Clin Chem Lab Med 2012;50(11):2061–2063 © 2012 by Walter de Gruyter • Berlin • Boston. DOI 10.1515/cclm-2012-0228

Letter to the Editor

Homocysteine, folic acid and vitamin B12 levels in females with severe acne vulgaris

Megha K. Arora 1, *, Shashi Seth 2 and Surabhi Dayal 3

1 Department of Biochemistry , LHMC and Associated Hospitals, New Delhi , India 2 Department of Biochemistry , Pt B.D. Sharma, UHS, Rohtak, Haryana , India 3 Department of Dermatology , Venereology and Leprology, Pt B.D. Sharma, UHS, Rohtak, Haryana , India

Keywords: acne vulgaris; folate; homocysteine; vitamin B12.

Acne is a pleomorphic disorder of the pilosebaceous unit, characterized by both infl ammatory and non-infl ammatory lesions. There are four primary pathogenic factors, which interact in a complex manner to produce acne lesions: fol-licular hyperkeratinization, excessive sebum production, hypercolonization of the duct by Propionibacterium acnes and direct or indirect infl ammation. The fi fth factor, now included in the pathogenesis, is matrix metalloproteinases (MMPs) (1) .

Homocysteine is a sulfur containing amino acid derived from methionine. Once synthesized, it can be converted back to methionine by 5-methyltetrahydrofolate reductase and methionine synthase by using cofactors such as vitamin B12 and folic acid. Hyperhomocysteinemia has been shown to be associated with premature cerebrovascular, peripheral and coronary artery disease (2, 3) .

Vitamin B12 medication is known to induce or worsen acne lesions but changes in endogenous vitamin B12 levels have not been elucidated well, therefore, we planned to esti-mate vitamin B12 levels in these patients (4) .

Some researchers have found that homocysteine levels increased in patients with moderate to severe acne after 1.5 – 2 months of isotretinoin therapy and vitamin levels remained unaltered (2, 5) . Karadag and colleagues found that isotretin-oin usage might cause decreased vitamin B12, folic acid and holotranscobalamin levels. They recommended that isotretin-oin side effects might contribute to the missing link between its usage, hyperhomocysteinemia, and neuropsychiatric dis-orders (3) .

Previous studies have shown increase in homocysteine levels in patients on isotretinoin therapy but it is not known if all the patients develop hyperhomocysteinemia after treat-ment. Moreover, it is important to identify patients who are at increased risk of developing hyperhomocysteinemia after treatment to allow choice of alternate treatment in these patients. Homocysteine is metabolized using folate and vita-min B12 and defi ciency of these vitamins can lead to hyper-homocysteinemia (2, 3) . So, we planned to evaluate serum homocysteine levels along with vitamin B12 and folic acid levels in 60 females with severe acne vulgaris attending the Dermatology Outpatient Clinic of Pt. B.D. Sharma UHS, Rohtak and compared their levels with healthy volunteers.

The presence of any one of the parameters classifi es the patient under category of severe acne vulgaris as defi ned by Lehman and Associates: > 5 cysts, or total comedone count > 100, or total infl ammatory lesion count > 50, or total lesion count > 125 (6) . All the patients with cerebrovascular disease, liver and kidney disease, patients on multivitamin supplements and smokers, on medications affecting the lev-els of parameters measured were excluded. Informed consent was taken from all patients and healthy females. This study was approved by the Review Board of the institute.

Venous blood was collected aseptically from the antecu-bital vein. Serum was separated by centrifugation (2000 g for 15 min). Homocysteine levels and vitamin B12 levels were measured by ADVIA Centaur chemiluminescent technology. Whole blood samples were collected in EDTA tubes for mea-surement of Folate assay by ADVIA Centaur chemilumines-cent technology.

Statistical analyses were performed using SPSS version 17.0 (SPSS, Inc., Chicago, IL, USA). We used unpaired t-test to compare the individual parameter between patients and controls. Serum homocysteine levels were signifi cantly high in the patients 11.01 ± 2.33 μ mol/L when compared to controls 6.97 ± 2.02 μ mol/L (p < 0.000). Serum vitamin B12 levels in acne patients were 487 ± 24 pg/mL and in controls were 498 ± 26 pg/mL, this difference was not signifi cant statistically. RBC Folate in patients was 640 ± 46 μ g/L and in controls 672 ± 34 μ g/L and levels were not signifi cant statistically (Table 1).

Standardized coeffi cient ( β ) was obtained by standardizing all the variables in the regression, including the dependent and all the independent variables. Standardized coeffi cient ( β ) was 0.554 for serum homocysteine which suggests that for every unit increase in acne vulgaris lesion, a 0.554 unit increase in homocysteine will occur and this value is statisti-

*Corresponding author: Dr. Megha K. Arora, Department of Biochemistry, LHMC and Associated Hospitals, New Delhi, IndiaE-mail: aroramegha26@gmail.com Received January 12, 2012; accepted April 17, 2012; previously published online May 14, 2012

Brought to you by | University of Missouri-ColumbiaAuthenticated | 128.206.9.138

Download Date | 3/6/13 6:40 PM

2062 Arora et al.: Homocysteine, folic acid and vitamin B12 levels in acne

cally signifi cant. No signifi cant change occurs in vitamin B12 or folate levels with increase in acne lesions (Table 2 ).

The area under the receiver operating characteristic curve was calculated for serum homocysteine; which is an effec-tive method to evaluate the performance of each individual diagnostic test. Sensitivity and specifi city were calculated at a particular cut-off point to predict its usefulness in females with severe acne vulgaris (Table 3 ).

Acne vulgaris is a common skin disease and may be an early sign of underlying systemic diseases like polycystic ovarian syndrome. Therefore it becomes essential to treat not only acne lesions but also to diagnose underlying systemic disease at an early stage. Homocysteine is a sulfhydryl group containing amino acid formed from methionine. It is metabo-lized in the liver by cystathionine β -synthase (CBS), enzyme using folate and vitamin B12 so dietary defects of the cofac-tors folic acid and B12 can impair homocysteine clearance leading to hyperhomocysteinemia (2) . In our previous study we investigated that females with severe acne vulgaris have a deranged lipid profi le which might increase their chances of cardiovascular disease; hence it is important to evaluate serum homocysteine levels as a marker for risk of cardiovas-cular disease in these patients (7) .

Serum homocysteine levels were found to be high in females with severe acne vulgaris as compared to controls. According to a study by Third National Health and Nutrition Examination estrogen levels are inversely related to homocysteine levels (8) . In our previous study we found signifi cantly decreased serum estrogen levels in females with severe acne vulgaris; this decrease in estrogen levels could possibly lead to increase

Table 1 Homocysteine, vitamin B12, RBC folate in females with severe acne vulgaris (mean ± SD).

Parameter Females with severe acne vulgaris (n = 60)

Healthy controls(n = 60)

p-Value

Serum homocysteine, μ mol/L

11.01 ± 2.33 6.97 ± 2.02 < 0.000 a

Serum vitamin B12, pg/mL

487 ± 24 498 ± 26 > 0.05 b

RBC folate, μ g/L 640 ± 46 672 ± 34 > 0.05 b

a Very signifi cant; b not signifi cant.

Table 2 Regression analysis.

Parameter Unstandarized coeffi cient

Standarized coeffi cient

p-Value

B β

Serum homocysteine, μ mol/L

0.189 0.554 0.000 a

Serum vitamin B12, pg/mL

0.012 0.027 0.654 b

RBC folate, μ g/L 0.016 0.029 0.529 b

a Very signifi cant; b not signifi cant.

Table 3 Homocysteine as a screening test in females with severe acne vulgaris.

Parameter Area under ROC curve

Sensitivity Specifi city Cut-off value

Serum homocysteine, μ mol/L

0.851 0.811 0.817 10.95

in homocysteine levels due to the effect of estrogen on methi-onine metabolism and interference in the transsulfuration pathway (7, 9) . The exact role of homocysteine in acne is not known. Homocysteine probably leads to acne vulgaris or worsens the lesions by increasing the production and enzy-matic activity of MMP2 and MMP-9 which have recently been included in the pathogenesis of acne vulgaris (10) .

AUC was > 0.851 which suggests that homocysteine can be used to evaluate the risk of premature cardiovascular disease in patients with severe acne vulgaris. Sensitivity and speci-fi city of this test is > 0.8 at a cut-off value of 10.95 μ mol/L, which suggests chances of cardiovascular disease are high in females with severe acne vulgaris when homocysteine lev-els ≥ 10.95 μ mol/L.

Vitamin B12 levels and RBC folate levels were not signifi -cantly different in females with severe acne vulgaris as com-pared to controls. Vitamin B12 levels, though within normal range, were towards lower limit of reference value in both the groups. A possible reason for this could be the vegetarian diet of both the groups.

These patients should not be given vitamin B12 or folic acid supplements to decrease homocysteine levels as vitamin B12 medication is known to worsen acne lesions (4) .

Hyperhomocysteinemia in these patients might be due to abnormality in enzyme CBS; required for metabolism of homocysteine, but to elucidate the exact etiology it is impor-tant to evaluate the quantity and function of the enzyme in these patients (2) .

In conclusion, serum homocysteine should be used as a screening test in females with severe acne vulgaris.

Confl ict of interest statement

Authors ’ confl ict of interest disclosure: The authors stated that there are no confl icts of interest regarding the publication of this article. Research funding: None declared. Employment or leadership: None declared. Honorarium: None declared.

References

1. Thiboutot D, Gollnick H, Bettoli V, Dreno B, Kang S, Leyden JJ, et al. New insights into the management of acne: an update from the global alliance to improve outcomes in acne group. J Am Acad Dermatol 2009;60:S1 – 50.

2. Roodsari MR, Akbari MR, Sarrafi -rad N, Saeedi M, Gheisari M, Kavand S. The effect of isotretinoin treatment on plasma

Brought to you by | University of Missouri-ColumbiaAuthenticated | 128.206.9.138

Download Date | 3/6/13 6:40 PM

Arora et al.: Homocysteine, folic acid and vitamin B12 levels in acne 2063

homocysteine levels in acne vulgaris. Clin Exp Dermatol 2010;35:624 – 6.

3. Karadag AS, Tutal E, Ertugrul DT, Akin KO. Effect of isotretinoin treatment on plasma holotranscobalamin, vitamin B12, folic acid, and homocysteine levels: non-controlled study. Int J Dermatol 2011;50:1564 – 9.

4. Sherertz EF. Acneiform eruption due to “megadose” vitamins B6 and B12. Cutis 1991;48:119 – 20.

5. Polat M, Lenk N, Bingol S, Oztas P, Ilhan M, Artuz F, et al. Plasma homocysteine level is elevated in patients on isotretinoin therapy for cystic acne: a prospective controlled study. J Dermatol Treat 2008;19:229 – 32.

6. Lehmann HL, Robinson KA, Andrews JS, Holloway V, Goddman SN. Acne therapy: a methodological review. J Am Acad Dermatol 2002;47:231 – 40.

7. Arora MK, Seth S, Dayal S. The relationship of lipid pro-fi le and menstrual cycle with acne vulgaris. Clin Biochem 2010;43:1415 – 20.

8. Morris MS, Jacques PF, Selhub J, Rosenberg IH. Total homo-cysteine and estrogen status indicators in the Third National and Nutrition Examination Survey. Am J Epidemiol 2000;152:140 – 8.

9. Dimitrova KR, Groot KD, Myers AK, Kim YD. Estrogen and homocysteine. Cardiovasc Res 2002;53:577 – 88. doi:10.1016/S0008-6363(01)00462-X.

10. Papakonstantinou E, Aletras AJ, Glass E, Tsogas P, Dionyssopoulos A, Adjaye J, et al. Matrix metalloproteinases of epithelial origin in facial sebum of patients with acne and their regulation by isotretinoin. J Invest Dermatol 2005;125:673 – 84.

Brought to you by | University of Missouri-ColumbiaAuthenticated | 128.206.9.138

Download Date | 3/6/13 6:40 PM