- Sayed Shahabuddin Hoseini MDDepartment of Clinical Studies, Student’s Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Saeed Shoar MD#ssht84 at yahoo dot comDepartment of Clinical Studies, Student’s Scientific Research Center; Department of Surgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
Acne Vulgaris is one of the most common skin diseases commonly starting from puberty. Due to the great psychological distress it imposes on individuals, there is a need for improving corresponding therapeutic modalities. In this case report, we describe the medical history of a patient suffering from severe acne that whose skin lesions dramatically subsided during fasting time in Ramadan month without a need for medical therapy. We also discuss possible mechanisms responsible for this interesting phenomenon.
Acne Vulgaris is a very common inflammatory skin condition with a prevalence of up to 93% in 16 to 18 years old individuals . Acne manifest itself by comedones, papules, nodules, pustules, cysts and if untreated it can generate permanent scars that appears mostly in areas of skin with dense sebaceous glands such as forehead, nose, cheeks, chest, shoulders and back . Although the medical consequences of acne are insignificant, the emotional impact of this dermatologic disease is comparable to that of arthritis, diabetes, epilepsy and disabling asthma .
A 28-year-old man with severe acne from 16 years ago was routinely taking treatment. His acne started from the age of 12 with facial papule and pustules that slowly spread to the chest, neck, shoulder and back. He had visited several physicians and received topical antimicrobial agents, Benzoyl peroxide cream, erythromycin gel and oral doxycycline. As vast area of skin was involved, he discontinued topical agents and continued doxycycline treatment. During time, some of the pustules finally generated permanent scars that imposed a great psychological pressure on patients and urged him to seek further medical help. In his medical records, he received two rounds of oral isotretinoin, none of which lasted more than 2 weeks due to severe dry eye and dry skin especially of lips. Therefore, the patient only continued to take doxycycline 100mg/day for over 5 years. During this time, he had several medical check-ups and blood, liver and kidney functional tests to detect possible side effects of doxycycline long term usage. Although doxycycline was effective to partially alleviate symptoms, new acne papules were arising persistently and were being aggravated whenever the drug was discontinued. The patient describes that his acne worsens three to four days following consumption of foods containing fat, egg, milk, coffee, cocoa, date and sugar-rich chocolates.
The patient was nonsmoker and did not have medical or psychological diseases. His body mass index was between 26 and 27 during the last 5 years. His parents as well as siblings had a history of acne.
The patient came to us when he was in the middle of Ramadan month in which Muslims fast. He was fasting the whole day except for 3 hours after dusk when he was eating food and drinking water. His food consumption dropped and he lost about three kilograms of body weight. Although he used to abstain eating sugary foods before the fasting month, date and chocolates were consumed after breaking the fast. He also stopped taking doxycycline during this time. When we visited the patient, he was very happy that from the very beginning of fasting, new acne papule formation decreased dramatically and there was no need to take doxycycline. Besides, some of the papules formed just before fasting month shrank and finally disappeared during the first days of Ramadan. A similar history of temporary acne diminution during Ramadan month of previous years was also recalled by our patient.
Due to its high prevalence and grave effects in the quality of life, self-esteem and social interactions of individuals, acne remains a skin disease seeking more attention. In contrary to several other disorders, acne therapeutics has not satisfied its own customers suffering from never ending skin papules which occasionally culminating in permanent scars. Unfortunately, most acne patients do not adhere to therapy . One reason is that such drugs need a couple of months until they show subjective improvements . In addition to interference with normal daily activity, it remains a tedious job to apply topical remedies all over the skin of face, chest, shoulders and back. To tackle the severe forms of acne, isotretinoin remains the last resort; however, its teratogenicity  and side effects limits its use in many cases such as in our patient.
In this case report, we described an exciting case of severe acne that was dramatically subsided during the first two weeks of fasting. Interestingly, the patient discontinued the only anti-acne drug he was taking for a long time and also increased his usage of chocolates to which he was sensitive, without exacerbation of skin lesions.
It has been recognized that insulin-like growth factor-1 (IGF-1) stimulate lipogenesis of sebaceous glands . Besides, there is a correlation between the level of IGF-1 and acne in adults . IGF-1 can also sensitize adrenal glands to the stimulatory effects of adrenocorticotropic hormone to produce dehydroepiandrosterone sulphate, a substance that is comedogenic . Having known that IGF-1 is a major player in acne pathogenesis, it is logic to investigate if fasting can affect the levels of this growth factor. Bang P et al. have shown that serum IGF-1 was significantly decreased in healthy obese and non-obese individuals after four days of fasting which was more likely to be due to a reduction in its production .
It is suggested that acne is a chronic inflammatory disease of pilosebaceous unit . Not surprisingly, proinflammatory cytokines such as tumor necorosis factor α (TNFα) and interleukin-8 (IL-8) play a role in acne pathogenesis . Results of a study that assessed post-Ramadan versus pre-Ramadan blood level of proinflammatory cytokines show that the level of several cytokines including TNFα and IL-8 decreases following fasting .
These evidences support a hypothesis that fasting leads to a decrease in IGF-1 production by which it alleviate acne lesions. In addition, it can reduce serum level of proinflammatory cytokines that are responsible for acne lesion development. Beside the endocrine role of fasting, a reduction in total food consumption including milk, fat, egg and coffee could be responsible at least in part for the observed results although this patient increased his chocolate eating.
To conclude, it seems that diurnal fasting can be an effective strategy to treat acne patients especially those with severe forms of the disease or in case potent drugs are contraindicated. Surely, clinical studies on acne patients during Ramadan month may support our observation, reveal mechanisms behind that and offer the patients who are suffering from acne a new approach for treatment.
The authors declare that there is no conflict of interests regarding the publication of this article.
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