3. Luan An Tom Tat - Eng.pdf

MINISTRY OF EDUCATION AND TRAINING MINISTRY OF DEFENCE 108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES PHAM THI BICH NA STUDY OF SERUM VITAMIN D AND IL 17 LEVELS IN ACNE VULGARIS PATIENT[.]

MINISTRY OF EDUCATION AND TRAINING MINISTRY OF DEFENCE

108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES

-

PHAM THI BICH NA

STUDY OF SERUM VITAMIN D AND IL-17 LEVELS IN ACNE VULGARIS PATIENTS BEFORE AND AFTER TREATMENT WITH ORAL ISOTRETINOIN AND VITAMIN D

Major/Specialization: Internal Medicine/Dermatology

Code: 9720107

ABSTRACT OF MEDICAL PH.D THESIS

Hanoi – 2023

THE THESIS WAS DONE IN: 108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES

Supervisor:

Reviewer 1:

Reviewer 2:

Reviewer 3:

This thesis will be presented at Institute Council at:

Day Month Year

The thesis can be found at:

1 National Library of Vietnam

2 Library of 108 Institute of Clinical Medical and Pharmaceutical Sciences

INTRODUCTION

Acne vulgaris are common skin diseases in the clinical practice of dermatologists Disease usually does not effect on general health but has a detrimental impact on the person’s psychology and social communication In addition to a number of pathogenic mechanisms that are well-known as the basis for treatment, many other factors are also thought to be associated with the onset and severity of disease, including serum vitamin D and IL-17 levels Numerous studies around the world have shown a statistically significant association between serum vitamin D and IL-17 levels with severity and clinical manifestations of patients, as well as demonstrating that C acnes is a bacterium that can stimulate the expression of IL-17 in areas of skin damaged by disease Clinical trials on the role of vitamin D in the treatment of disease have also been conducted for the results of supplementing vitamin D into the fish egg treatment regimen producing statistically significant improvements when compared to the placebo-controlled group Furthermore, studies around the world have also demonstrated the inhibitory effect of Isotretinoin and Vit

D on the production of IL-17 due to the stimulation of C acnes

In Vietnam, no studies have been conducted on serum levels

of vitamin D and IL-17 in acnes vulgaris patients That’s why we

decided to conduct the theme “Study of serum vitamin D and IL-17

levels in acne vulgaris patients before and after treatment with oral Isotretinoin and vitamin D” with the following objectives:

1 Survey of related factors and clinical features of acnes vulgaris at Ho Chi Minh City Hospital of Dermato-Venereology

2 Study of serum vitamin D and IL-17 levels before and after treatment and their relationships with clinical features in patients with moderate and severe acne vulgaris

3 Study the results of Acne Vulgaris treatment with oral Isotretioin and Vitamin D

CHAPTER 1: LITERATURE REVIEW 1.1 Overview of acne vulgaris

Acne vulgaris is a very common disease of the sebaceous hair follicles, affecting up to 80% of adults In which, many cases need treatment because the disease has progressed for too long, due to complications or other accompanying disorders

1.1.1 The pathogenesis of acne vulgaris

Acne vulgaris is formed by the influence of many factors, of which the main mechanism is the increase in sebum secretion, the keratinization of the hair follicle neck and the proliferation of inflammatory bacteria

Keratinization of hair follicles is the source of the initial damage of acne vulgaris, that is comedone This clogged hair follicle horn causes keratin, sebum, and bacteria to be trapped in the hair follicle All of the above substances clump together, causing dilation

of hair follicles and the formation of acne micronuclei The process

of keratinization of the neck of the sebaceous hair follicles is influenced by a number of factors: androgen hormone, increased activity of Interleukin-1α (IL-1α), linoleic acid deficiency, increased free fatty acids in the sebaceous glands, bacteria,

Overproduction of sebum from the sebaceous glands is also one of the causes of acne vulgaris, a process that is influenced by androgen hormones

Inflammation is noted in both early and late stages of acne C acnes and the sebum component plays a very important role in the inflammatory process of acne vulgaris and some proliferative factors such as androgens, growth factors, IL-1α, are also present can directly cause inflammation Several recent studies have demonstrated that C acnes is a strong Th17-mediated inducer, and that Vitamin D inhibits the expression of Th17 induced by C acnes, thus can be considered an effective tool in the treatment of acne vulgaris In acne vulgaris, the factors in the above 4 pathogenesis also interact with each other, so the treatment of acne vulgaris needs multi-mechanical action to bring optimal effect

1.1.2 Clinical features of acne vulgaris

The most common location of acne vulgaris is on the face, then

on the chest, back, and shoulders Primary lesions are classified into non-inflammatory lesions (whiteheads, blackheads) and inflammatory lesions (papules, pustules, nodules, cysts, tunnels) Common accompanying lesions are concave scars, post-

inflammatory hyperpigmentation, keloid scars, vasodilating redness, hypopigmentation, The diagnostic criteria of acne vulgaris are based on basic clinical lesions, especially the expression of the caviar nucleus

There are many different scales used for grading acne vulgaris The most commonly used system in research is the Global Acne Classification System (GAGS) The evaluation method is based on 6 regions (5 regions on the face and 1 region on the upper back/chest) Each of these regions is related to a multiplier of 1 to 3 (1 point each for the nose and chin; 2 points each for the forehead, left cheek, and right cheek; and 3 points each for the chest and upper back) The degree of damage in each area is divided proportionally: 1 if there is more than 1 acne nucleus, 2 if there is more than 1 pustule, 3 if there is more than 1 pustule, and 4 if there

is more than 1 cyst/mass If there is no acne damage in any area, the score is 0 The severity score for each area will be given based

on the injury type with the highest score This score will be multiplied by the score for each region The sum of all 6 regions will give a GAGS score: light 1 ≤ GS ≤ 18; Average 19 ≤ GS ≤ 30; Weight

31 ≤ GS ≤ 38; Very heavy GS>38 The advantages of this scale are high accuracy, relatively simple, easy to apply, low time consumption, and the ability to evaluate back and chest injuries Therefore, we chose this scale for our research

1.1.2 Elements related to acne vulgaris

Age: Acne can appear at different ages, but the incidence rate is

the highest among adolescents Recently, due to the influence of skincare products and stressful lifestyles, this disease often occurs more frequently in adults

Gender: Most studies have shown that women have a higher

proportion of vulvar acne than men, but men have more severe clinical manifestations than women

Family factors: Many studies have shown that genetic factors

play an important role in the development of acne vulgaris People with a family history of "acne vulva" are related to the early appearance of the disease, the increase of pathological changes, the possibility of recurrence and the difficulty of treatment

Skin color factor: "Acne" appears in all people, races, and other

skin types around the world Regardless of race or ethnicity, this disease is considered the most common type of skin disease

Endocrine factors: acne vulgaris can be associated with a

variety of unusual endocrine disorders Endocrine disorders, such

as polycystic ovary syndrome (including hyperandrogenism, insulin resistance, acanthosis nigricans), CAH, and adrenal and ovarian neoplasia may be associated with the acne vulgaris condition

Psychological factors: Psychological factors induce the release

of neuropeptides and hormones that activate cells involved in the pathogenesis of acne vulgaris Many patients report that their acne vulgaris flares up when they are stressed

Diet: Although there is no clear answer regarding the

relationship between diet and acne vulgaris, the results of several studies suggest that a high carbohydrate, milk, and fat diet may be associated with and exacerbate acne vulgaris

Environmental factors, drug use, cosmetics, and mechanical effects: According to some medical literature, they are also related

to the onset and severity of acne vulgaris

1.2 The role of IL-17 in acne vulgaris

IL-17 is a cytokine family composed of six individuals, among which IL-17A, IL-17F, and their IL-17A/F isoforms have varying levels of inflammatory effects

IL-17 is mainly produced by type 17 (Th17) helper T cells In addition, it is also produced together with other cells such as CD8+T cells, gamma delta T cells, natural killer T cells (iNKT), natural killer

T cells (NK), and lymphoid tissue inducible cells (LTi) IL-17 has various physiological functions, including neutrophil motility, stimulation of Th2 cell expression in response to microorganisms, and stimulation of macrophage production of IL-1 β and TNF α Th17 and IL-17 cells have been identified to be associated with the incidence rate of a variety of human autoimmune diseases, such

as rheumatoid arthritis, multiple sclerosis, inflammatory bowel disease, systemic sclerosis, primary Sjogren's syndrome, plaque alopecia, and vitiligo

Several studies have shown that the presence of T cells producing IL-17A and cytokines involved in Th17 pathway activation in acne vulgaris lesions may play an important role in the

disease process Agak et al.'s 2014 study showed that Clostridium acnes can stimulate Th17 and Th1 cells in human peripheral blood monocytes (PBMCs) to produce IL-17 and INF

Some authors from around the world have concluded that drugs such as vitamin D3, retinoic acid, vitamin A, and zinc may play important roles in the treatment of acne vulgaris disease by inhibiting inflammatory expression of the Th17 pathway and increasing regulatory T cell activity

1.2 The role of vitamin D in the disease acne vulgaris

Overview of vitamin D: vitamin D is the common name for a

group of substances with the structure secosterol, which is a vitamin in oil Vitamin D is divided into two main forms: Vitamin D2 (ergocalciferol) and Vitamin D3 (cholecalciferol)

There are 3 main sources to help the body supplement vitamin D: Synthesized on the skin when exposed to sunlight, supplementing vitamin D from foods and supplementing vitamin D from functional tablets Both forms of vitamin D2 and D3 are diffused through the intestinal mucosa along with fats and oils during meals, transported in the blood to adipose tissue and skeletal muscle, vitamin D partly accumulates here, the other part binds with proteins that move in the blood Calcitriol is the active form of vitamin D in the body, and is regulated by blood calcium levels The Calcidiol form, which is bound to plasma proteins and circulates in the blood, is the form used to quantify serum vitamin D levels

The function of vitamin D for physiological activities of the body includes balancing calcium and phosphorus levels in the blood, regulating genes and participating in the immune system The role of Vit D in the skin includes the role of skin differentiation, antibacterial effects, participation in the activity of the innate translational system and the adaptive immune system According to the American Food and Nutrition Board (FNB), the risk of vitamin D deficiency is less than 30 to 50 nmol/l in serum

The role of vitamin D in acne vulgaris: Vitamin D deficiency

is associated with various skin diseases and pathologies, including skin cancer, psoriasis, autoimmune skin diseases such as vitiligo, scleroderma, and systemic lupus erythematosus, as well as atopic

dermatitis and hair loss, Skin infections Based on recent systematic reviews, including 290 pre study studies and 172 randomized trials, it has been concluded that vitamin D deficiency appears to be a related marker of skin pathology through inflammatory reactions, including acne Research has also shown that Clostridium acnes is a powerful Th17 mediated inducer, and vitamin D inhibits Th17 expression induced by Clostridium acnes, making it an effective tool for treating acne vulgaris in acne

The usual therapeutic dosage for adults with Vitamin D deficiency is 1000 international units once daily Taking vitamin D usually doesn't cause side effects However, taking vitamin D for a long time or taking an overdose of vitamin D can cause some of the following side effects: increased blood pressure, high fever, irregular heartbeat, abdominal pain, bone pain, constipation, diarrhea, thirst, increased frequency of urination, loss of appetite, metallic taste in the mouth

1.4 Studies on Vitamin D and Isotretinoin in acne vulgaris disease

1.4.1 Isotretinoin

Isotretinoin acts on all the pathogenesis of acne vulgaris, making it the drug of choice for the treatment of moderate and severe acne vulgaris, individual cystic acne, eel acne, and resistant acne, recurrent acne or acne with accompanying complications The recommended dosage of isotretinoin is 0.5-1 mg/kg/day However, this dose often causes undesirable effects, so in clinical practice, many physicians tend to choose a lower dose in treatment, usually 20 mg/day Regarding the effectiveness of Isotretinoin, many domestic and international studies have shown that this is an interventional treatment on all mechanisms of acne vulgaris disease, thus promoting a good treatment effect The majority of patients improve between 9-12 weeks of treatment

Regarding the adverse effects of isotretinoin in clinical, the most common manifestations are dry lips, dry skin and mucous membranes, other side effects occur with less frequency but are worth noting signs of flare-ups acne vulgaris during the initial period of treatment Undesirable effects on liver function, kidney function, blood fat after using isotretinoin in the treatment of acne have been monitored by many domestic and foreign authors, most

of them have not been seen or seen a very small percentage with increases in AST, ALT or increase cholesterol, triglycerides at a mild level and then return to normal The drug is contraindicated for pregnant women

1.4.2 Vitamin D

The study on the role of vitamin D in hepatitis can be explained

by the relationship between vitamin D and the reduction of 6,

IL-8 and metalloproteinase-9 (MMP-9) synthesis In addition, a study published by Agak and colleagues in 2014 showed that vitamin D affects the expression of IL-17 by inhibiting Th17 cell activity In addition, a study published by Agak and colleagues in 2014 showed that vitamin D affects the expression of IL-17 by inhibiting Th17 cell activity

A study by Zouboulis et al described the effect of vitamin D on the sebaceous glands, as well as the increase in fat production during vitamin D deficiency, which promotes inflammatory expression in VULGARIS ACNE disease

On the other hand, a considerable number of studies around the world have shown that there is a statistically significant difference in serum vitamin D levels among acne vulgaris patients compared to the normal population without acne vulgaris A study published by Ghadah Alhetheli et al in 2020 found that acne vulgaris patients had more frequent vitamin D deficiency, but there was no significant correlation between serum vitamin D levels and the severity of acne vulgaris A study published by Mostafa Yildizgore and colleagues in 2015 found that the average serum vitamin D levels in patients with nodular follicular caviar were significantly lower than those in healthy individuals In 2016, a study conducted by Seul Ki Lim and colleagues in South Korea found that 48.8% of acne vulgaris patients had vitamin D deficiency, but only 22.5% of healthy controls had a negative correlation between vitamin D levels and the severity of acne vulgaris There is

a significant negative correlation with inflammatory damage In subsequent clinical intervention trials, taking a vitamin D supplement of 1000 IU per day for 2 months resulted in a statistically significant increase in vitamin D levels and clinical improvement compared to placebo A study published by El Hamd

MA and colleagues in 2019 found that serum vitamin D levels in

acne vulgaris patients were significantly higher than those in the control group There is a statistically significant negative correlation between serum vitamin D levels and the severity of acne vulgaris disease before treatment After treatment with isotretinoic acid, serum vitamin D levels significantly increased From the above research, the author concludes that vitamin D may play an important role in the pathogenesis of acne vulgaris disease, or acne vulgaris disease may have a negative impact on serum vitamin D synthesis

CHAPTER 2: MATERIALS AND METHODS

2.1 Study objects and materials

Criteria for selecting patients:

- For objective 1: The patient who came to the hospital for examination and treatment at Ho Chi Minh City Dermatology Hospital was diagnosed as a acne vulgaris vulgaris disease, aged from 18 years old and the patient agreed to participate in the study

- For goal 2:

• Group of diseases: Patients were clinically diagnosed with moderate and severe acne vulgaris disease, aged from 18 years old and the patients agreed to participate in the study

• Healthy group: Healthy people similar to the disease group in terms of gender and age, aged from 18 years old, currently free of acne vulgaris disease and agreed to participate in the study

- For target 3: Moderate and severe acne vulgaris disease aged

18 years, consent to participate in the study, no contraindications to Isotretinoin and oral serum vitamin D, divided into study group and control group Control group:

• Study group (RESEARCH GROUP): treatment with Isotretinoin dose of 20 mg/day combined with Vit D3 dose of 1000 IU/day for 3 months

• Control group (CONTROL GROUP): treated with isotretinoin dose of 20 mg/day for 3 months Month

Exclusion criteria:

- For objective 1: patients do not have behavioral capacity to answer questions in the study

- For goals 2 and 3: • Patients under 18 years of age

• Patients who did not consent to participate in the study

• Patients who had taken oral vitamin D and/or isotretinoin within 3 months prior to the examination

• Patients with other skin diseases that may affect serum vitamin

D levels: psoriasis, rosacea, skin cancer, eczema

• Female patients who are pregnant or intend to become pregnant in the next 3 months next

• Patients in the group of subjects at high risk of vitamin D deficiency due to other causes such as people not exposed to sunlight, people with chronic inflammatory bowel disease, vegetarians, patients with kidney failure

• The patient is taking or has used drugs that affect serum vitamin D levels in the 3 months prior to the examination: oral vitamin D, oral steroids

• The patient has conditions that are not suitable for treatment with oral isotretinoin such as: elevated liver enzymes, hyperlipidemia, history of depression, history of allergy to isotretinoin

• Patients with conditions that are not suitable for oral vitamin D treatment such as: hypercalcemia, vitamin D allergy, syndrome malabsorption…

2.1.2 Research materials:

Data collection form, consent form to participate in the study, consent form to use drugs, test sheet, Isotretinoin 20 mg oral tablet and 1000 IU Vitamin D3 oral tablet

2.2 Research method

2.2.1 Study design

- Objective 1: cross-sectional, prospective description

- Objective 2: A cross-sectional description with comparative comparison

- Objective 3: Comparative controlled clinical trials

- Goal 3: Randomly divide 70 patients with moderate to severe acne vulgaris in Goal 2 into 35 patients in the research group and

35 patients in the control group

2.2.3 Steps for conducting research

Goal 1: Receive patients, conduct clinical examinations, and collect research information

Objective 2: 70 patients with moderate and severe acne vulgaris were selected for GAGS scoring before and 3 months after treatment (total blood cell analysis, AST, ALT, TG, Vit D, IL-17 serum) During the study period, 70 healthy control groups underwent a quantitative test of serum vitamin D and IL-17

Goal 3: 70 patients in Goal 2 were randomly divided into a study group and a control group During the 3 months of treatment, these two groups of patients were not allowed to use antibiotics, anti-inflammatory drugs, or any other drugs that affect the progression

of acne vulgaris and changes in serum vitamin D and IL-17 levels, oral medications, creams, or facial cleansers Based on the GAGS score, disease level (see page 3), and the degree of improvement in Christian et al.'s score, the treatment outcomes of the study and control groups were divided into four levels, based on the number

of injuries compared to the previous visit: very good (100% clean), Good (75% -99% damage improvement), moderate (50% -74% damage improvement), and poor (less than 50% damage improvement) At the same time, changes in test indicators and clinical adverse effects were also recorded in the study table after 1-2 to 3 months of treatment

2.2.4 Data processing and analysis

- Data entry: using Epidata 3.1 software Design control steps during input to avoid errors Clean the data before entering into the analysis

- Data analysis: using Stata 14.0 software

2.3 Location and time of the study

Study location: medical examination department, Ho Chi Minh City Dermatology Hospital and Hoa Hao General Clinic (Medic Lab) testing department Research period: March to December 2021

2.4 Ethics in research

Before conducting the study, we clearly explained the purpose, meaning and steps to obtain patient consent The study does not cause physical or mental harm, and is less troublesome or dangerous for the patient Sampling is for research purposes only Oral isotretinoin and vitamin D used in the treatment of patients with moderate and severe acne vulgaris for 3 months are consistent with the indications in the literature Before treatment with Isotretinoin, patients are tested for pregnancy, total blood count, liver enzymes and blood lipids to ensure the safety of treatment

We also have a plan to deal with complications and adverse effects that may be encountered during treatment Therefore, our research ensures compliance with ethical regulations in research

2.5 Limitations of the topic

Our IL-17 assay is quantitative in serum IL-17 and not tissue quantification through histopathology like some previous studies,

so the changes may not be as pronounced by other studies Quantitative study of IL-17 in acne vulgaris diseased tissue samples Our study used Vitamin D in combination with oral Isotretinoin, so the therapeutic effect of Vit D will be masked by Isotretinoin, making it difficult to conclude the independent therapeutic role of Vitamin D in acne vulgaris disease

Study chart:

Chapter 3: RESULTS 3.1 Some related factors and clinical characteristics of acne vulgaris

Table 3.1: Some factors related to acne vulgaris disease (n =

119)

frequency (n) percent(%) Gender