Discussion
Acne is an important risk factor for psychological morbidity in young
and advanced ages in both genders. It is related to satisfaction with
appearance, decreased self-esteem and self-confidence, and increased
internalization (anxiety and depression) and suicidal tendency. In a
meta-analysis obtained from 42 studies on anxiety in acne cases, a
significant relationship was found between acne and depression and
anxiety and acne. It has been reported that the prevalence of depression
and anxiety are higher in acne cases (14). According to the hypothesis
of Stokes and Pillsbury; Emotional conditions such as depression and
anxiety disrupt the function and microbiota of the gastrointestinal
system, which paves the way for local and systemic inflammation. It is
thought that there may be a serious relationship between the
bacteriology and physiology of the gastrointestinal system, inflammatory
skin diseases and mood. In addition, based on the evidence, 40% of acne
cases have hypochlorhydria. This insufficient stomach acidity causes
colon bacteria to migrate to the distal part of the small intestine and
this disrupts the normal intestinal microflora. According to the
authorities, microbial flora changes triggered by stress increase
intestinal permeability and predispose to systemic and local
inflammation (2,3). Although the gut-brain skin axis hypothesis has been
known for a long time, it is not well understood, but microbiome studies
are opening the uncertainties here. In addition, the increase in
Substance P secretion with the stimulation of the nerves that release
substance P was observed in both acne cases and intestinal dysbiosis.
Substance P is responsible for the release of proinflammatory cytokines
in acne pathogenesis (15,16,17,18).
Multiple comorbidities associated with IBS have been reported as somatic
pain syndromes (fibromyalgia, chronic fatigue syndrome, and chronic
pelvic pain), other gastrointestinal diseases (gastroesophageal reflux
dyspepsia), and psychiatric diseases (major depression, anxiety, and
somatization) (19). Low-grade inflammation was found to be important in
IBS pathogenesis. In a study, serum inflammatory cytokines were found to
be increased in IBS cases compared to controls (20,21). Increase in
small intestine bacterial flora is associated with anxiety and
depression, and recovery of flora provides emotional improvement)
(22,23). In half of the cases, IBS originates from the intestine first
and psychological stress develops later(4,5,6,7). Parallel to the
literature a significant difference was found between the anxiety scores
of the acne cases and the control group in this study, but there was no
relationship with depression. It can be due to the number of cases or
the characteristics of the selected sample. Depressive patients may not
have been detected due to their unwillingness to participate in this
study. When looked in terms of intestinal habits and IBS, patients with
acne and control group did not differ. There was no relationship between
the global acne scores and bowel habits or IBS. In the recent study by
Demirbaş et al., 300 acne patients were evaluated with Rome IV criteria
and IBS was found significantly higher in patients with acne. IBS was
also correlated with the global acne scores (24). In our study, Rome III
criteria were used because it was validated and reliable in Turkish
(Ozgürsoy Uran.et al) whereas Rome IV criteria has not been validated
for Turkish population yet. Threshold values of Rome IV criteria are
based on Western data and language issues are important; if it is not
translated properly, it may lead to misunderstanding. The different
results are due to the use of Rome IV criteria, which is criticized for
reliability in non-Western population in many articles(25, 26). Among
other studies on IBS and skin diseases relation, Shalom et al. showed
that IBS increased in patients with chronic urticaria (27). İslamoğlu et
al. Reported that IBS was more common in atopic dermatitis group. In the
study of Kim et al., a relationship was found between rosacea and IBS,
while an increase in acne rosacea was found in cases with IBS(28).
There are limited number of studies investigating the relationship
between acne and physical activity. Alshammrie et al. did not find a
significant relationship between physical exercise and acne(29).
Similarly, in another study conducted in Tehran, it was reported that
there was no relationship between physical activity and acne(30). In our
study, in accordance with the literature, no difference was found
between the acne cases and the control group in terms of physical
activity.
In recent studies, the role of a low glycemic index high fiber diet in
the course of acne vulgaris treatment has been shown (31). In the study
conducted by Kaufmann et al., a significant improvement was observed in
the skin in the study in which he consumed 30 g of high-fiber breakfast
cereal per day (32). Smith et al. demonstrated the positive effect of a
diet rich in fiber and low glycemic index diet(33). In our study, we
could not find a relationship between fiber consumption and acne.
Further studies are needed to evaluate both fiber and glycemic index
impact in large case series.
In a study investigating acne vulgaris and BMI, it was found that the
incidence of severe acne was increased in adolescents with high BMI
compared to normal ones(34). Inflammatory acne lesions were increased in
patients with higher BMI and non-inflammatory acne lesions were found to
be increased in those with low BMI(34). High BMI also triggers high
levels of insulin-like growth factor-1 (IGF-1) release. IGF-1 stimulates
keratinocyte proliferation, sebaceous lipogenesis, and androgen
synthesis (34). In our study, no statistical difference was found
between the acne cases and the control group in terms of BMI.
Smoking is related with many adverse effects on the skin(35). Smoking
affects sebum production, induce microcirculation and oxidative
stress(36). According to a study by Schäfer et al. acne prevalence was
significantly higher in active smokers like our study (37). Smoking can
increase vascular endothelial inflammation, causing exacerbation of both
acne lesions and irritable bowel syndrome (38). Contrary to
expectations, there was no relation between smoking and irritable bowel
syndrome in current study.
Coffee consumption reduces non-melanoma skin cancer, melanoma, and
rosacea (39). Consumption of foods containing a high glycemic index
negatively affects acne, but there is no information in literature about
coffee interaction. In our study, acne patients were consuming more
coffee. Coffee type was not questioned; it would be informative to make
further studies with different coffee types. Older people consume mostly
Turkish coffee and young people increasingly consume filter coffee or
instant coffee in Turkey.
A limitation of this study is the relatively small sample size.