Original Paper

Dermatology 2017;233:145–154 Received: July 6, 2016

Accepted after revision: April 16, 2017
DOI: 10.1159/000475775
Published online: June 14, 2017

Epidemiology of Acne Vulgaris in

18-Year-Old Male Army Conscripts in
a South Brazilian City
Rodrigo Pereira Duquia a, b Iná da Silva dos Santos a Hiram de Almeida Jr. b, c
     

Paulo Ricardo Martins Souza d Juliano de Avelar Breunig e
   

Christos C. Zouboulis f  

a
Postgraduate Program in Epidemiology, and b Department of Dermatology, Federal University of Pelotas, and
   

c
Department of Dermatology, Catholic University of Pelotas, Pelotas, d Postgraduation Program in Dermatology,
   

Santa Casa of Porto Alegre, Porto Alegre, and e Department of Dermatology, University of Santa Cruz do Sul,
 

Santa Cruz do Sul, Brazil; f Departments of Dermatology, Venereology, Allergology, and Immunology, Dessau
 

Medical Center, Brandenburg Medical School, Dessau, Germany

Keywords
Acne · Prevalence · Adolescents · Male gender · Ethnic skin ·
Risk factors · Body height · Nutrition
Abstract
Background: Prevalence of acne varies worldwide. Several
factors (age, skin color, body fat, diet, and smoking) have
been investigated as risk factors. Objective: A total of 2,201
18-year-old males living in Pelotas, South Brazil, were evalu-
ated in order to examine the prevalence of acne and associ-
ated factors. Methods: A cross-sectional population-based
study was conducted. A dermatologist performed the clini-
cal examination of the face and trunk for identification of
acne lesions. Acne was evaluated as clinically noninflamma-
tory, inflammatory, and acne with both types of lesions. Skin
color, schooling, height, smoking, skinfolds, waist circum-
ference, BMI, and dietary dairy intake were the independent
variables used. Results: A response rate of 97.2% was ob-
tained. Individuals without any acne lesion were 241 (10.9%);
161 (7.3%) only had noninflammatory lesions, 404 (18.4%)
only inflammatory lesions; and 1,395 (63.4%) presented
both types of lesions. In multivariate analysis, the type of le-
sions was different in light and dark skin phototype adoles-
cents, with more common inflammatory lesions in the light
phototype and noninflammatory ones in the dark photo-
type patients. Height was directly associated with the occur-
rence of all types of acne, whereas lower fat mass was asso-
ciated with the occurrence of noninflammatory acne. While
daily consumption of whole milk or yogurt was found to be
associated with inflammatory acne in crude analysis, the as-
sociation with milk was not detected and that with yogurt
was low in multivariate analysis. Conclusion: Our results
suggest that future studies should explore determinants of
noninflammatory and inflammatory acne separately, espe-
cially if mixed populations are studied.
© 2017 S. Karger AG, Basel

© 2017 S. Karger AG, Basel Prof. Dr. med. Prof. h.c. Dr. h.c. Christos C. Zouboulis
Departments of Dermatology, Venereology, Allergology, and Immunology
Dessau Medical Center, Theodore Fontane Medical University of Brandenburg
E-Mail karger@karger.com
Auenweg 38, DE–06847 Dessau (Germany)
www.karger.com/drm
E-Mail christos.zouboulis @ klinikum-dessau.de
 Introduction
Acne vulgaris is a distressing condition involving the
so-called sebaceous follicle [1]. It is mainly considered an
“adolescent” disorder and is characterized by spontane-
ous resolution in the late teens or early twenties in the
majority of cases, in some of them with facial scar forma-
tion [2]. Prevalence of acne varies worldwide: studies
published in the last decade reported prevalence ranging
from 25.2%, among prepubertal children in Peru to 93.2
and 93.3% among adolescents in Iran and Australia [3].
A series of methodological aspects, including definition
of the disease (type and location of the lesions) and de-
mographic characteristics of the studied population may
be responsible for discrepancies in the prevalence of the
disease in different investigations. Indeed, in some stud-
ies, a single closed or open comedone was sufficient to
consider the subject as a “patient with acne,” while in oth-
ers more than 20 inflammatory and noninflammatory le-
sions were required to diagnose the subject as having acne
[4].
Several factors (age, skin color, body fat, diet, and
smoking) have been investigated as risk factors for acne.
In most studies, diet and body fat have been shown to be
associated with the disease [5–12]. However, one study
showed a statistically significant association between
higher body fat and acne [9], while another found a pro-
tective effect [13]. Other factors, such as skinfolds, height,
and waist circumference, have not shown to be consis-
tently associated with acne [14].
Comedones are considered the earliest acne lesion [1].
They may become inflamed, producing tender papules
that may progress to pustules and, in severe cases, to nod-
ules and cysts [15]. Papules and pustules can occur with-
out the presence of comedones [16]; however, the major-
ity of the patients present both comedones and papules/
pustules. Interestingly, although comedones are clinically
considered noninflammatory lesions, they exhibit sub-
clinical signs of inflammation [17].
The objective of this investigation was to measure the
prevalence of individuals with clinically noninflamma-
tory, inflammatory and with both types of acne lesions, as
well as to identify factors independently associated with
each subtype of acne presentation through a population-
based study of 18-year-old males living in Pelotas, South-
ern Brazil.
Patients and Methods
For further details, see the online supplementary material (see
www.karger.com/10.1159/000475775 for all online suppl. mate-
rial) (Fig. 1).

Adolescents enlisted in the army

n = 2,264

Lost/refusal
n = 63

Adolescent interview
n = 2,201

Adolescents without acne lesion

n = 241 (10.9%)

Adolescents with any acne lesion

n = 1,960 (88.9%)

Adolescents with only Adolescents with only Adolescents with inflammatory

noninflammatory lesions inflammatory lesions and noninflammatory lesions
n = 161 (7.3%) n = 404 (18.4%) n = 1,395 (63.4%)
Fig. 1. Flowchart of the distribution of acne
subsets.

146 Dermatology 2017;233:145–154 Pereira Duquia  et al.

 

DOI: 10.1159/000475775
 Table 1. Description of individuals without acne and individuals with noninflammatory only, inflammatory only,
and both types of acne lesions

Variable Individuals with Individuals Individuals Individuals with

no acne lesions with only non- with only inflammatory and
inflammatory inflammatory noninflammatory
lesions lesions lesions

Skin color
Light skin phenotype 147 (61.0) 76 (47.2) 291 (72.0) 1,039 (74.5)
Dark skin phenotype 94 (39.0) 85 (52.8) 113 (28.0) 356 (25.5)
Schooling, years
0–8 142 (58.9) 98 (60.9) 213 (52.7) 685 (49.1)
≥9 99 (41.1) 63 (39.1) 191 (47.3) 710 (50.9)
Height in tertiles
First 113 (46.9) 59 (36.7) 147 (36.4) 502 (36.0)
Second 70 (29.1) 51 (31.7) 140 (34.6) 467 (33.5)
Third 58 (24.1) 51 (31.7) 117 (29.0) 426 (30.5)
Smoking
No 194 (80.5) 135 (83.9) 341 (84.4) 1,211 (86.1)
Yes 47 (19.5) 26 (16.2) 63 (15.6) 184 (13.2)
TSF in tertiles
First 82 (34.0) 78 (48.5) 112 (27.7) 467 (33.5)
Second 70 (29.1) 42 (26.1) 148 (36.6) 477 (34.2)
Third 89 (36.9) 41 (25.5) 144 (35.6) 451 (32.3)
SSF in tertiles
First 78 (32.4) 63 (39.1) 125 (30.9) 470 (33.7)
Second 76 (31.5) 51 (31.7) 131 (32.4) 479 (34.3)
Third 87 (36.1) 47 (29.2) 148 (36.6) 446 (32.0)
Waist circumference (tertiles)
First 85 (35.3) 54 (33.5) 120 (29.8) 481 (34.5)
Second 63 (26.1) 60 (37.3) 126 (31.3) 477 (34.2)
Third 93 (38.6) 47 (29.2) 157 (39.0) 436 (31.3)
BMI
First 80 (33.3) 58 (36.0) 115 (28.5) 480 (34.5)
Second 70 (29.2) 57 (35.4) 131 (32.5) 474 (34.0)
Third 90 (37.5) 46 (28.6) 157 (39.0) 439 (31.5)
Cheese (daily)
No 192 (79.7) 131 (81.4) 311 (77.2) 1,063 (76.2)
Yes 49 (20.3) 30 (18.6) 92 (22.8) 332 (23.8)
Whole milk (daily)
No 158 (65.6) 108 (67.1) 232 (57.4) 777 (55.7)
Yes 83 (34.4) 53 (32.9) 172 (42.6) 618 (44.3)
Low fat milk (daily)
No 226 (93.8) 154 (95.7) 373 (92.3) 1,300 (93.2)
Yes 15 (6.2) 7 (4.4) 31 (7.7) 95 (6.8)
Yogurt (daily)
No 223 (92.5) 143 (88.8) 361 (89.4) 1,233 (88.4)
Yes 18 (7.5) 18 (11.2) 43 (10.6) 162 (11.6)
Powder chocolate (daily)
No 163 (67.6) 121 (75.2) 259 (64.1) 868 (62.2)
Yes 78 (32.4) 40 (24.8) 145 (35.9) 527 (37.8)
Chocolate bar (daily)
No 218 (90.5) 146 (90.7) 372 (92.1) 1,266 (90.8)
Yes 23 (9.5) 15 (9.3) 32 (7.9) 129 (9.2)
Total 241 161 404 1,395

Data are presented as n (%). TSF, triceps skinfold; SSF, subscapular skinfold; BMI, body mass index.

Epidemiology of Acne in Males in Dermatology 2017;233:145–154 147

Southern Brazil DOI: 10.1159/000475775
Table 2. Prevalence and crude and adjusted prevalence ratios (PR) for noninflammatory acne only according to independent variables

Variable Prevalence, p value Crude PR p value Adjusted PR p value

% (95% CI) (95% CI)

Skin color 0.008a 0.007c 0.04c

Light skin phenotype 34.1 1.00 1.00
Dark skin phenotype 47.5 1.39 (1.10 – 1.77) 1.29 (1.01 – 1.63)
Schooling 0.8a 0.7c 0.7c
0 – 8 years 40.8 1.00 1.00
≥9 years 38.9 0.95 (0.75 – 1.22) 1.05 (0.82 – 1.36)
Height in tertiles 0.03b 0.03d 0.02d
First 34.3 1.00 1.00
Second 42.2 1.23 (0.92 – 1.65) 1.26 (0.94 – 1.69)
Third 46.8 1.36 (1.02 – 1.82) 1.39 (1.05 – 1.85)
Smoking 0.4a 0.4c 0.3c
No 41.0 1.00 1.00
Yes 35.6 0.87 (0.62 – 1.21) 0.84 (0.60 – 1.18)
TSF in tertiles 0.003b 0.003d 0.003d
First 48.8 1.00 1.00
Second 37.5 0.77 (0.58 – 1.03) 0.78 (0.59 – 1.04)
Third 31.5 0.65 (0.48 – 0.87) 0.64 (0.48 – 0.87)
SSF in tertiles 0.1b 0.1d 0.9d
First 44.7 1.00 1.00
Second 40.2 0.90 (0.68 – 1.19) 0.95 (0.70 – 1.28)
Third 35.1 0.79 (0.59 – 1.05) 1.07 (0.66 – 1.73)
Waist circumference (tertiles) 0.4b 0.4d 0.6d
First 38.9 1.00 1.00
Second 48.8 1.26 (0.95 – 1.66) 1.24 (0.94 – 1.63)
Third 33.6 0.86 (0.63 – 1.18) 1.04 (0.71 – 1.52)
BMI 0.2b 0.2d 0.7d
First 42.0 1.00 1.00
Second 44.9 1.07 (0.81 – 1.41) 1.09 (0.78 – 1.52)
Third 33.8 0.81 (0.59 – 1.09) 0.88 (0.55 – 1.43)
Cheese (daily) 0.7a 0.7c 0.7c
No 40.6 1.00 1.00
Yes 38.0 0.94 (0.69 – 1.28) 1.06 (0.77 – 1.47)
Whole milk (daily) 0.8a 0.8c 0.3c
No 40.6 1.00 1.00
Yes 39.0 0.96 (0.74 – 1.24) 1.18 (0.86 – 1.62)
Low fat milk (daily) 0.5a 0.5c 0.9c
No 40.5 1.00 1.00
Yes 31.2 0.79 (0.42 – 1.47) 0.96 (0.50 – 1.84)
Yogurt (daily) 0.2a 0.2c 0.2c
No 39.1 1.00 1.00
Yes 50.0 1.28 (0.90 – 1.82) 1.28 (0.89 – 1.85)
Powder chocolate (daily) 0.1a 0.1c 0.1c
No 42.6 1.00 1.00
Yes 33.9 0.80 (0.60 – 1.06) 0.81 (0.60 – 1.08)
Chocolate bar (daily) 1.0a 0.9c 0.7c
No 40.1 1.00 1.00
Yes 39.5 0.98 (0.65 – 1.49) 0.91 (0.59 – 1.42)

TSF, triceps skinfold; SSF, subscapular skinfold; BMI, body mass index. a χ2 test. b Linear trend test. c Heterogeneity Wald test. d Wald
linear trend test.

148 Dermatology 2017;233:145–154 Pereira Duquia  et al.

 

DOI: 10.1159/000475775
Table 3. Prevalence and crude and adjusted prevalence ratios (PR) for inflammatory acne only according to independent variables

Variable Prevalence, p value Crude PR p value Adjusted PR p value

% (95% CI) (95% CI)

Skin color 0.004a 0.006c 0.008c

Light skin phenotype 66.4 1.00 1.00
Dark skin phenotype 54.6 0.82 (0.71 – 0.95) 0.83 (0.72 – 0.95)
Schooling 0.1a 0.1c 0.8c
0 – 8 years 60.0 1.00 1.00
≥9 years 65.9 1.10 (0.98 – 1.24) 1.02 (0.90 – 1.16)
Height in tertiles 0.02b 0.02d 0.03d
First 56.5 1.00 1.00
Second 66.7 1.18 (1.02 – 1.36) 1.18 (1.02 – 1.36)
Third 66.9 1.18 (1.02 – 1.37) 1.17 (1.01 – 1.36)
Smoking 0.2a 0.2c 0.5c
No 63.7 1.00 1.00
Yes 57.3 0.90 (0.76 – 1.07) 0.94 (0.79 – 1.12)
TSF in tertiles 0.5b 0.5d 0.9d
First 57.7 1.00 1.00
Second 67.9 1.18 (1.01 – 1.37) 1.11 (0.95 – 1.30)
Third 61.8 1.07 (0.92 – 1.25) 0.97 (0.77 – 1.21)
SSF in tertiles 0.8b 0.8d 0.6d
First 61.6 1.00 1.00
Second 63.3 1.03 (0.88 – 1.20) 0.99 (0.84 – 1.15)
Third 63.0 1.02 (0.88 – 1.18) 0.95 (0.79 – 1.14)
Waist circumference (tertiles) 0.4b 0.4d 0.8d
First 58.5 1.00 1.00
Second 66.7 1.14 (0.98 – 1.33) 1.07 (0.90 – 1.28)
Third 62.8 1.07 (0.92 – 1.25) 0.97 (0.76 – 1.23)
BMI 0.4b 0.4d 0.5d
First 59.0 1.00 1.00
Second 65.2 1.11 (0.95 – 1.29) 1.09 (0.93 – 1.26)
Third 63.6 1.08 (0.93 – 1.25) 1.06 (0.92 – 1.23)
Cheese (daily) 0.5a 0.5c 0.9c
No 61.8 1.00 1.00
Yes 65.3 1.06 (0.92 – 1.21) 1.01 (0.87 – 1.16)
Whole milk (daily) 0.05a 0.04c 0.2c
No 59.5 1.00 1.00
Yes 67.5 1.13 (1.01 – 1.28) 1.09 (0.97 – 1.23)
Low fat milk (daily) 0.5a 0.5c 0.4c
No 62.3 1.00 1.00
Yes 67.4 1.08 (0.88 – 1.34) 1.09 (0.88 – 1.36)
Yogurt (daily) 0.2a 0.1c 0.2c
No 61.8 1.00 1.00
Yes 70.5 1.14 (0.96 – 1.36) 1.14 (0.96 – 1.35)
Powder chocolate (daily) 0.4a 0.4c 0.4c
No 61.4 1.00 1.00
Yes 65.0 1.06 (0.94 – 1.20) 0.93 (0.79 – 1.09)
Chocolate bar (daily) 0.5a 0.5c
No 63.1 1.00 1.00 0.5c
Yes 58.2 0.92 (0.73 – 1.16) 0.92 (0.72 – 1.17)

TSF, triceps skinfold; SSF, subscapular skinfold; BMI, body mass index. a χ2 test. b Linear trend test. c Heterogeneity Wald test. d Wald
linear trend test.

Epidemiology of Acne in Males in Dermatology 2017;233:145–154 149

Southern Brazil DOI: 10.1159/000475775
 Results
A total of 2,264 adolescents were enlisted in the army.
Of these, 63 (2.8%) did not attend the medical examina-
tion. The remaining 2,201 adolescents were invited and
agreed to participate in the study (Fig.  1). Individuals
without any acne lesion were 241 (10.9%); 161 (7.3%)
only had noninflammatory lesions; 404 (18.4%) only had
inflammatory lesions; and 1,395 (63.4%) had both nonin-
flammatory and inflammatory lesions (Fig. 1).
Table 1 describes the four subgroups of individuals (no
acne lesions, only noninflammatory lesions, only inflam-
matory lesions, and both types of lesions). There were
more patients with a light skin phenotype than with a
dark skin phenotype among those with inflammatory le-
sions alone or in combination with noninflammatory le-
sions. Among the subjects with noninflammatory lesions
only, the proportion of patients with light and dark skin
phenotypes was similar (52.8 and 47.2%, respectively).
Among individuals without acne, the proportion of pa-
tients with a light skin phenotype was markedly higher
than the proportion of patients with a dark skin pheno-
type (61 and 39%, respectively).
The proportion of shorter adolescents (first tertile in
height) was higher among those without acne than among
individuals from the 3 case groups. There were more thin
adolescents of the first tertile in triceps skinfold (TSF),
subscapular skinfold, and BMI in the noninflammatory
group than among the others. The four groups were sim-
ilar with regard to daily consumption of cheese, milk, yo-
gurt, and chocolate.
Table 2 shows the prevalence of individuals with non-
inflammatory lesions only as well as crude and adjusted
prevalence ratios (PR) with corresponding 95% CI ac-
cording to independent variables. In the crude analysis,
the prevalence of comedonal acne alone was higher
among adolescents with a dark skin phenotype, and those
who were taller and thinner. These results were con-
firmed in multivariate analysis. The probability of nonin-
flammatory acne was 29% higher in the dark than in the
light skin phenotype individuals. The occurrence in-
creased linearly with the adolescent height and inversely
with TSF: the taller and the thinner the adolescent was,
the higher was the probability of having noninflamma-
tory acne. Comparatively to the shortest adolescents (first
tertile) taken as the reference group, those in the second
and third tertiles had a higher probability of 26 and 39%,
respectively, of presenting noninflammatory acne. The
lower the TSF was, the higher was the probability of only
having noninflammatory acne. There was no association
150 Dermatology 2017;233:145–154
DOI: 10.1159/000475775
between noninflammatory acne and school attainment,
smoking, daily consumption of milk, dairy products or
chocolate, or with the remaining body fat indicators (sub-
scapular skinfold, BMI, and waist circumference).
Table  3 presents the prevalence of individuals with
only inflammatory lesions according to the independent
variables. In crude analysis, the prevalence of inflamma-
tory acne alone increased with height and was greater
among adolescents with a light skin phenotype and
among those who reported daily consumption of whole
milk. There was no association between inflammatory le-
sions and the other variables. In multivariate analysis,
only skin color and height remained associated with in-
flammatory lesions. Adolescents with a light skin pheno-
type had a 17% higher probability than those with a dark
skin phenotype of presenting inflammatory acne. Inflam-
matory acne was also directly associated with adolescent
height. Taller adolescents had a 17% higher probability of
presenting inflammatory acne alone than their counter-
parts from the shorter group (first tertile).
Table 4 shows the results from patients with both types
of acne lesions. In crude analysis, the prevalence of acne
was greater among patients with a light skin phenotype
and increased with years of schooling and adolescent
height. Prevalence was also higher among nonsmokers
and among those who reported daily consumption of
whole milk and yogurt. In multivariate analysis, only skin
color, height, and daily consumption of yogurt remained
associated with acne. The probability of presenting both
types of lesions was 9% higher in adolescents with a light
skin phenotype in comparison to those with a dark skin
phenotype. Daily consumers of yogurt had a 5% higher
probability of presenting acne than their counterparts.
The association with height was similar to the findings
observed with the above subgroups, with the probability
of occurrence directly increasing with the adolescent’s
height.
Discussion
The measured prevalence of 89% is the real prevalence
of acne (all types) in 18-year-old male adolescents in the
city of Pelotas, Brazil. This finding is in agreement with
results from Australia, Nigeria, Peru, and Turkey [3, 18–
22] (Table 5).
The method of classification of acne and the area of
skin evaluated varied in different studies, making the
comparison between the available studies difficult. More-
over, high rate of losses found in some of the studies, may
Pereira Duquia  et al.
Table 4. Prevalence and crude and adjusted prevalence ratios (PR) for associated noninflammatory and inflammatory acne according
to independent variables

Variables Prevalence, p value Crude PR p value Adjusted PR p value

% (95% CI) (95% CI)

Skin color <0.001a <0.001c <0.001c

Light skin phenotype 87.6 1.00 1.00
Dark skin phenotype 79.1 0.90 (0.86 – 0.95) 0.91 (0.86 – 0.96)
Schooling 0.005a 0.005c 0.2c
0 – 8 years 82.8 1.00 1.00
≥9 years 87.8 1.06 (1.02 – 1.10) 1.03 (0.98 – 1.07)
Height in tertiles 0.002b 0.002d 0.006d
First 81.6 1.00 1.00
Second 87.0 1.07 (1.01 – 1.12) 1.06 (1.01 – 1.11)
Third 88.0 1.08 (1.03 – 1.13) 1.07 (1.02 – 1.13)
Smoking 0.01a 0.02c 0.06c
No 86.2 1.00 1.00
Yes 79.7 0.92 (0.86 – 0.99) 0.94 (0.88 – 1.00)
TSF in tertiles 0.5b 0.5d 0.6d
First 85.1 1.00 1.00
Second 87.2 1.03 (0.98 – 1.08) 1.01 (0.97 – 1.06)
Third 83.5 0.98 (0.93 – 1.03) 0.98 (0.92 – 1.04)
SSF in tertiles 0.3b 0.3d 0.8d
First 85.8 1.00 1.00
Second 86.3 1.01 (0.96 – 1.06) 1.00 (0.95 – 1.05)
Third 83.7 0.98 (0.93 – 1.03) 1.01 (0.94 – 1.08)
Waist circumference (tertiles) 0.3b 0.3d 0.07d
First 85.0 1.00 1.00
Second 88.3 1.04 (0.99 – 1.09) 1.03 (0.98 – 1.08)
Third 82.4 0.97 (0.92 – 1.02) 0.95 (0.90 – 1.00)
BMI 0.2b 0.2d 0.7d
First 85.7 1.00 1.00
Second 87.1 1.02 (0.97 – 1.07) 1.01 (0.96 – 1.07)
Third 83.0 0.97 (0.92 – 1.02) 1.01 (0.94 – 1.10)
Cheese (daily) 0.3a 0.2c 0.7c
No 84.7 1.00 1.00
Yes 87.1 1.03 (0.98 – 1.08) 1.01 (0.96 – 1.06)
Whole milk (daily) 0.005a 0.003c 0.06c
No 83.1 1.00 1.00
Yes 88.2 1.06 (1.02 – 1.10) 1.04 (1.00 – 1.08)
Low fat milk (daily) 0.9a 0.7c 0.7c
No 85.2 1.00 1.00
Yes 86.4 1.01 (0.94 – 1.10) 1.02 (0.94 – 1.10)
Yogurt (daily) 0.06a 0.03c 0.05c
No 84.7 1.00 1.00
Yes 90.0 1.06 (1.01 – 1.12) 1.05 (1.00 – 1.11)
Powder chocolate (daily) 0.1a 0.1c 0.3c
No 84.2 1.00 1.00
Yes 87.1 1.04 (0.99 – 1.08) 0.98 (0.93 – 1.03)
Chocolate bar (daily) 0.9a 0.9c 1.0c
No 85.3 1.00 1.00
Yes 84.9 1.00 (0.93 – 1.07) 1.00 (0.93 – 1.07)

TSF, triceps skinfold; SSF, subscapular skinfold; BMI, body mass index. a χ2 test. b Linear trend test. c Heterogeneity Wald test. d Wald
linear trend test.

Epidemiology of Acne in Males in Dermatology 2017;233:145–154 151

Southern Brazil DOI: 10.1159/000475775
Table 5. Prevalence of acne vulgaris in 18-year-old males; review lescents may have had epiphyseal ossification later than
of large studies worldwide the shorter ones and since the androgens are among the
main factors involved in this process, it is possible that a
Country n Prevalence, Type of Reference
% study later exposure to androgens close to the 18th year of age
may be responsible for the highest prevalence of acne ob-
Australia 117 97.8 CB, Q, CE [18] served in this group.
Brazil 2,201 89.3 CB, CE This study Smoking was reported to be a clinically important con-
Iran 36 55.6 CB, Q, CE [3] tributor to acne prevalence, severity, and type [6, 28]. Re-
Mali 40 57.5 CB, P [22]
Nigeria 110 97.3 CB, Q, CE [19] cent investigations revealed that cigarette smoke contains
Peru 198 75.3 CB, Q, CE [20] high amounts of arachidonic acid and polycyclic aromat-
Turkey 227 73.6 CB, Q, CE [21] ic hydrocarbons, which induce a phospholipase A2-de-
pendent inflammatory pathway; this effect may further
CB, community-based; CE, clinical examination; Q, question-
stimulate arachidonic acid synthesis. On the other hand,
naire; P, photograph evaluation.
smokers may have a higher saturated fat intake with their
food and much lower polyunsaturated fat intake, princi-
pally due to a lower linoleic acid intake compared with
have biased the prevalence and the associations found nonsmokers, as reported by Zouboulis et al. [5]. In an ex-
[23–26]. perimental study, topically applied linoleic acid was
Besides sample size, methodological strengths of the shown to induce an almost 25% reduction in the overall
current study include standardization of skin examina- size of microcomedones over a 1-month treatment period
tion and of anthropometric measures, and the high intra- [29]. However, in all three subgroups of our study, the
and interobserver agreement rate obtained in type and prevalence of acne was higher among nonsmokers. The
counting of acne lesions and of anthropometric mea- small number of teenage smokers in each subgroup anal-
sures. The process of calibration increased the accuracy ysis may have affected the assessment of the relationship
of the measures, contributing to the quality of the analy- between smoking and acne.
sis. Moreover, skin examination performed by dermatol- Some studies suggested that Western diet with char-
ogists, as in the current study, is a methodological advan- acteristically high glycemic index leads to hyperinsu-
tage over self-reported acne because self-perception of linemia and a resulting cascade of endocrine conse-
having acne may depend of individual subjective values. quences which may mediate acne pathogenesis [11].
At last, the subgroup analyses are an issue not addressed Cordain et al. [30] and Kaymak et al. [31] suggested that
in a number of previous studies [27]. Homogeneity of the hyperinsulinemia elicits endocrine responses that may
adolescent age, the fact that only males were examined, affect the development of acne through mediators, such
and the cross-sectional nature of the study are limitations as androgens insulin-like growth factor (IGF)-I, IGF-
of this work. binding protein 3, and retinoid signaling pathways. The
In the literature, skin color was reported to be associ- role of diet in endocrine activity is supported by the ob-
ated with increased acne rates [7]. Our study showed a servation that improvements in nutrition have been
consistent association between skin color and acne. In linked to an earlier onset of sexual maturation and the
crude and adjusted analyses, light skin phenotype was development of acne in young girls and boys. Further-
protective against the presence of noninflammatory acne more, in the last years, some studies have linked acne to
alone, whereas light skin phenotype was a risk factor for milk intake [10, 32].
inflammatory acne. Litman et al. [8] identified that dark If acne is due to hyperinsulinemia, it would be expect-
skin phenotype men had higher dihydrotestosterone ed that obese individuals, who are relatively chronically
levels and dihydrotestosterone/testosterone ratio when insulin resistant, would present a higher prevalence of
compared with patients with a light skin phenotype and acne [30, 31]. In a cross-sectional population-based study
Hispanic men. This higher level of androgens may affect with children aged 6–11 years, the BMI in acne children
the prevalence of acne in dark skin phenotype persons was significantly higher than that in children without
[8]. Our study showed a difference in the direction of the acne [9]. In our study, we used waist circumference and
associations found between acne and skin color. BMI as markers of insulin resistance, and no association
Height of the individuals had a positive association was found in all acne subgroups. However, although
with acne in all three groups evaluated. Since taller ado- widely used to make estimates of body fat, several studies

152 Dermatology 2017;233:145–154 Pereira Duquia  et al.

 

DOI: 10.1159/000475775
have shown that BMI is not an accurate measurement of
body composition, since it does not accurately distin-
guish body fat from lean mass.
In order to further estimate the body fat mass, we eval-
uated skinfolds, which is likely to be a more reliable indi-
cator. Individuals with lower fat mass, as measured by
TSF, had a higher rate of noninflammatory acne than the
ones with higher fat mass, in crude and adjusted analyses.
No association of this variable was found with exclusive-
ly inflammatory acne or in those with both types of le-
sions.
Association between acne and food consumption
(sweets, chocolate, oily foods, and nuts) have been ex-
plored in several studies [3, 12, 32, 33], some of them
showed statistically significant associations [3, 33]. How-
ever, in the majority of the studies, presence of acne was
self-reported by the interviewed persons, which may af-
fect the outcome classification and, therefore, the internal
validity of the studies [4]. As stated above, self-reported
acne may be affected by the relative relevance given by
each individual to the presence of a skin lesion.
In our study, daily consumption of yogurt was associ-
ated with the simultaneous presence of noninflammatory
and inflammatory lesions in crude and adjusted analyses.
The association between daily consumption of whole
milk and inflammatory acne was only present in crude
analysis. Although the results of adjusted analyses were
not statistically significant, the prevalence ratios for daily
consumption of whole milk may point to a weak positive
association with inflammatory acne. Daily chocolate con-
sumption was not associated with any kind of acne lesions
[3]. The statistical power of the study for two subgroups
(noninflammatory or inflammatory only) was limited
due to the small size of the samples. Other studies with
greater sample sizes may be necessary to afford sufficient
power to detect small associations.
In summary, our findings show that acne is highly
prevalent among adolescent males in Southern Brazil and
that most of the adolescents exhibit simultaneously both
types (noninflammatory and inflammatory) of lesions.
Skin color was consistently associated with acne occur-
rence in all three subgroups, but the type of lesions was
different in adolescents with light and dark skin pheno-
types (inflammatory lesions in the former and nonin-
flammatory in the latter group). Height was directly as-
sociated with the occurrence of all types of acne, whereas
lower fat mass was associated with the occurrence of non-
inflammatory acne. Daily consumption of whole milk or
yogurt may be associated with inflammatory acne. Our
results suggest that future studies should explore deter-
minants of noninflammatory and inflammatory acne
separately.
Key Message
Male adolescents in Brazil present a high prevalence of acne
(89.1%), mostly with both inflammatory and noninflammatory le-
sions. Inflammatory lesions are more prominent in light photo-
type patients, while noninflammatory ones in dark phototype ado-
lescents. Height is directly associated with the occurrence of acne.
Statement of Ethics
The study protocol was approved by the Ethics Committee of
the Faculty of Medicine of Federal University of Pelotas and ad-
hered to the Declaration Helsinki guidelines. Written informed
consent was obtained from each participant before enrolling in the
study.
Disclosure Statement
All authors declare no conflict of interest.

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