Dissertation

The Influence of Environmental and Lifestyle

factors in the Pathogenesis of Acne in adults

环境因素和生活方式对成人痤疮发病机制的影
响
Table of Contents
ABSTRACT ............................................................................. 3

INTRODUCTION .................................................................... 4

RESULTS .............................................................................. 16

DISCUSSION ........................................................................ 14

CONCLUSION ...................................................................... 33

REFERENCES ....................................................................... 34
1. ABSTRACT
BACKGROUND: Acne is a chronic inflammatory condition that is prompted or infuriated
by numerous environmental and lifestyle factors. Acne is a skin condition that arises when
hair follicles become clogged with oil and dead skin cells. The classic clinical
manifestation includes papules, pustules, comedones, scars and Cystic acne. Acne break out
has been considered as an inconsiderable issue, yet throughout the years it has showed that
people with acne lesion out has encountered social, mental, and emotional ramifications at
similar level of those with ongoing medical issues, similar to cardiovascular diseases,
diabetes, and joint inflammation. The negative influence of acne, particularly related to
health-related quality of life (HRQL) has been demonstrated regularly in studies but not
much evidence is available to correlate the factors that affect acne. This research work is an
attempt to provide some awareness and perception as well as suggest and illuminate some
solutions to acne related problems. To assess the impacts of individual, natural and social
environmental and lifestyle factors on acne and to construct a framework for the potential
influence of these factors on acne. Considering numerous skin conditions, including acne,
health-related quality of life is a welfare issue that has received valuable observation in the
past few years. It has been defined as the ‘functional effect of an illness and its subsequent
treatment approach towards the patient. To stretch further, health-related quality of life is a
multidisciplinary component that accounts for the repercussions of a patient’s condition on
psychological, physical and social sphere of welfare.

OBJECTIVE: This study aimed to investigate the relationship between influencing factors
and acne. A comprehensive and detailed research on different developing factors of acne
and their influence on individual’s quality of life was the main objective to be reviewed
here. The important impacting factors included, environmental factors, lifestyle and
hormonal factors as well as sebum production evaluation, skin barrier function and water
hydration function were also analyzed. It was estimated that most lifestyle and
environmental factors would be precisely linked with pathogenesis of Acne along with
overproduction or underproduction of sebum. In regards to skin hydration it was
approximated that it does not squarely influence acne but a healthy balance of skin
hydration and sebum contributes to healthy skin and therefore prevents acne lesion or
growth.

METHODS: In this research work a total of 60 individual all in the same age range (19-30
years) were divided equally according to the absence or presence of acne lesions. A brief
physical examination was conducted before selecting the cases for each group. Two groups
were formed each with 30 cases to study, a control group with inclusion criteria of absence
of any acne relation lesion and a patient group with inclusion criteria of presence of active
acne lesions as well as abnormal skin texture on physical examination. Both the groups
were subjected to a series of questionnaires, survey on background history and mandatory
laboratory tests.

RESULTS: The results of this study were remarkable in aiding with the better
understanding of factors that are linked directly or indirectly to acne. Acne was found to be
positively affected by environmental factors such as, pollution, extreme climate changes,
sun exposure, and lifestyle factors such as food habits (greasy, sweet, spicy) cosmetic
allergies, menstrual (hormonal) and certain medications, additionally high or low sebum
production, skin barrier damage and VISIA analysis of red areas indicating inflammation,
Pores and porphyrins detecting bacterial secretion on skin, were all directly linked to acne
aggravation or breakouts. Some factors were found to be indirectly affecting or causing
acne such as obesity, psychological, exercise, genetics, abnormal skin hydration, VISIA
analysis of Brown spots indicating hyperpigmentation and Spots suggesting acne scars or
conditions like freckles. While skin pH does not directly influence the pathogenesis of
acne, fluctuation in normal flora of the skin can still result in damaged skin that is more
susceptible to microorganisms and lead to acne. Similarly Transepidermal water loss
(TEWL) results in the damage of skin barrier function which cannot cause acne directly but
make it worse in individuals who already have it. Furthermore, the research of VISIA
analysis on Red areas of skin proved that these spotted areas precisely contributes to
inflamed acne lesion along with porphyrins that are the bacterial secretions clogged in the
pores paving way for severe acne lesion like comedones or cysts. More number of enlarged
pores were also found to be more visible in patient group then control group which
constitutes that acne prone skin is more vulnerable to develop pore areas that are
susceptible to be infected with microorganisms.

CONCLUSION: An attempt was made in this study to determine the direct and indirect
relationships between these environmental and lifestyle factors and acne regarding the
influence of laboratory skin tests such as sebum, TEWL and skin hydration analysis on the
risk factors for acne. To provide better treatment and therapy options for such a chronic
disease, it is crucial to recognize the indirect correlation between such factors and acne by
gaining understanding as to the influence of traditional factors on the pathogenesis of acne.
With reference to skin pH, it was assumed that it does not influence acne directly but
maintains a role in balancing the normal flora of skin to sustain healthy skin. Skin pH is
known to be more acidic in normal conditions, any further fluctuation in it can lead to the
growth of bacteria like Propionibacterium and eventually cause sebaceous glands to
overproduce sebum, and hence the pH and sebum function is also proved to be related in
regards to compensate the healthy skin function. This study determined an interrelationship
between sebum production measure, superficial barrier function, and skin hydration of the
stratum corneum (SC). When compared with the control population it was found that
patients with acne experienced excess sebum secretion and Transepidermal water loss
(TEWL) at higher levels.
This research paved the way to establish better analysis plan of Acne according to its
underlying cause with inflammatory/non inflammatory lesions, it also supported to
understand the impact of moderate and severe acne on patient's lifestyle and health as well
as creative idea of initiating a data processing and analysis platform for Acne patients in
Anhui in English. It can also assist to set up a more natural way to reduce the prevalence of
Acne. This study also had the potential to signify a better treatment plan by paving way for
new technology.

KEYWORDS: influencing, factors, acne, pathogenesis, sebum, TEWL, pH, hydration,

inflammatory, VISIA, obesity, pollution.

2. INTRODUCTION
A multitude of Chinese urban population encounter many skin related health provocations
provoked by rapidly changing city environments (e.g., air pollution, and increasing
population) and lifestyles (e.g., less physical movements, unhealthy diets, smoking and
alcohol consumption). Several skin condition are also non-contagious chronic diseases,
peculiarly acne that distinctly appears on the face, which can be undoubtedly stimulated by
a lot of external factors. When hair follicles end up becoming lodged in the pores with
excess oil and extra dead skin, that’s what causes acne to breakout. The typical clinical
manifestation includes papules, pustules, comedones, scars and in some worst cases Cyst.
Acne is a rising issue that is starting to effect individual’s lives much more than its previous
impact on patients. Acne effects more than just an individual’s skin, it effects their self-
esteem and confidence. Due to the high prevalence rate and recurrence because of treatment
failure, acne patients endure a lot of economic implications. Additionally, even though acne
is not considered a hazardous or serious health condition, it can still disfigure the external
physical appearance, which is why if it’s not treated timely, it leave lifelong scars on
patients. Four major pathogenesis are involved in the development of Acne, androgen-
induced increased sebum hyper production, altered follicular keratinization, inflammation
and Propionibacterium acnes. It is also influenced by environmental pollution, social
environment, changes in dietary habits and lifestyle, for instance, exacerbating air
pollution, consumption of sugary drinks. Hence, the prevalence of acne increases yearly
due to these numerous but common risk factors.
The negative impact of acne, particularly related to health-related quality of life (HRQL)
has been illustrated in many studies but very few studies have been conducted to study the
factors that lead to acne. Acne is known as a routinely skin disease with a substantial effect
on the standard of life. Presently, the research work related to influencing factors in the
pathogenesis of acne have been increasing in all categories and fields including sociology
studies, medicine or clinical researches, as well as epidemiological researches. Nonetheless,
the interconnection between environmental or lifestyle factors and acne has yet to be fully
investigated. This suggests that the emotional association of acne should also be considered
when dealing patients that have Acne. Therefore, just treating individuals with Acne is not
the solution to eradicate this condition and its related problems. More comprehensive
studies needs to be conducted through research work in order to be aware of the underlying
causes of Acne thoroughly.

In the past Acne has been considered as an insignificant problem but over the years it has
manifested that individuals with acne has experienced social, psychological, and emotional
implications at the same level of those with chronic health problems, like epilepsy,
diabetes, and arthritis. This brings us to the idea interpreting that why is it important to
study the developing factors of Acne. The facial lesions of acne can cause embarrassment
that is significant both socially and economically as acne can cause difficulties in finding
employment, low self-esteem, and depression. Despite the prevailing lay view that acne is
caused by lifestyle factors, a U.K. study reported that cosmetics, prescribed drugs, and
occupation were not associated with acne. On top of discomfort due to the clinical
symptoms of acne, patients may experience other negative impacts. One study researched
the relationship between unemployment among acne patient as compared to the control
group and the results suggested a direct correlation between acne and employment rates
(70). Furthermore, acne has be identifies to negatively affect the social behavior, personal
self-esteem and physical body appearance of individuals and it often co exists with
psychological conditions like depression, anxiety or extreme stress. Moreover, acne is
associated with poor financial burden, where one research study stated that cost of treating
acne in Germany adds up to approximately four hundred million euros yearly (71).
Motivation behind this research work is to write something which was less known earlier
and trying to contribute some useful information to those who seek it. This research work
may provide some insights and solutions to Acne related problems. To assess the impacts
of individual, natural and social environmental and lifestyle factors on acne and to
construct a framework for the potential influence of these factors on acne. The overall
purpose of this research work is to improve the social, psychological and emotional plight
of the patients suffering from acne by providing them with a better understanding of the
factors that develop to their acne conditions.
Acne is a chronic disease in which all environmental, lifestyle and genetic factors interlink
(17). However, previous acne epidemiological studies principally focused on individual
factors either family history, dietary, lifestyle, occupation, or psychological factors and
other natural and social environmental factors (29, 30), there is very limited research that
examines whether factors or elements accelerating and causing Acne can be studied and
prevented. In order to fill up this gap, this article will first do a comprehensive review on
the environmental and lifestyle factors affecting Acne and, and further build a framework
for the potential impact of how these components aid in the pathogenesis of Acne and
therefore what preventive measure can be acquired to decelerate the high prevalence of
Acne. The aim of this research and study is to explore and comprehend different underlying
causes and factors that develop acne. The main objective of this research plan is to obtain
maximum understanding of acne related causes as in simple words –why is acne caused?
At the end of this research the following specific Aims will be accomplished:-

i) Brief exposition about the impact of moderate–severe acne on individual’s lifestyle and
health.

ii) Comprehensive and detailed understanding of developing factors of Acne and their
underlying mechanisms.

iii) To enhance the effectiveness of future treatment method for Acne.

2.1 MATERIALS AND METHODS

2.1.1. Implementation of research work
Determination of study area and population

Study Population
Control Group: - 30 individuals with no medical history of Acne or any other
dermatological condition were selected voluntarily from the Study Area. Informed consent
was taken from all the selected people.
Target Group: - 30 patients were selected from outpatient clinic for survey, physical
examination and skin analysis.
Selection basis for Target group was confirmed diagnosed cases of Acne, the medical
history and clinical data was check and evaluated. The inclusion criteria for sample
population is those individuals suffering from acne and undergoing treatment or those
previously treated with acne and retaining preventive methods. In both cases the main
ground basis to select the individuals, is to understand the progressive factors leading to
their acne or acne related conditions.

Study Area: This research study was conducted in First affiliated Hospital of Anhui
Medical University, Outpatient Clinic of Dermatology and Ferry Skin Hospital. The staff
and doctors from Department of Dermatology of First Affiliated Hospital of Anhui Medical
University showed full cooperation and support for the research work. All individuals were
selected in the same age range from 19 years to 35 years old. Acne is more predominant in
females but in this research no such preference was given and individuals and patients were
selected from both genders for both the groups and as the cases occurred.

2.1.2. Data collection Methods

this research work’s design is descriptive analysis, therefore the data collecting methods are
mostly observatory and patient’s historical analysis.

Physical
Examination
Primary
Background
Data collection History
Methods
Laboratory
Secondary
Skin tests

Primary Sources for collecting data: -

1.Pysical examination: - The physical examination directed towards the acne lesion of
both the groups and observed the following lesion criteria for the research:-

Comedones: Comedones are one of the most routinely occurring types of acne lesions.
These lesions arise when the hair follicle becomes plugged with excess oil and debris which
is dead skin cells, that eventually precipitates to acne vulgaris. Comedones classically occur
as blackheads or whiteheads, both of which are ordinary lesion of acne.
Papules: Inflammatory lesions are regarded as papules. These small bumps are usually red
or pink and have the tendency to be extremely painful, tender and sensitive to touch
characterized by inflamed bumps.
Pustules: These inflamed lesions are typically filled with pus. This creates a yellow or off-
white color.
Scars: - Acne scars are permanent textural changes and indentations that occur on the skin
as a result of severe acne.
Cysts: This is the most severe form of acne that becomes inflamed deeply and gets infused
with pus. The skin texture of cysts feels much softer than the nodules but like papules, they
also have the tendency to become very tender.
Nodules: Nodules are another type of severe acne lesion like cyst, they are not infused with
pus and they grow under the skin. Nodules are generally bigger as compared to other acne
lesions and they are typically 1-2 centimeters wide.

2. History taking: - All sample population individuals and patients were subjected to very
thorough background history checking based on the following common triggering factors of
Acne:-

ENVIRONMENTAL FACTORS

-History of exposure to any t ype of pollut ion:

The most demanding type of urban environment hazard faced by Chinese mega cities is
undoubtedly air pollution is the most challenging environmental problem for Chinese cities.
Pollution can cause superficial skin to be clogged with germs and harmful chemicals that
disrupt the normal skin membrane and once that physiological barrier is damaged, the skin
is more prone to develop acne. Recently, a higher number of studies indicate a link between
skin problems and exposure to chemical pollutants, such as particulate matter (PM), volatile
organic compounds, ozone (O3), nitrogen dioxide (NO2) and sulfur dioxide (SO2). For
instance, pigment spot formation on cheeks has been related to NO2 exposure in women.
Yet, very few research information is available today with respect to the prevalence or
exacerbation of acne symptoms and pollution exposure (67).

History of working under extreme weather condit ions:

Temperature variations and humidity in different seasons and regional areas may give rise
to a number of discrete prevalence rates of acne. It was statistically noteworthy that acne
patient suffered from more acne related problems in summer months (standard temperature
range 32.2◦C) as compared to rainy weathers (standard temperature range 31.0◦C)and
winter season (average temperature 15.1◦C (48). Overproduction of sebum might cause
acne lesions to worsening. According to a systematic review and meta-analysis, the
prevalence rates of acne in the southern China was higher than that of the northern China,
because the southern areas are more humid and warmer than the northern regions.

- History of frequent sun exposure:

Sun exposure is assumed to play a huge part in the frequency of acne break out on skin.
Frequent sun exposure dries the skin out, the sebaceous glands get over active and this
excess sebum production known as seborrhea, is one of the main step in the formation of
blemishes causing acne. Another result of dried out skin is that it cornifys or keratinizes.
This indicates that skin cells on the surface become hard and therefore interfering with the
natural process by which dead skin cells are shed and prevents sebum from being able to
drain from the pores and as result Comedones are formed. Excess sweat production
increases under sun exposure, as does the rate at which it degrades on skin’s surface. This
creates an environment in which propionic bacterium acnes can thrive and spread.

- History of bacterial infestation:

A skin infection that can cause the pimple to be infected with Staphylococcus aureus may
cause cystic acne or painful red bumps. This type of infection is usually common in
patients with history of impetigo, rosacea or cystic acne. Bursting these pimples could lead
to further infection as bacteria can enter the lesion and cause pustules acne.

-History of superficial skin inflammat ion:

Patients with previous history of conditions like Eczema, dermatitis or pruritus can end up
with breakouts of Acne due to disrupted skin barrier or function. These type of conditions
usually cause cystic or nodular acne that more difficult to treat.

LIFESTYLE FACTORS
-History of Dietary Acne:
The relationship between unhealthy and unbalanced dietary habits and acne has generally
been in discussion of the research in acne and its pathogenesis. Presently, numerous
research studies have stated and established that consumption of high amounts of sweet,
sugary products and dairy products are potential risk factors for developing acne (32).
Considering that most of the studies did not bifurcated the types of spicy foods, the
correlation between spicy food and acne needs to be further inspected. Numerous studies
have estimated the importance of the glycemic index of several types of food and
abundance of glycemic in acne patients, which indicates that acne patients who intake diet
that is low in glycemic, also have reduced acne lesions s compared to the people on
relatively higher glycemic diets (68). The effects of certain dairy products has also been
studied in regard to dietary impacts on acne. The effects of omega-3 fatty acids and y-
linoleic acid intake has also been studied in patients with acne which indicated that diet
high in these two ingredients is healthy and beneficial because they contain fish and healthy
oils, therefore they consumption of omega-3 and fatty acids should be encouraged in
individuals with acne lesion (68).

-History of cosmet ic products allergies contribut ing to Acne :

Recurrence of certain acne lesions is caused by inappropriate use of cosmetic products, in
one specific research study it was indicated there is a significant positive correlation
between frequent exposure to cosmetics and the severity of acne in adolescent women (43).
In one study conducted in Korea the relationship between acne and the use of cosmetics
was established. This study set forth the influence of cosmetics, especially in acne patients
with a history of repeated treatment failures. The outcome of this study also displayed some
differences according to specific cosmetic types and formulations (74).

-History of Stress related Acne:

With the relentless social and economic alterations and fluctuation in today’s competitive
and challenging world, and with the broadening of remuneration void and the high levels of
stress attributed to it, the prevalence of cognitive disorders in China is as high as 9.3% (56).
Psychological factors prompt the secretion of neuropeptides and hormones that actuate cells
to partake in the acne lesions (57). This research study demonstrated that amidst college
students in the Northeast region of China, mental stress and depression were main risk
factors for acne (14). Dreno et al. suggested that personage with acne suffered from
significantly higher stress levels than in acne-free individuals (17).

-History Medicat ions Induced Acne:

Drug-induced acne, is a negative effect of certain systemic drugs, the drug class mostly
include corticosteroids, lithium carbonate, antiepileptic drugs (e.g. phenobarbital and
hydantoin derivatives), vitamin B12, thyroid hormones, cyclosporine A, antibiotics (e.g.
tetracycline and streptomycin), antituberculosis drugs, antiepileptic drugs (e.g.
phenobarbital and hydantoin derivatives), antimycotics, clofazimine, epidermal growth
factor receptor inhibitors (cetuximab, gefitinib), and halogen compounds (e.g. iodine,
bromine, fluorine). Usually, topical agents in cosmetics may give rise to acne breakouts
in women, particularly in the chin region. Reversing of symptoms was observed when
the causative agent’s drugs were discontinued.

-History of exercise related Acne.

Extravagant heat and sweating also promote to inflammation of the follicles which can
trigger and precipitates different type of acne lesions. The obstruction of pores and
accumulation of sebum and sweat in these pores is not directly linked to exercising and
acne but the use of tight clothing that prevents the natural process from occurring. Hot,
humid and sweaty environments may give rise to acne flares in individuals whose skin are
more vulnerable and susceptible.
-History of menstrual Acne:
Hormonal fluctuations are most frequently associated with acne breakouts in women with
hyperandrogenism being the most important link. Therefore, irregular menstruation in acne
patients should be attributed to hormonal imbalance and further studies must be conducted
to find the cause. In a study on a U.K. population-based sample, no correlation was
established between reproductive or hormonal risk factors and acne apart from the use of
Oral Contraceptive pills (72). In another research survey conducted in USA, the common
belief that women experience pre or peri-menstrual acne flares was studied. However, the
exact prevalence of premenstrual acne is unknown. Based on the analysis of previous
research prior to this USA study, an estimation of 44 percent of reoccurrence rate was
indicated in pre-menstrual women, although Lucky et al (75) suggested that 63 percent of
women had a higher rate of inflammatory acne lesions in the late luteal phase of the
menstrual cycle. Out of the women who reported peri-menstrual acne symptoms, 56
percent were found to have exacerbation of typical symptoms one week prior to
menstruation, 17% were documented to show worsening symptoms during their menses,
only 3% percent reported worsening symptoms after their menstruation has ended, and 24%
women detailed worsening lesion throughout their cycle. The women that were found with
peri-menstrual acne, 91% of participants observed that their acne breakouts initiated within
the seven days before the start of their menses and 77 percent noted that their acne lesions
disappeared within one week of menstruation ceasing (73).

-Obesit y related Acne:

The predominant BMI categories in China are obese and overweight which is 46 percent
for adults and 15 percent for children respectively. The growing prevalence of obesity and
its correlation with chronic diseases has a consequential impact (21). Increased production
of the insulin-like growth factors−1 (IGF-1) in the body (22, 23) and insulin resistance are
potential mechanisms through which obesity has an influence on the occurrence of acne
(24). Many research studies have already demonstrated and established a positive link
between obesity and acne (25-27). However, a study in Taiwan, China, suggested that BMI
was negatively and indirectly linked with the occurrence of acne lesions ranging from
moderate to severe post-adolescent acne among women aged between 25 -45 years (28).
Recently a nationwide study of 600,404 adolescents in China mentioned and demonstrated
that overweight and obesity were inversely linked with acne. Hence, the quantity of
adolescents with acne decreased gradually from the underweight to the severely obese.
Therefore, the correlation between obesity and acne should be further explored by keeping
in mind other influencing factors.

GENETICS FACTORS
-History of any family members wit h Acne:
Off springs and family members of acne patients tend to suffer from acne, which is
clinically observed. Heredity and genetic factors plays a domineering part in the occurrence
of acne, particularly in severe acne lesions with nodules, cysts and scars. The results of a
large study conducted in U.K suggested a strong genetic mutation for acne as 81% of the
population showed variation in acne scores. Adult twins were linked to genetic factors
inheritance and family history of the disease confirmed a consequential familial clustering
(72). The connection between acne and higher androgen levels has been disputable as some
studies have reported increased levels of both total and free androgens in acne, whereas
others have reported androgen levels within normal range and no association or link
between acne severity scores and testosterone levels. (72).

Secondary Sources for collecting data:

1- Survey: - The candidates answered a questionnaire that would include general social
information e.g., age and sex, personal habits e.g., smoking, alcohol intake, and dietary
habits, menstrual pattern and history, history of adolescence acne, history of acne in
relatives, acne pattern identification, and stress levels. The above information was collected
from questionnaires and survey forms subjected to each individual in target population. A
basic survey form was designed to record all the background required detail as well as
personal information.

2- Lab Skin tests: - The following lab tests were performed on both the sample
populations in order to give a collective insight on the factors that contribute most to the
pathogenesis of Acne.

Corneometer (skin hydration):- The Corneometer indicates the hydration level of the
superficial layers of the skin that is stratum corneum. The purpose of this test is to measure
the relative permittivity of upper skin layers to determine whether the skin is very dry, dry
or normal as extremely dry skin could lead to the breakout of Acne in some cases. The
Corneometer® CM 825 is the most used instrument to determine the skin hydration level
on the surface, mainly the stratum corneum. The measurement principle is based on
capacitance quantification of a dielectric apparatus. The Corneometer® CM 825 quantifies
the alteration in the dielectric constant because of superficial hydration levels changing the
inductance of a precision capacitor.

Transepidermal water loss (TEWL):- Transepidermal water loss (TEWL) is the amount
of water that passively evaporates through skin to the external environment due to water
vapor pressure gradient on both sides of the skin barrier and is used to characterize skin
barrier function. The Tewa meter is a quantifying device which asses trans-epidermal water
loss (TEWL). This parameter illustrates details on the coherence of the protective limiting
functions of the skin. The calculations are recorded by the implementation of a probe to the
skin surface for 30 seconds. Upon contact with the skin, the water evaporation rate is
obtained. Higher or lower levels of TEWL may indicate a damaged skin barrier function.
If the skin barrier is damaged, the amount of water emitted from the body is increased
meaning increased TEWL which in turn could make skin more vulnerable to develop Acne.

Skin pH: - An acidic pH allows the resident flora to grow on skin. As the pH increases, the
resident flora changes. In particular, acnes grows well in an environment with a pH range
of 6.0-6.5; however, when pH drops to 5.5, its growth noticeably decreases. The Skin-pH-
Meter pH 905 is a faster, more reliable, easy and economical friendly device that
particularly measures the pH on the surface of the skin or the scalp. The quantifying
measuring principle is built on a superlative combined electrode, where both H+ ion
sensitive electrode and supplementary reference electrode are fixed and situated in one
glass probe. It is connected to another probe handle containing the measurement
electronics.

Sebum analysis:- Elevated sebum excretion is involved in the pathophysiology of acne, as

body parts rich in sebaceous glands are the areas where acne lesions are manifested. An
excess of sebum combined with dead skin cells can block pores and cause comedones such
as blackheads and pimples. The Sebumeter® SM 815 is a widely acknowledged device to
calculate sebum on skin, scalp and hair. The measurement concept is built on grease spot
photometry. The strip of the Sebumeter® SM 815 is touched with skin or hair. It becomes
transparent with proportion or quantity of the sebum on the surface of the quantifying area.
Then the tape is placed into the opening of the tool and the transparency is calculated by a
photocell. The exhibition of light transmission illustrates the sebum content.

VISIA Skin Analysis:-

The RBX® Technology splits up the distinctive color impression of red and brown skin
area components for visualization of conditions such as spider veins, hyperpigmentation,
rosacea, and acne. Sun damage areas are visualized by UV photography for better analysis
and assessment results which comprises of UV fluorescence imaging for clear displaying of
porphyrins.
In addition to skin health assessment, the VISIA Complexion Analysis system can also an
aid to compare the progress of treatment to ensure patients are achieving the desired results.

1. SPOTS: Also referred to as “skin irregularities,” these areas cover conditions like
hyperpigmentation, freckles, vascular lesions or acne scarring. VISIA analysis is able to
sight their location, size and color, for better treatment and therapy options accordingly.
2. WRINKLES: This analysis shows the location from fine lines to deeper creases and how
much in depth they are. Fine lines are characterized as light green lines, while deeper
creases appear in a darker green hue.

3. TEXTURE: This provides information and details about the exfoliation need of the skin.
Areas shown in yellow are generally pimples and debris which can also present as raised
bumpy skin. Concavities that are resulted from fine line and enlarged pores, are designated
in blue.

4. PORES: Sebaceous glands openings can become lodged with bacteria and sebum that
give rise to acne flares. When clusters and groups of enlarged pores can be viewed through
VISIA, it demonstrates acne prone oily skin.

5. UV SPOTS: Frequent sun exposure leads to damaged skin that eventually gives rise to
the buildup of melanin under the surface of the skin. UV spots can be precisely viewed by
VISIA analysis to establish a better treatment plan for areas where the skin damage is the
most.

6. BROWN SPOTS: Birth marks, freckles, and aging spots can be identified as brown spots.
These spots can give rise to irregular or uneven skin texture that is clearly apparent on the
surface of the skin and resulted from excess melanin secretion.

7. RED AREA: Red inflamed areas of the skin are frequently and particularly resulted from
damaged and broken vascular capillaries and are most predominant on the nose and cheeks.
They can suggest and specify skin conditions like acne and rosacea.

8. PORPHYRINS – They are bacterial excretions and secretions that can become lodged
and infest in the enlarged pores and cause acne lesions.

2.1.3. Data analysis & statistical analysis

Data analysis:-
Comparisons between patients and control group with respect to amounts of Sebum, Skin
pH, TEWL, skin hydration and VISIA analysis, were done using student’s t-test using
SPSS software analysis. The n=30 in both the groups and individuals samples were taken
from both the groups, for the above mentioned five components to compare the results. The
strength of the association between these five components and acne was evaluated using
One-Sample Kolmogorov-Smirnov Test and the level of significance set at p <0.05 and the
test studied the parameters including mean, standard deviation and p value of the groups.
Data Visualization:-
The collected data was transformed into tables and graphs for better understanding. The
data is divided in to two forms, first is the data collected through questionnaires forms
about background history of cases and second the data collected through samples of sebum,
kin pH, TEWL, Corneometer and VISIA analysis. Both forms of the data are displayed
using different methods that better accommodate each component individually.

3. RESULTS
The Factors that affect Acne can be divided in to ENVIRONMENTAL FACTORS,
LIFESTYLE, and GENETICS.
The major lifestyle and Genetics factors were studied and researched through the inclusion
criteria. Inclusion criteria comprised of – documented in English. Exclusion criteria
comprised of (1) participants with underlying systemic disorders, (2) Research studies not
focused or based on acne. After much thorough searching through the literature, only a few
relevant studies on pathogenesis and acne were found. Research demonstrated that the
prevalence of acne was resolutely allocated to the vulnerability of skin in the environment,
the cognitive issues and obesity, which could be influenced by environmental factors. In
order to establish an indirect relationship between factors affecting acne, the search
stratagem also used the term “Factors affecting,” with the following combinations: obesity,
mental health, Skin hydration, excess sebum production and skin barrier function. Inclusion
criteria comprised: (1) Research documented and conducted in English, (2) Only original
articles. Exclusion criteria comprised: studies not based on factors affecting acne or lifestyle
components.

3.1. PHYSICAL EXAMINATION RESULTS:

Control group: The physical examination of control group individuals revealed no obvious
Acne lesions such as papules, nodules, pustules, comedones or cysts. Most of the cases in
control group had normal looking smooth skin with occasional scars or spots. Some cases
were identified to have extra oily skin but that did not contribute to any acne lesions
apparently. The most common skin factor identified in control group cases was dry skin that
could be due to environmental, seasonal or personal habits. Overall the general appearance
of skin in this group was labelled normal with the exclusion of any acne prone lesions.

Target group: The physical appearance of patient group was thoroughly examined
 including, face, trunk and back. A multitude of patients were recognized to have mixed
primary acne lesions.

The patients whose skin appeared more dry had lesions likes papules, comedones and scars.
Oily skin patients were observed to have more inflammatory acne lesions such as nodules,
cysts or pustules. A small number of patients even had secondary lesion like scales, crust or
excoriation. Generally the skin texture of cases in this group appeared rougher and the skin
color appeared darker.
Overall, the patient group lesions that were observed to be on face (i.e. forehead, cheeks, and
chin), trunk and back were mostly primary lesions and the skin appeared to be oilier in cases of
truncal or back acne and drier in cases of lesion on chin or cheeks with rough texture. Patients
with acne lesions on forehead also appeared to have frequent hair loss complain which could
be due to sebaceous acne or bacterial infestation or both.

FIGURE 1: pustules, papules FIGURE 2: Acne scars, papules, pustules FIGURE 3: Inflamed pustules
脓疱，丘疹 痤疮疤痕，丘疹，脓疱 丘疹发炎脓疱
 FIGURE 4: Cystic acne lesion FIGURE: 5 sebaceous back Acne
囊性痤疮病变 皮脂回粉刺

FIGURE 6: Acne scars, enlarged pores FIGURE 7: Severe excoriated acne lesion on back
痤疮疤痕，毛孔粗大 背部严重痤疮病变
3.2. BACKGROUND HISTROY RESULTS:
These results are divided into three factors, environmental, lifestyle and
genetics and they are simply displayed in the table below:

TABLE 1: Results of Background History distributed by factors and

their number in Control and Patient group

Contributing Patient Control Overall Overall range

Factors Group (+) Group(+) range (Control
(Patient n=30)
n=30 )

Environmental 1. Pollution 1. 8 + 1. Null 20 total 9 total cases

2. Seasonal 2. 12+ 2. 4+ cases
3. Sun exposure 3. 10 + 3. 5 +
4.bacterial 4. Null 4. Null
infestation 5. Null 5. null
5. Superficial skin
inflammation

Lifestyle a. Dietary a. 23 + a. 15 + 30 total 20 total cases

b. Cosmetics b. 15 + b. 10 + cases
allergies c. 2 + c. Null
c. Psychological d. 5 + d. Null
d. Medications e. 14 + e. Null
e. obesity f. 2 + f. Null
f. exercise g. 8 + g. 6 +
g. menstrual

Genetics 1. family history 1. 5 + 1. null 5 total null

cases

In both the groups the individuals choose multiple factors that they attributed to the cause
of their Acne breakouts. Therefore, it can be observed that overall Lifestyle factors are the
most common reason for acne pathogenesis followed by environmental factors being the
second most common triggers and finally genetics being the least affected factor according
to this research.

3.3 LAB SKIN TESTS RESULTS:

Five important laboratory skin test were performed to evaluate the cause of acne in patient
group and it was compared the samples collected from control group. The results are as
follows:-

Sebum Analysis
There were more subjects with normal Sebum in the control group compared to the patient
group, and the majority of acne occurrences in the Patient group were related to high skin
sebum production (p=0.000). Mean Sebum among patients was higher than normal
reference value (Sebum 70-180) and that of controls p (<0.001). No significant association
was observed between sex and sebum production in either patient or controls group
(p>0.05).

Number of patients with very dry skin was almost equal in both the groups with 64% and
60 % in patient group and control group respectively. This lack of moisture could
counteract the dryness and the glands beneath can produce excess sebum that could lead to
Acne. About 14% of cases in patient group had excess sebum production compared to only
5% in control group. This oily skin is more prone to acne due to high sebum production
through sebaceous glands.

Table 2: Classification of Facial Skin Type According to Mean Facial Sebum

Excretion

DRY NORMAL OILY

Controls (n=30) 18 (60%) 10(33.33%) 2(6.66%)

Patients (n=30) 19 (63.33%) 7 (23.33%) 4(13.33%)

TEWL Analysis
There were more subjects with normal TEWL in the control group compared to the patient
group, and the majority of acne occurrences in the Patient group were related to high
TEWL value (p=0.050). Mean TEWL value among patients was higher than normal
reference value (TEWL 15-25) and that of controls p (<0.005). No significant association
was observed between sex and TEWL in either patient or controls group (p>0.05)

In patient group, the number of unhealthy and abnormal skin in TEWL analysis is 13% and
17% respectively, whereas the number is much lower in control group with just 3%
unhealthy and 7% abnormal. However, there is no remarkable difference between the
number of normal skin individuals in both the groups with 43% in control and 37% in
patient group. Very healthy skin analysis in TEWL of both the groups is same with 10%
individuals from both case and control group.

CONTROL Patient
Very Healthy Skin Healthy Skin
Normal Unhealthy Skin
Abnormal
Normal
17%
Very Healthy Skin
7% 10% 37%
3% 13% Healthy Skins
Unhealthy
37% 23% 10%
43% Abnormal

Figure 8: Value of TEWL distribution in Control group Figure 9: Percentage of TEWL distribution in Patient
对照组中 TEWL 分布的百分比 TEWL 在患者组中的分布百分比

Corneometer Analysis
There was no significant difference between control and patient group with abnormal skin
hydration value. The Mean Corneometer Value among patient group was within normal
reference range (Skin Hydration >40) with p (>0.05). As for the control group mean
Corneometer value was also with normal ranges (skin hydration >40) with p (<0.040).
Therefore no apparent association can be linked with abnormal Skin Hydration in Acne
patients compared to normal individuals p (>0.05).
 Table 3: Classification of Skin hydration analysis according to Corneometer
results

Very dry Dry Fully Moisturized

Controls (n=30) 9 (30%) 2 (6.66%) 19 (63.66)

Patients (n=30) 5 (16.66%) 3 (10%) 22 (73.33%)

The Skin hydration analysis revealed no remarkable difference between the two groups. On
the contrary, more patients, 73%, had fully moisturized skin than 63% in the control group.
Similarly, 30% individuals in the control group had Very dry skin compared to just 17% in
patient group. These results show that skin hydration apparently plays very little or no role
in the pathogenesis of acne as it is. Further analysis is obviously required to study this area
in more depth.

Skin pH Analysis
the mean pH value of both the groups fall within normal reference ranges (5.0-6.9) with the
p (> 0.05) in both patient and control group. Consequently, skin pH does not play any role
in Acne development among patient groups compared to control group p (>0.05). A slight
shift of pH towards the alkaline will help the p. acne thrive but further in detail analysis is
required to study the effect of alkaline and acidic skin pH on aggravating Acne.

VISIA Analysis
Only the following Five VISIA parameters were studied specifically for any role in Acne
development:

PORES: There was significantly higher number of pores among Patient group with p
(<0.017), the control group showed relatively small number of people with enlarged pores
hence p (<0.018).Enlarged pores could get clogged by bacteria causing comedones like
blackheads or whiteheads. These enlarged pores were slightly more visible in patient group
cases. Therefore, further study on enlarged pores leading to this specific type of Acne
lesions is required to understand the underlying pathogenesis.

BROWN SPOTS: In patient group higher number of cases had increase brown spots p
(<0.011) however the control group didn’t show any obvious decrease in Brown spots p
(>0.05), hence no remarkable difference between the two groups. These areas of
hyperpigmentation are more frequently linked with conditions like freckles, moles and
melisma. Despite their high occurrence in patient groups, it is observed that brown spots
play no apparent role in the underlying pathology of Acne development.

RED AREA: In patient group more Red area spots were observed p (<0.023) than
compared to control group where the number of Red spots area was generally lower p
(<0.000). However, there was no significant direct link between red area spots of Acne
patients to that of normal individuals. These red areas indicate inflamed blood vessels or
hemoglobin levels that could cause condition like Acne or rosacea. In control group,
remarkably lower number of individuals showed these red spots as compared to patient
group which further explains the significance of this Red area analysis in development of
acne.

PORYPHORINS: In patient group more purple area spots were observed p (<0.003) than
compared to control group where the number of purple spots area was generally lower p
(<0.001). Therefore, significant link can be observed between Purple area in both control
and Acne group p (<0.033). Porphyrins are bacterial excretions that can become lodged in
pores and lead to acne. Clearly, more patients had areas covered with porphyrins than
control group. Porphyrins can be identified with UV light and can be helpful in deciding on
the best treatments for acne. The VISIA system reveal these areas as yellow highlight
against a black and blue background of the skin. Therefore, significant difference was
observed in both the groups, hence the study of porphyrins can further aid in the
pathogenesis and treatment of acne.

SPOTS: Individuals in patients group showed remarkably increase number of Spots under
VISIA analysis with the p (<0.03) as compared to control group in which relatively lower
number of people had high Spots with p (<0.015). Therefore, there was a considerable
difference between the Spots analysis of acne patients and normal individuals without Acne
lesion. Spots can be identified as different skin lesions such as, acne scars,
hyperpigmentation, freckles, acne or vascular lesions. Therefore, since a remarkable
difference was observed between patient and control group, it can be estimated that early
identification of these Spots and their treatment can further decrease the cases of Acne
among vulnerable group.
4. DISCUSSION
There is still a lack of scientific research on whether the effects of environmental factors
are related to the occurrence of acne. To provide a general overview we further discuss the
results of this research in depth taking in account the lifestyle, environmental and key
laboratory factors.

4.1. PHYSICAL EXAMINATIONS

As it occurred, the physical evaluation of individuals in this research was just the first key
step for the layout of the research area and to determine which cases should be put in
respective groups. Physical examinations lead to divide the groups in to control group in
which people were placed on the basis of their skin appearance, absence of lesions and skin
texture, on the other hand the patient group was allocated to those individuals that fulfill the
criteria of acne diagnosis i.e. active acne lesions.
The rough, uneven and dry skin texture observed in patient group might be due to the
environmental factors such as pollution or extreme weather conditions as well as lifestyle
factors including food (i.e. oily, spicy, sweet),cosmetic allergies, obesity (indirect: PCOS)
and hormonal (menstrual). These factors mainly contributed to non-inflammatory acne
lesion such as pores, scars, comedones and papules. Patients with advanced and severe acne
showed inflammatory lesions including pustules, nodules, and cysts. Furthermore, these
inflammatory lesions are direct results of factors such as bacterial infestation or abnormal
laboratory test results. In few patients some secondary lesions were identified as well such
as scales and excoriation. The excoriation was caused usually due to excessive scratching
and scales appeared due to excessive dryness of the skin. The general physical appearance
of the skin in both groups can be moderately regulated by weather conditions since this
research was conducted in winter months, it can be assumed that the excessive dry skin in
both the groups is partially due to weather influence.

Chart 1: Breakdown of physical examination

and grouping criteria
体格检查和分组标准分类
4.2. HISTORY BACKGROUND
4.2.1. Environmental Factors
The environmental factors that mainly contributed to both the groups for any type of acne
lesions were pollution, extreme hot or cold weather and sun exposure. Most cases in patient
group recalled that their acne lesion become worse or multiply during summer due to
excess sweating or sun exposure, while a few cases in both the groups confirmed they get
more acne pimples in winter which is due to either dry skin or lower hydration level. No
cases were confirmed or recalled for bacterial infestation such as rosacea or impetigo which
can be considered due to small number of cases in both groups, however it cannot be ruled
out and should be included in future research studies that cover larger population.
Only 84 (25%) of the 338 cities have attained qualified air quality standards for the residing
of human beings in accordance with 2016 environment report in China. During recent
decades, public had increasingly become distressed about the living condition of mega
cities environment and the health risks associated to the progressive and hazardous air
pollution such asPM2.5 and PM10. Dermatologists and health care workers are particularly
concerned about the negative impacts of air pollution on the skin (53). Clinical studies have
reported and demonstrated that air pollutants had a detrimental impact on the skin by
increasing oxidative stress, leading to abnormal changes in the physiological functions of
lipids, deoxyribonucleic acid and certain proteins in the human skin (58). One research
study also showed that the higher the altitude, the lower the prevalence of acne, which may
be related to higher altitudes and lower temperature and humidity (85).One research study
showed that extreme hot weather conditions was risk factors for acne. However, Dreno et
al. revealed there was no consequential variation in occurrence of individuals with or
without acne living in extreme temperature regions. On the contrary, acne prevalence was
remarkably more persistent in hot or humid regions (17). Williams et al. pointed out that
sebum secretions were changing with local temperature, meaning, and sebum excretion
secretion rate increased by 10% for every 1◦C escalation in temperature (49). A much
recent study also illustrated that forehead is prone to high sebum excretion particularly in
hot summer months (50).
The skin quality diminished with chronic exposure to surrounding air pollution in the lesser
polluted regions of Shanghai and Mexico. (53, 54). A research study in Beijing also pointed
out that elevated concentrations of surrounding PM2.5, PM10, and NO2 showed a direct
coherence with total outpatient visits of acne patients in the last two years, which
additionally provides an indirect evidence for a positive correlation between acne vulgaris
and air pollution (55). Another research study illustrated that the temperature fluctuations
was noted in worsening of acne lesion of 44.5% patients, due to frequent sun exposure in
the hot months of summer (47). Dreno et al. found acne lesions were consequentially
increased and multiplied in patients with slight or severe sun exposure due to their work or
daily activities (17). Lee et al. indicated that ultraviolet B irradiation elevated the
expression of inflammatory cytokines in cultured sebocytes (52).
4.2.2. Lifestyle Factors
The lifestyle factors contributed the most in both the groups. More than half of the patient
group and literally half of the control group as well choose dietary habits to be responsible
for acne breakouts. Under this category spicy and sugary were the two most common type
of food that cases selected as reason for acne aggravation. The next category in this factor
was cosmetic allergies, caused by facial products including makeup foundation, cleansers
and whitening products. Some allergies were caused by certain type of face wash or soaps
as well. Obesity is next component in this factor, which was seen responsible for almost
half of patient group cases. Some patients even claimed that weight loss helped them
improve in their acne lesions. Obesity itself is not directly linked with Acne, but instead its
conditions like PCOS in women which can lead to hyperandrogenism and high testosterone
levels in males can cause breakouts of acne. Furthermore, menstrual or cyclic acne was
responsible for a small number of patients in both groups. Individuals in both the groups
stated that they experience a bout of acne lesions like pustules or papules just before their
menstruation begins. This is again due to drop in levels of estrogen and progesterone just
before menstruation, which can cause sebaceous glands to produce more sebum, hence
causing pre-menstrual acne. Drugs are known to fluctuate hormone levels in the body.
Additionally certain medications including oral corticosteroids were stated by few cases in
patient group. The steroids can cause acne by increasing proliferation of hair follicles.
Other medications pointed out by patients were contraceptive agents which reduces female
hormones and that can result in acne. Psychological factors giving rise to acne lesions were
only reported by two cases in patient group. Both the cases confirmed extreme stressful
conditions aggravate or worsen their acne. It is understandable that stress itself cannot
directly cause acne but if the acne is already present, then such conditions like stress or
depression can make it worse. Researchers have found that acne lesions are much slower in
healing when a person is under stress. Slower healing of acne means that the lesions like
pustules, papules or cyst, may stay longer and become more vulnerable to increase in
severity. Last lifestyle factors that was reported by two cases in patient was exercise
induced acne. Now these two cases were the same who selected extreme hot conditions
aggravating acne, which simple illustrates that exercising in hot, sunny weathers can cause
excess sweating and sweat on body if left for longer without proper hygienic measure, can
lead to bacterial infestations, hence, causing acne.
Increased levels of sugar consumption (≥100 g/d), frequent intake of soft drinks (≥7 times
per week) such as sweetened or carbonated drinks, and daily intake of dark chocolate were
markedly positively associated with acne (19, 33–37). Diet high in glycemic can rise the
blood sugar levels, compelling Islets cells to produce huge amounts of insulin to lower
blood glucose, and increased insulin levels in the blood cause elevated secretion of insulin-
like growth factors1 (IGF-1), which can in turn increase androgen levels, aggravate excess
sebum secretion, and stimulate hyperkeratosis of hair follicle and sebaceous glands to
control lipid excretion levels, inevitably, instigating or promoting the occurrence of acne
(38, 39, 59-60). In addition, acne can be resulted from the consumption of greasy, oily,
fatty foods (40, 41), in regards to the fact that they secrete free fatty acids by triglycerides
under the influence of Propionibacterium acnes, it could encourage the development of
acne (61). However, it is still debatable whether spicy food has an impact on acne. The
epidemiological survey of college students in Northeast China reported that spicy food was
a risk factor for acne (14). But other studies have shown that spicy food was not related to
the duration or severity of acne (19, 42)

Chart 2: Breakdown of Acne types and dietary factors effect on them

痤疮类型的分解和饮食因素对其影响

In an American dietary survey conducted in 2018 it was reported that at least 36% of acne
patients follow one specific type of diet. Out of which, 16% were on low carbohydrate diet,
including high protein and ketogenic diet. Another 10% were on intermittent fasting,
further 6% were following a gluten-free diet, 5% were undertaking Mediterranean diet and
last 5% followed a whole 30 diet plan (elimination diet). About 27% individuals were
reported to skip at least one meal a day on usual basis or replacing one meal a day with
light snacks sometimes (68).
Some Chinese research studies also indicated that cosmetic use was also risk factor of acne
(16). The reason was due to inappropriate skin care practices such as essential oils,
disproportionate cleansing of the skin and soaps with pH 8.0 can reform skin barrier
function and high skin sebum regions, particularly the microbiome balance, activating
internal immunity to trigger inflammation (45).
The contribution of androgens in the pathogenesis of acne vulgaris is well recognized.
Testosterone, Dihydroepiandrosterone Sulfate (SDHEA) and Dihydrotestosterone (DHT)
aggravate the secretions of sebaceous gland and sebum production. Estrogens have quite
the contrary inhibition effect on the excretion of androgens, regulating genes are involved
in the growth of the sebaceous gland and obstruction of their function. The sebaceous gland
function is thereby dependent on the estrogen/androgen ratio (69). Shrestha et al.
demonstrated that hormonal imbalances in females with adult acne had marked correlation
with irregular menstruation (30). Ghodsi et al. indicated that the premenstrual phase was
established as one of the many risk factors for moderate to severe acne (19). Additionally,
Wei et al. also suggested and linked that dysmenorrhea was a risk factor to the acne patients
as well (14).

4.2.3. Genetic Factors

Genetic factors were reported only in five cases in patient group. Genetic mutations in
genes such as, SRD5A1/Insulin-like growth factor-1 (IGF-1), are responsible in causing
acne in family members of the same group. For instance the patient who stated positive
family history of acne was also the positive for obesity and conditions like diabetes in
family. An Italian research study established that moderate to severe acne is approximately
linked to family history of first-degree relatives (18). An epidemiological research study in
Iran also illustrated that the severity risk of acne was directly proportional to the cases of
acne in family, particularly a mother with acne history had the greatest influence on acne
gravity of next generation (19). Equivalent outcomes were also established in research
studies conducted in China (14) and Europe (15). Several other studies attributed early
onset of acne to the family history, severe skin lesions and more demanding treatment (20).

4.3. LABORATORY TEST RESULTS

Sebum
It was estimated before that high sebum levels are the main cause of acne. However in this
research high and low sebum production was observed in both the groups. The
underproduction of sebum is related to factors such as malnutrition, fasting or drug
induced. In patient group low sebum levels were observed in one patient taking oral
contraceptives. Severe underproduction can result in dry, itchy and flaky skin which was
observed in few cases of both the groups. Overproduction of sebum was also documented
for both the groups with slightly larger number in patient group. Excessive sebum is mainly
linked to hormone imbalance such as overproduction of growth hormones in both females
and males. Some cases in patient group had normal sebum production although this could
be due to the fact that the samples were taken in winter when the skin is usually drier and
also the point to taken under consideration is that sebum levels are always fluctuating
accordingly, hence further detailed study is required to constitute sebum levels with acne.
According to one study, the sebaceous gland cell is a key player in the initiation of the
conditions like Acne and sebocytes culture models have become so far very useful tools to
provide new chances for further research [1]. This study also found that increased sebum
excretion, alteration of lipid composition and the oxidant/antioxidant ratio characteristic of
the skin surface lipids are major concurrent events associated with the development of acne
[5]. If sebum obstructs or influence with the process of follicular keratinization in the
Pilosebaceous gland, clogging of pores may arise, providing way for lesions to accumulate
and result in acne [1]. Apart from androgens and estrogens, stimulating the production of
sebum: the sebaceous gland is a neuroendocrine organ and the production of sebum can
also be prompted, under stressful situations, by neuropeptides and hormones such as
melanocortins and corticotrophin-releasing hormone (CRH). CRH elevates the activity of
3β-hydroxy-steroid dehydrogenase mRNA, the enzyme that is responsible for the
conversion of dihydroepiandrosterone (DHEA) to testosterone. Also neuropeptides,
histamine, retinoid, vitamin D and insulin-like growth factor 1 (IGF-1) have been described
as regulators of sebum production (69).

Transepidermal water loss (TEWL)

The evaluation of skin surface vapor loss is a better indicator of the coherence of the skin
barrier function which naturally refers to the skin's ability to retain moisture. An increase in
the TEWL indicates an impaired barrier function. Only 3 individuals in control were
reported for unhealthy or abnormal skin and this could be due to humidity or weather
conditions because the values were not extreme. However in patient group about 10 cases
were recorded for damaged skin barrier, this could also be possible due to age as few cases
in patient group were above 30 and it is known through various research that as the age
increases the skin barrier function decreases. Despite these results of damaged skin barrier,
majority of the cases in control group were reported to have normal or healthy skin barrier.
Transepidermal water loss is not directly linked with acne but studies have shown that
disrupted barrier can be aggravate conditions like acne in post-menopausal women due to
low levels of hormones and advanced age. Since this research did not include that
population area, further research can be conducted to study the function of TEWL and its
effects of skin. One study suggested that an impaired water barrier function (WBF) caused
by decreased amounts of ceramides may be responsible for comedones occurrence, due to
the fact that barrier dysfunction is supplemented by hyperkeratosis of the follicular
epithelium [63].
Figure 12. Pilosebaceous gland in facial skin of acne patients. Slight hypertrophic sebaceous gland can be seen.
Dilated capillaries and perivascular lymphocytes (A and C) are early signs of inflammatory process in acne-
involved skin. Dilated plugged orifice of hair follicle—sign of acne comedones (B).
痤疮患者面部皮肤中的皮脂腺。 可以看到轻微的肥厚皮脂腺。 扩张的毛细血管和血管周淋巴细胞（A 和 C）是
痤疮相关皮肤炎性过程的早期迹象。 扩张的毛囊堵塞孔-粉刺粉刺的迹象（B）。

Skin hydration
The analysis of this test indicated that only 17% of cases in patient group had extreme low
levels of skin hydration while 73% were fully moisturized, which could be due to numerous
factors, one being that patients in this group were already on acne medications such as
benzyl peroxide or retinoic acid and secondly according to some studies abnormal skin
hydration levels is not directly linked to acne but other conditions such as atopic dermatitis,
eczema or ichthyosis vulgaris, therefore skin hydration should not be considered as good
measure in acne breakouts because thirdly, 36% of individuals in control group had
abnormal skin hydration as well but showed no primary or secondary lesions on face, back
or trunk. Hence, by this remarkable difference in skin hydration between both the groups it
can be assumed that healthy skin is associated with the appropriate balance of the normal
function of the skin barrier, which depends on the continuity of the skin’s superficial lipids
structure [15,16]. Skin superficial lipids have been reported to aid as water modulator in the
stratum corneum [12]. Thus, the water hydration levels can be determine the condition of
the skin and can be used as an indicator for healthy skin, which interprets that superficial
skin hydration is not directly linked to acne.

Skin pH
Both the internal and external factors can have an influence on the skin pH. According to
research studies (64) there are “functional physiologic voids” in the acid barrier dependent
on skin area, especially the interdigitating regions and hyperhidrosis areas such as axillae,
groin, are the inframammary zone. The pH is relatively raised in these regions as compared
to other skin area (14). Higher pH in the axilla leads to clustering by several odor-
producing bacteria such as Propionibacterium and staphylococci. However, one study
conducted in India stated that elevated skin pH on the face in acne patients reflects a
chronic state of stratum corneum instability, which could be exposing individuals to acne
prevalence and recurrences [2]. This study also pointed that the acidic nature of the body
skin surface was first demonstrated by Heuss in 1892; however, the first scientific study
relating to skin surface pH was conducted by Schade and Marchionni in 1928, who called it
the “acid mantle.” The process of configuration of the acidic cover is complicated, yet
interesting. A huge amount of factors are known to affect skin pH, which are classically
categorized as exogenous (external) and endogenous (internal). However, in accordance to
the skin condition under discussion, it can be divided as modifiable and non-modifiable.
Non-modifiable factors are primarily the ethnic origin, age, gender, and anatomic site. The
pH of darker skin is found to be lower than that of fairer skin. Modifiable factors of skin pH
include cleansers, sweating, sebum production, and dietary habits. Cleansers can be
categorized on the basis of the type of surfactant used in them. Documented affirmations in
the literature indicates advantages of acidifying skin surface in acne. Studies have shown
that by reducing the skin pH, the inflammatory Th2 response can also be lowered and that
can activated that barrier function recovery to more rapidly, hence preventing epidermal
hyper proliferation [2].
The uppermost layer of the stratum corneum is acidic. The low acidic pH provides
protection by slowing down the growth of some bacteria. Increase of skin surface pH leads
to impaired barrier function, disturbances in skin microbiome and inflammation.
Inflammatory conditions may be linked to changes in skin surface pH and disturbances of
the stratum corneum, which allows bacteria to stimulate the production of inflammatory
cytokines and that eventually results in acne. The pH analysis in this research revealed no
obvious changes in skin pH, acidic or alkaline, both the groups had normal pH levels. It can
be considered that the pH levels were normal in patient group because of low inflammatory
or secondary skin lesions. Nevertheless, effects of disrupted pH levels should be further
studied involving larger population area.

VISIA Analysis
PORES: Enlarged pores were spotted in increase numbers in patient group, making them
more susceptible for clogging and microorganism to infiltrate. Most enlarged pores were
seen around the cheeks on cheekbones and around nose and slightly on the forehead
surrounding the eyebrows. The pores can easily get infected and cause acne lesions such as
comedones etc. Control group individuals also showed a small number of enlarged pores
and that can be attributed to frequent exfoliating or sun exposure. Therefore, VISIA
analysis of Pores can contribute in detecting enlarged pores that are acne prone.

BROWN SPOTS: Increase number of brown spots was observed in patient group than
control group. This attributes to hyperpigmentation due to acne scars, freckles or melisma.
However control group also observed slight high number of brown spots which concludes
that brown spots are not acne prone or directly resulted from acne lesion, instead they are
simply areas of higher pigmentation on the skin.

RED AREA: The red areas on VISIA analysis indicate the inflamed blood vessel, or
hemoglobin levels etc. the control group remarkably showed fewer red areas on analysis
then compared to higher number of red areas in patient group. The cases in patient group
were found to have more red area lesion on forehead, nose and cheeks. These areas
represent underlying inflamed skin which can be seen in conditions like Acne, rosacea,
cystic acne. The interpretation of this results indicate that VISIA analysis of red areas is
directly linked in detecting acne prone lesions or lesions that are resulted from acne. The
structures get their red color from the vascular blood supply and hemoglobin present in the
dermal layer of the skin. Acne spots, scars and inflammation areas fluctuate in size but are
typically round in shape. In one comprehensive study the relative intensity of red areas
were positively correlated to erythema severity with a coefficient of 0.999345 (p < 0.001).
The study demonstrated a simple and more precise method to quantify and compare facial
skin erythema by analyzing the RGB channel values of the VISIA Red areas (66).

PORYPHORINS: These are areas of bacterial secretions that can get clogged and lead to
acne. This research analysis indicated that patient group had more areas of porphyrins than
compared to control group in which very little porphyrins area were spotted. The VISIA
analysis highlights these areas as yellow against black background and in patient group
these areas were spotted on mainly nose forehead and cheeks. Hence, there a remarkable
difference between both the groups was observed, interpreting that studying porphyrins
stained areas can not only identify acne lesions but also detect the bacterial secretions spots
before they can transform and result in acne.

SPOTS: Spots were identified in both groups with a larger number in patient group than
control group. Spots indicate conditions such as acne scars, freckles, or vascular lesions.
This analysis simply interprets that early identification of spots through VISIA analysis can
decrease the risk of acne among the vulnerable group.
In accordance with a research study in China, 30.8% acne patients reported that acne had a
negative impact on their quality of life (6). Several other research studies showed that acne
patients had lower self-esteem, the difficulty in socializing, trouble maintain academic life,
and the hazard of finding employment (7, 8). Furthermore, acne patients have a higher
susceptibility and vulnerability of developing any underlying mental disorders, including
extreme levels of stress, anxiety, and depression (9, 10). The prevalence of acne can not
only impact the cost of drug treatment, but also the psychological disorders associated with
acne and quality of life.
4.4. STRENGHTS AND LIMITATIONS
The core merit of this research lies in a thorough review of the relevant environmental
factors, lifestyle factors and key laboratory tests that could have an influence on acne as
well as on the underlying mechanisms. On the basis of these facts, the positive and negative
and indirect interrelationships were established between environmental and lifestyle factors
(pollution, climate/weather conditions, food, cosmetic obesity, hormonal etc.) and acne by
reviewing the effects of laboratory tests on skin health, thus setting forth a theoretical
grounds for a further research on the effective means of contributing factors intervention.

It is essential to acknowledge the weaknesses of the current research, that is, there remains
very few studies focusing on the influence of environment and lifestyle factors on acne. In
this situation, attempt was made in this study to determine the indirect relationship between
these factors and acne by exploring its influence on skin hydration and skin ph. It was
possible to overlook some information and details about the potential confounding impacts
and effects on acne.

5. CONCLUSION
Acne is a chronic inflammatory condition that is caused and affected by numerous factors
surrounding individuals. In this research it was concluded that acne is directly linked to
many lifestyle factors and it can be positively affected by obesity, oily and mixed skin,
menstrual cycles, sweet food, greasy food, the improper use of cosmetics, and stress. In
addition, environmental factors play a significant role, including temperature, sun exposure,
air pollution, serve as potential risk factors for acne. Furthermore, a more exploring
qualitative research is required to study the impact of each of these factors individually on
acne. Acne is also effected by either overproduction or underproduction of sebum, slightly
affected by the damaged skin barrier however although an important component, acne can
be negatively affected by abnormal skin hydration and neither does skin pH was found to
be abnormal in any acne patients. This research also concludes on some significant findings
of VISIA analysis that can aid in detecting acne prone lesions or also help in the future
treatment of these lesion. Red areas, porphyrins and pores were found to be most
remarkably aiding in detecting and treating acne. Brown area and spots were not found to
be directly linked in Acne breakouts.
However, the impact of environmental or lifestyle factors on acne has not been clearly
reported in previous studies. Thus, an attempt was made in this study to determine the
indirect relationships between these factors and acne regarding the influence of laboratory
skin tests such as sebum, TEWL and skin hydration analysis on the risk factors for acne. To
treat this kind of a long term and chronic condition, it is obligatory to fully understand the
oblique and allusive correlation between such factors and acne by gaining understanding as
to the influence of traditional factors on the pathogenesis of acne.
In the future, more studies based on the background of medicine, larger population and
geography should be conducted to reveal the specific relationship between environment and
lifestyle factors and acne. The prospective environmental factors for acne should be
analyzed by collecting the data on lifestyle habits, social characteristics, physiological
factors, psychological and mental factors, as well as sebum production, skin hydration, skin
barrier function, skin pH, and VISIA analysis of pores, porphyrins and red areas and so on
with direct relation to the incidence of patients with acne, in combination with any genetic
research factors. In doing so, the influence of environmental and lifestyle factors of acne
can be fully acknowledged to provide specific guidelines on reducing the occurrence of
acne. Furthermore, this research study can be concluded by stating that as much as acne is
influenced by several factors, the underlying pathogenesis it still yet to be researched and
studied thoroughly in order to understand the correlation between acne and environmental
and lifestyle factors.
The treatment of acne requires a long term plan with multiple clinical visits and tests. We
can only hope to achieve a better, quicker and more effective acne treatment plan after
understanding the key factors that are responsible for its break out. Each individual is
subjected to different treatment methods according to their lesion type, underlying
pathogenesis and background history, however, through this research it was demonstrated
that some risk factors for acne can be studied and calculated very early in the disease
progression, and hence prompt measures can be taken to treat it or even prevent it from
occurring.
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