|Year : 2019 | Volume
| Issue : 2 | Page : 83-88
Insulin resistance in androgenetic alopecia and acne vulgaris
M. Yousry Abdelmawla1, Abdulla M Esawy1, Elsayed Khater1, Naglaa A Khalifa2
1 Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
2 Department of Clinical Pathology, Faculty of Medicine, Zagazig University, Egypt
|Date of Submission||28-Jun-2018|
|Date of Acceptance||22-Apr-2019|
|Date of Web Publication||03-Jul-2019|
Abdulla M Esawy
28 Mahmoud ashore, Zagazig, 44519
Source of Support: None, Conflict of Interest: None
Background Insulin resistance (IR) is the inability of a known quantity of exogenous or endogenous insulin to increase glucose uptake and utilization in an individual as much as it does in a normal population. Some conditions strongly associated with IR such as acanthosis nigricans, acne, and psoriasis. Some conditions potentially associated with IR such as androgenetic alopecia (AGA), hirsutism, and hyperandrogenism. Some conditions anecdotally linked to IR such as alopecia areata and vitiligo. We aimed to analyze the relationship between IR and AGA and acne vulgaris, in comparison to controls.
Patients and methods The study was carried out on 54 AGA and 54 acne vulgaris patients selected from Dermatology, and Venereology Department, Zagazig University Hospitals, 54 volunteers as a control, general, and dermatological examination were done. IR was estimated by the Homeostasis Model Assessment of Insulin Resistance.
Results Statistically no significant differences between cases and control regarding sociodemographic distribution, blood glucose, and insulin. Nonsignificant differences between AGA and acne groups regarding sociodemographic distribution and duration of the disease. Nonsignificant differences between AGA and acne regarding blood glucose and insulin.
Conclusion There is a role of insulin in the etiopathogenesis of AGA and acne.
Keywords: acne vulgaris, androgenetic alopecia, insulin resistance
|How to cite this article:|
Abdelmawla MY, Esawy AM, Khater E, Khalifa NA. Insulin resistance in androgenetic alopecia and acne vulgaris. Egypt J Dermatol Venerol 2019;39:83-8
|How to cite this URL:|
Abdelmawla MY, Esawy AM, Khater E, Khalifa NA. Insulin resistance in androgenetic alopecia and acne vulgaris. Egypt J Dermatol Venerol [serial online] 2019 [cited 2019 Sep 23];39:83-8. Available from: http://www.ejdv.eg.net/text.asp?2019/39/2/83/262037
| Introduction|| |
Insulin resistance (IR) is a condition in which tissues do not respond to the normal physiological actions of insulin. It has also been accurately defined as the requirement of 200 or more units of insulin per day to reach adequate glycemic control and to hinder ketosis .
Androgenetic alopecia (AGA), or pattern alopecia, is an extremely common disorder affecting both men and women. The incidence of AGA is generally considered to be greater in males than females, although some evidence suggests that the apparent differences in incidence may be a reflection of different expression in males and females .
Disagreements exist regarding the relationship between IR and AGA, although insulin was suggested to play a role in the regulation of cutaneous androgen metabolism and hair-growth cycle. Nabaie et al.  did not find an association between IR and AGA and suggested that IR may result from aging rather than AGA or due to the presence of metabolic syndrome (MS). Bakry et al.  studied the presence of MS and IR in patients with AGA to detect if AGA can be considered as a clue for underlying serious systemic diseases. They summarized that MS is significantly associated with AGA particularly, early onset alopecia. IR is mostly the underlying pathologic mechanism.
Acne vulgaris is a disease of the pilosebaceous unit can affect people of all age group, but it is most prevalent in adolescence. Over 90% of male and 80% of female have experienced acne by the age of 21 .
Emiroğlu et al.  investigated the presence of IR in patients with severe acne vulgaris. They found a positive correlation between IR and severe acne vulgaris. Treatments prescribed for IR are worth investigating for treatment of severe acne vulgaris. Munichandrappa et al.  evaluated IR in acne. They did not suggest a major role of IR in acne.
The aim of the study is to assess the role of IR in patients with AGA and acne vulgaris.
| Patients and methods|| |
This case–control study was conducted at Dermatology, Venereology and Andrology Department and Clinical Pathology Department, Zagazig University Hospitals, including 54 AGA patients and 54 acne vulgaris patients. In addition, 54 sex-matched and age-matched healthy volunteers served as controls.
A written consent was taken from every patient included in this study. The protocol was approved by the Ethical Committee, Faculty of Medicine, Zagazig University.
Age from 20 to 40 years old to exclude the possible effect of puberty, AGA and/or acne patients from both sexes, different duration and clinical presentation, normal hepatic and renal functions, normal thyroid and adrenal assessment, normal blood count, and standard urine analysis.
Pregnancy, diabetes, prediabetics and first degree relatives with diabetes, severe anemia, congenital adrenal hyperplasia, cardiovascular disease, thyroid disease, smoking, Cushing disease, history of insulin-sensitizing drugs or insulin treatment, history of viral hepatitis, cirrhosis, liver failure or renal failure and alcoholics, androgen or antiandrogen therapy and glucocorticoid treatment within the previous 6 months, and daily intake of medications known to influence glucose metabolism (restricted to asthma medicines, antipsychotics, antidepressants thiazides, and hormonal contraception).
Full history included, complete general and clinical examination for every patient included in the study. Complete dermatological examination to assure acne diagnosis and evaluate the degree of its severity assessed by the American Academy of Dermatology consensus conference. According to this consensus, this grading system of acne includes mild acne, the presence of comedones as well as few to several papules-pustules. Moderate acne, distinguished by several papules, pustules and few to several nodules. Severe acne, characterized by numerous or extensive papules, pustules, or both, along with many nodules. Very severe forms of acne, including the most destructive conditions of the disease, such as acne conglobata, acne fulminans, and the follicular occlusion triad .
Estimation of body mass index by dividing the weight by the square of height (kg/m2). Estimation of fasting and postprandial blood glucose level, estimation of IR by the homeostasis model assessment of insulin resistance (HOMA-IR). IR=fasting insulin (mlu/l)×fasting glucose (mmol/l)/22.5 .
| Results|| |
The study included patients with acne vulgaris and AGA versus control patients was showed statistically significant differences regarding age, weight, height, and BMI (P>0.05) ([Table 1]). The included patients were 46 (42.6%) males and 62 (57.4%) females and the control group included 20 (37%) males and 34 (63%) females. Out of 108 cases, 42 cases (38.8%) were working; but in control group, there were 26 (48.1%) patients were working. Regarding marital status, in the case group, there were 64 (59.3%) married cases and 44 (40.7%) single cases and in control group, there were 40 (74.1%) married patients and 14 (25.9%) single patients. Statistically, there were no significant differences between cases and control group regarding sex, occupation, and marital status (P>0.05) ([Table 2]). There were nonsignificant differences between patients and control group regarding fasting glucose, postprandial glucose, fasting insulin, and IR (P>0.05) ([Table 3]).
|Table 3 Comparison between patients versus control groups regarding blood glucose and insulin|
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There were nonsignificant differences between control group, acne group, and AGA group regarding fasting glucose, postprandial glucose, fasting insulin, and IR (P>0.05) ([Table 4]). There were nonsignificant differences between AGA group and acne group regarding fasting glucose, postprandial glucose, fasting insulin, and IR (P>0.05) ([Table 5]).
|Table 4 Comparison among control, acne, and androgenetic alopecia groups regarding blood glucose and insulin|
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|Table 5 Comparison between androgenetic alopecia and acne groups regarding blood glucose and insulin|
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| Discussion|| |
In this study, the mean age of acne patients was 28.09±6.2. In agreement with Saitta et al. , that acne can affect people of all age group, but it is most prevalent in adolescence. Over 90% of male and 80% of female have experienced acne by the age of 21 years. Budamakuntla et al.  found an association between the same age group in men with early onset of AGA. Sixty male patients participated in their study, 30 cases, and 30 controls. All were between 18 and 35 years of age.
Regarding sex distribution in our cases, they were 62 females and 46 males with the female predominance. In agreement with us, Collier et al.  observed that acne is more frequent in women than men. A study done by Munichandrappa et al.  evaluated IR in acne and compared the IR among cases and controls using HOMA-IR. Their study included 45 cases, out of which 26 were females and 19 were males with an equal number of age-matched and sex-matched controls.
In our study, there were statistically nonsignificant differences between cases and control regarding sociodemographic distribution (including age, weight, height, BMI, sex, occupation, and marital status) and blood glucose and insulin (including fasting glucose, postprandial glucose, fasting insulin, and IR). Also, there was a nonsignificant difference between AGA and acne groups regarding sociodemographic distribution (including age, weight, height, and BMI) and duration of the disease.
Matilainen et al.  showed a statistically significant difference between cases and control patients regarding BMI and reported that mean value of fasting serum insulin was significantly higher in AGA cases than in the control group. However, Arias-Santiago et al.  found that BMI did not differ between AGA cases and normal controls, but found a nonsignificant difference in body weight. Del Prete et al.  provided evidence that young Italian males affected with acne had a high BMI and exhibited IR.
In the study done by Munichandrappa et al. , mean fasting insulin levels among cases was 8.0 and 6.8 among controls, which showed no statistically significant difference (P=0.07). Mean HOMA-IR value for cases was 1.7 and 1.4 for controls. The difference among the mean values was not statistically significant. The median for fasting glucose levels for both cases and controls was 86.
Our study showed that family history was significantly associated with AGA. In the study done by Budamakuntla et al. , family history of AGA was significantly more in the participants in cases group than the control group, with a P value of 0.0073.
Our study found no significant differences between AGA and acne regarding blood glucose and insulin. The relationship between AGA and hyperinsulinemia and cardiovascular-related disorders was first suggested by Matilainen et al. , but the mechanism of action has not been elucidated. Hyperinsulinemia caused by increased resistance to the peripheral action of insulin explains the association between AGA and cardiovascular disease. Elevated insulin levels are the main cause of MS and favor intolerance to carbohydrates and central obesity. Insulin has also been shown to favor vasoconstriction and nutritional deficiency in the follicles of the scalp, and it enhances the effect of dihydrotestosterone (DHT) on follicular miniaturization.
Mumcuoglu et al.  found a relationship between IR and early baldness. Hirsso et al.  demonstrated a reduction in insulin sensitivity in males with AGA. Conversely, Nabaie et al.  could not demonstrate a significant difference between AGA cases and control patients with respect to levels of fasting insulin and IR. Abel Fattah and Darwish  concluded that there is no true association between AGA and IR, but their coexistence with MS could contribute to worsening of AGA.
Ray et al.  have discussed the positive correlation between blood glucose and severity of acne. This was attributed to increased blood glucose which in turn stimulates increased insulin secretion. Increased insulin decreases the availability of binding protein for IGF-1 which facilitates the effects of IGF-1 on basal keratinocyte proliferation. Also, insulin stimulates synthesis of androgens which can cause acne.
Balato et al.  in their study on 35 cases and controls of postadolescent acne did not find any significant difference in insulin levels between cases and controls. Also, they did not find any significant correlation between acne severity and insulin levels between patients with acne and controls. A study by Nagpal et al.  showed increased blood glucose levels in cases compared with controls.
Munichandrappa et al.  did not find any significant correlation between acne severity and fasting glucose and HOMA-IR values. However, a weak positive correlation between acne severity and fasting insulin levels was observed.
IR plays a pathogenetic role in the miniaturization of hair follicles. Vasoactive substances associated with endothelial dysfunction in IR lead to microcirculatory disturbance, perifollicular vasoconstriction, and proliferation of smooth muscle cells in the vascular wall. This condition leads to microvascular insufficiency, local-tissue hypoxia, and progressive miniaturization of hair follicles .
Hyperinsulinemia plays a role in local androgen production, whether de novo from cholesterol or by locally converting testosterone to DHT. DHT inhibits adenyl cyclase activity, and is able to curtail the anagen cycle and could be responsible for the miniaturization of follicles in AGA .
Su and Chen  reported that the most significant association was observed between high-density lipoprotein-cholesterol level and AGA in their studied population. Conversely, Yi et al.  reported a nonsignificant association between all components of MS and AGA.
Abel Fattah and Darwish  assessed IR in young nonobese patients with AGA with and without MS. They concluded that patients with MS, with or without AGA, were significantly more IR compared with patients with AGA with no MS and with healthy patients and, therefore, no true association exists between AGA and IR.
Bakry et al.  studied the presence of MS and IR in patients with AGA to detect if AGA can be considered as a clue for underlying serious systemic diseases. They summarized that MS is significantly associated with AGA particularly, early onset alopecia. IR is mostly the underlying pathologic mechanism.
In the study done by Budamakuntla et al. , the insulin level was 6.644±4.29 µIU/ml in the patient group and 8.27±4.65 µIU/ml in the control group, the difference between the two groups was not statistically meaningful (P>0.05).Emiroğlu et al.  investigated the presence of IR in patients with severe acne vulgaris. They found a positive correlation between IR and severe acne vulgaris. Treatments prescribed for IR are worth investigating for treatment of severe acne vulgaris.
Cerman et al.  investigated possible associations among dietary glycemic index, glycemic load, milk consumption, and IR in the pathogenesis of acne vulgaris. They concluded that a high-glycemic index/load diet was positively associated with acne vulgaris, but Munichandrappa et al.  did not suggest a major role of IR in acne.
In our study, there was a statistically significant difference in IR. Genetic difference depending on the Mediterranean diet that refers to a food model lifestyle consisting of increased intake of olive oil, fish, and antioxidants, and low glycemic load food as compared with western diets. It is believed to be protective with regards to the development of cardiovascular disease and MS.
Skrosa et al.  concluded that adhering to a Mediterranean diet appeared to play a protective role when it comes to the development of acne. This could be attributed to the lake of dairy or increased intake of omega-3 fatty acids (olive oil and fish) as compared with western diets.
Since AGA and acne are problems in adolescents, the early recognition of IR might help in better management of AGA and acne patients.
| Conclusion|| |
There is a role of insulin in the etiopathogenesis of AGA and acne. We found a statistically significant association between IR and AGA and acne and an association between acne severity and fasting insulin levels.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]