Smoking and obesity are associated factors in acne inversa: results of a retrospective investigation in 100 patients

ARTICLE

Auteur(s) : Elvir Cesko, Andreas Körber, Joachim Dissemond

Department of Dermatology, Venerology and Allergology, University of Essen, Hufelandstr. 55, 45177 Essen, Germany

accepté le 1 Avril 2009

Acne inversa is a chronic, recurring, suppurative, acneiform skin disease with inflammation of the follicular epithelium of the sebaceous glands and the terminal hair follicle. It primarily manifests in the intertriginous areas. Eccrine and apocrine sweat glands are drawn into the inflammation process secondarily [1]. The disease pattern was described first in 1839 by the French physician, Velpeu, as a specific inflammatory process with superficial abscess formation in the axilla, chest and perianal areas. Due to the distribution, it was originally viewed as a disease of the sweat glands. In 1956, Pillsbury and co-workers coined the term “follicular occlusion triad” to describe the triad of acne conglobata, hidradenitis suppurativa and perifolliculitis capitis abscedens et suffodiens. In 1975, Plewig and Steger incorporated a final symptom, the pilonidal sinus, to the clinical picture of acne triad and changed the nomenclature to “acne tetrad” [1]. After the follicular origin of the disease was confirmed in further studies, Plewig and Steger introduced the term “acne inversa” in 1989. Currently, this term has almost completely replaced the term “hidradenitis suppurativa”, at least in the German speaking countries [2].

An incidence of 0.3% to 4% in industrialized countries is described for acne inversa [3]. The ratio of women to men is reported to be 2-5:1 [1]. Men often develop acne inversa in the perianal area and present a more severe degree than women, who are often affected in the axilla [4]. The initial manifestation can be observed from the age of 12 and is not age-restricted. Usually, the disease manifests predominantly in young adults. Up to now, the exact aetiology of acne inversa is unknown [5]. The association with nicotine consumption has been discussed repeatedly [5, 6]. Scientific data concerning the negative effects of smoking exist, especially for cardiovascular diseases and neoplasms. Although a negative influence on psoriasis vulgaris, wound healing or skin ageing have been described empirically, hardly any scientific studies exist that confirm the development or exacerbation of dermatological diseases through nicotine consumption. Therefore, the aim of our study was to investigate influencing factors in a group of 100 patients with acne inversa.

Methods and patients

Patients

Collected parameters

The Body Mass Index (BMI) was determined as follows: The ratio between the weight and height squared.

Statistical analysis

Results

Sex ratio

Age

Localisation of acne inversa

Smoking behaviour

Smoking quantity and duration

In 28 cases, details of the duration of nicotine consumption were available. The average value was 19.1 years (2-40 years). When differentiating between the sexes, the female patients presented a lower value of 16.3 years (2-30 years), compared to the 13 male patients, with a value of 22.4 years (10-40 years) with regard to the duration of nicotine consumption.

Latent phase from the initiation of smoking to the initial acne inversa diagnosis

Weight

BMI (Body-Mass-Index)

Discussion

Nicotine consumption has a negative influence on many skin diseases [9]. Nicotine, with its damaging capacity, mainly attacks the blood and vascular systems, the collagen metabolism and the interactions on an immunological basis. In the context of wound healing, and respectively, wound healing disturbances, for example, altered rheological characteristics of the blood, an increased vasoconstriction and vessel wall epithelium damages present important factors in the development of the disease and its progression [9]. The empirically described high incidence of smokers amongst acne inversa patients suggests that nicotine consumption could be a trigger for acne inversa [10]. The combination of a reduced circulation of the inflamed tissue with a reduced humoral and cellular immune reaction seems to be a relevant precondition for the chronicity of the disease pattern [11]. In vitro studies on the influence of nicotine on neutrophile granulocytes have shown that the suppression of apoptosis by nicotine leads to a prolonged survival of the neutrophile granulocytes. Furthermore, their reactivity to chemotactic peptides is increased, so that tissue inflammation is promoted [1].

In a study published in 1999, it was shown that 89.9% of 63 acne inversa patients were smokers. In the control group chosen, there were only 46% smokers [5]. In a study published in 1995 by Breitkopf et al., similar results were shown, with 85% of 149 examined acne inversa patients being smokers. The results of our study show similar results, although our smoker quota of 98% was noticeably higher. In two cases the diagnosis of acne inversa was already manifest a few years before the beginning of cigarette smoking. So the proportion of smokers which is relevant for the first manifestation of acne inversa is 96% (table 4). According to statistics of the Federal Statistical Office of Germany from 2006, 73% of the adult population in Germany is comprised of non-smokers. However, 19% of these were former smokers [12]. The data collected in the context of this study confirms the results published so far and shows that the proportion of smokers amongst acne inversa patients is significantly higher compared to the number of smokers in the general population.

Obesity is defined as an increase in body fat exceeding normal limits. The most common basis for calculation of the weight class is the Body Mass Index (BMI). According to the WHO, overweight is defined as BMI ≥ 25 kg/m², obese as BMI ≥ 30 kg/m² (table 2). The prevalence of obesity (BMI ≥ 30 kg/m²) has been continuously increasing in recent decades in Germany. In 1998 18.3-24.5% of the German population in the age group 18-79 years showed a BMI of > 30. Added to this, 31.1-48.7% of the population was already overweight with a BMI of between 25.0 and 29.9 [13]. Obesity is also often under discussion as an etiological factor concerning the development of acne inversa [10]. In a study carried out by Jemec, the weight of acne inversa patients was compared to the corresponding ideal weight. No significant differences were found [8]. In a study done by Werth and Williams, 45% of the 110 interviewed patients reported a worsening of the disease due to heat and sweating, 16% reported a worsening caused by tight-fitting clothing and friction and a third indicated a worsening during the summer months [14]. In the group we examined, more than a half had a BMI of > 30. 72.7% fall at least into the category pre-obesity (table 3). Only 26.1% of the patients showed a normal weight (table 3). These results deviate significantly from the average values of the adult German population and could therefore be discussed as a further aetiologically potentially relevant factor concerning acne inversa. Yet, it could also be possible that the obesity could be secondarily promoted by the inactivity that so often results from the acne inversa.
Table 4 Quota of smokers among acne inversa patients (comparison of different studies)

Conclusion

Acknowledgements

References

2 Plewig G, Steger M. Acne invesa. In: Marks R, Plewig G, eds. Acne and related disorders. London: Martin Dunitz, 1989: 345-57.

3 Brown TJ, Rosen T, Orengo IF. Hiddradenitis suppurativa. South Med J 1998; 91: 1107-14.

4 Jemec GBE. The symptomatology of hidradenitis suppurativa in women. Br J Dermatol 1988; 119: 345-50.

5 König A, Lehmann C, Rompel R, Happle R. Cigarette smoking as a triggering factor of hidradenitis suppuativa. Dermatology 1999; 198: 261-4.

6 Yu CC, Cook MG. Hidradenitis suppurativa: a disease of follicular epithelium, rather than apocrine glands. Br J Dermato 1990; 122: 763-9.

7 Morgan WP, Leicester G. The role of depilation and deodorants in hidradenitis suppurativa. Arch Dermatol 1982; 118: 101-2.

8 Jemec GBE. Body weight in hidradenitis suppurativa. In: Marks R, Plewig G, eds. Acne and related disorders. London: Martin Dunitz, 1989: 365-6.

9 Krug M, Wünsche A, Blum A. Tabakabhängigkeit und die Folgen auf die Haut. Hautarzt 2004; 55: 301-16.

10 Jansen T, Altmeyer P, Plewig G. Acne inversa (alias hidradenitis suppurativa). J Eur Acad Dermatol Venereol 2001; 15: 532-40.

11 Smith JB, Fenske NA. Cutaneous manifestations and consequences of smoking. J Am Acad Dermatol 1996; 34: 717-32.

12 Statistisches Bundesamt Deutschland: Drei Viertel der Bevölkerung in Deutschland sind Nichtraucher. Online Communication 2006; No. 249.

13 Bergmann KE, Mensink GB. Körpermaße und Übergewicht. Gesundheitswesen 1999; 61: 115-20.

14 von der Werth JM, Williams HC. The natural history of hidradenitis suppurativa. J Eur Acad Dermatol Venereol 2000; 14: 389-92.