiani, 2013)

also

revealed negative correlation between HDL and

severity of acne. Studies by El-Akawi et al (El-

Akawi et al., 2007) in 2007 and Manzoor et al

(Manzoor et al., 2016) in 2016 reported statistically

significant increased of triglycerides and LDL in

severe AV compared to mild and moderate AV, they

also found significantly decreased of HDL as the

severity of AV increased. While Bakry et al (Bakry

et al., 2014) in 2014 revealed that total cholesterols

and LDL were significantly higher in severe AV

compared to mild and moderate AV, while HDL

were significantly lower in severe AV compared to

mild and moderate AV. The latter studies showed

different results compared to our studies, which

might be caused by the high fat and high

carbohydrate dietary habits in India and Jordania,

where the studies were conducted. Variable results

of studies about lipid profile and severity of AV

might be due to other factors which affecting lipid

profile, such as genetics, race, diet, and lifestyle (e.g

exercise).

A study about risk factors of AV was conducted

by Bataille et al (Bataille et al., 2002).

in 2002. The

study involved 400 twin subjects with AV and 2414

twin subjects without AV as the control group. They

reported a significant relationship between family

history and AV, while there were no significant

differences in BMI, body height, birth weight,

cholesterol levels, triglyceride levels, HDL levels,

and blood glucose levels between the AV group and

the control group. The study, whose sample

population was larger than our study, revealed that

the emergence of AV is affected by genetics, while

lipid profile was not a risk factor for AV.

Our hypothesis of how an increase in lipid

profile may lead to an increase in androgen

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152

(DHEAS) and sebaceous glands activity needs

further investigation. Chen et al (Chen et al., 2011)

studied 318 subjects with polycystic ovary syndrome

(PCOS) and reported DHEAS was related to AV

occurrence in patients with PCOS, although

contrarily, DHEAS had a weak negative correlation

to cholesterol, LDL, and triglyceride levels. The

mechanism of how an increase in DHEAS leads to

decreasing lipid profile is unknown. Lipid profile is

influenced by genetic factors and liver metabolism,

while DHEA levels are influenced by its synthesis in

the gonads and adrenal glands; thus high levels of

cholesterol in the blood are not entirely converted

into DHEAS.

Despite the lack of correlation between lipid

levels and AV severity, the normal lipid profile in

our study’s subjects showed that AV patients aged

18-40 years have normal lipid profile. While

severity of AV may be influenced by other internal

factors, such as genetic factors (family history of

AV) and hormonal factors.

Our study discovered a moderate positive

correlation between sebum levels and AV severity.

It was compatible with previous studies such as

Janiczek-Dolphin et al.’s (Janiczek-Dolphin et al.,

2010) meta-analysis study in 2010, which reviewed

6 studies on the relationship between sebum levels

and AV. They found positive correlation between

AV and sebum levels. Choi et al (Choi et al., 2013)

conducted a study in Korea, their study investigate

the correlation between sebum levels and the

number of inflamed lesions in 914 AV patients. The

study found a weak positive correlation between

sebum levels and inflamed lesions in patients with

AV.

Sebum production is affected by genetic,

hormonal, and environmental factors. Walton et al

(Walton, Wyatt and Cunliffe, 1988) investigated

sebum excretion and its relationship with AV

severity in 20 pairs of identical twins, and 20 pairs

of fraternal twins. They reported the identical twins

had the same level of sebum excretion but with

different AV severity levels, while both variables

differ in the fraternal twins. The study showed that

sebum excretion was influenced by genetic factors,

while environmental factors played a larger role in

AV severity.

Studies by Youn et al (Youn et al.,

2005) in 2005 and Qui et al (Qiu et al., 2011) in

2011 suggested facial sebum levels in summer is

higher compared to winter.

Both studies supported

the theory of increasing sebum production rates is

affected by warmer temperatures. Based on those

previous studies, positive correlation between sebum

excretion levels and severity of AV in our study

could be affected by genetic, hormonal, and

environmental factors, such as the hot weather in

Jakarta.

There was no previous study about the

correlation between sebum levels and lipid profile in

patients with AV. However, Bhattacharyya et al

(Bhattacharyya, Connor and Spector, 1972) in 1972,

measured sebum excretion and cholesterol

composition in the sebum of five subjects with

hypercholesterolemia and six subjects in the control

group. They found no significant differences in

cholesterol levels in the sebum of subjects with

hypercholesterolemia and the control group, and

concluded that the relationship between lipid and

sebum levels can be studied further, especially in

patients with AV.

As we found positive correlation between sebum

excretion levels and severity of AV, the role of

medications to reduce sebum excretion is essential in

AV treatment. Retinoids are the main component of

AV treatment, especially in managing excessive

sebum production. However, oral and topical

retinoids use are limited due to their side effects,

which include teratogenicity, skin and mucose

irritation and dryness. Cleansing is important to rid

the dirt, cosmetics, germs, and reduce sebum lipids

on skin surface. It also helps the application of

topical medications. But currently, there are limited

studies about cleanser substances and role of

cleansing in AV patients. Therefore, more studies on

medications or substances which can reduce sebum

production in AV are also needed.

5 CONCLUSION

This study showed that the relationship between

lipid profile and AV still varies. Nevertheless, this

study also revealed that sebum levels are affected by

severity of AV. There are many factors affecting the

results of this study such as diets, genetics,

hormones and weather. Factors may vary depending

on the country where the study is conducted and

consequently affect the result. Further studies are

needed to observe the relationship between dietary

patterns and profile lipid in AV patients.

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