Characterizing Clinical and Hormonal Profiles of Acne in North African Women with Polycystic Ovary Syndrome

Characterizing Clinical and Hormonal Profiles of Acne in North African Women with Polycystic Ovary Syndrome | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Characterizing Clinical and Hormonal Profiles of Acne in North African Women with Polycystic Ovary Syndrome Fatma Ben Abdessalem, Taieb Ach, Nadia Ghariani Fetoui, Emna Mraihi, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4889348/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Introduction: Polycystic ovary syndrome (PCOS) is the leading endocrine disorder in young women of childbearing age. Dermatological issues, particularly acne, are a major reason for medical consultations. This study seeks to establish the prevalence of PCOS among patients with acne and to compare the metabolic and hormonal clinical characteristics of acne patients with PCOS to those with isolated acne. Patients and Methods: This was a prospective study conducted with analytical objectives at the Endocrinology Department and Dermatology Department of CHU Farhat Hached Sousse. The study included patients seeking treatment for acne from January 2023 to January 2024, divided into two groups: those with confirmed PCOS (G1) and those with isolated acne (G2). All patients underwent hormonal assessment and ovarian ultrasound. Results: We conducted a study involving 212 patients. We found that 65.6% of acne patients had been diagnosed with PCOS. Nodular lesions were significantly more frequent in G1 (p = 0.02). Acne was linked with hirsutism, which was more prevalent in G1 (94.2% G1 vs. 67.1% G2), as well as androgenic alopecia (51% G1 vs. 21.9% G2) (p < 10 − 3 ). G1 showed evidence of biological hyperandrogenism, with a mean testosterone level of 0.72 ± 0.27 ng/mL, significantly higher than in G2. The LH/FSH ratio was greater than 1 in 72.7% of G1 cases, with a notable difference from G2. In our study, acne in G1 appeared to be more severe and was associated with hypertestosteronemia (p = 0.041) and hyperprolactinemia (p = 0.008). According to our results, phenotype A was the most likely to cause severe acne (p = 0.043). Conclusion: Our work is unique in that it brings to light this hidden aspect of the dermatological impact of PCOS, prompting physicians to screen for this endocrine disorder in all adult women seeking acne treatment. Acne Polycystic ovary syndrome hirsutism alopecia androgens Introduction Polycystic ovary syndrome (PCOS) is the most common endocrine disorder among young women of childbearing age [ 1 ]. Its prevalence has risen sharply in recent years, with diagnostic criteria suggesting that up to 20% of the female population may be affected [ 2 ]. PCOS is a complex condition resulting from hormonal imbalances involving both the ovaries and the central nervous system [ 3 ]. This imbalance leads to an overproduction of androgens, particularly testosterone, which is typically produced in small amounts in women [ 4 ]. Although the precise pathophysiological mechanisms of PCOS remain incompletely understood, insulin resistance, along with resultant hyperinsulinism and hyperandrogenism, is believed to play a central role [ 5 ]. PCOS is associated with multiple comorbidities, including metabolic, reproductive, neoplastic, and cardiovascular disorders, posing significant public health challenges and, in some cases, leading to severe outcomes. Therefore, early diagnosis and appropriate management are essential [ 6 ]. The latest guidelines, updated in 2023, recommend that PCOS be diagnosed based on the Rotterdam Consensus criteria of 2003, with the addition of Anti-Müllerian Hormone (AMH) as a diagnostic marker [ 7 ]. Diagnosis requires the presence of at least two of the following criteria [ 1 ]: - Clinical hyperandrogenism (manifesting as hirsutism, acne, or androgenic alopecia) or biochemical hyperandrogenism. - Oligo-anovulation (irregular or absent ovulation), where menstrual cycles shorter than 21 days or longer than 35 days are considered indicative of anovulation. - Polycystic ovarian morphology on endovaginal ultrasound, characterized by at least one ovary with more than 20 follicles measuring 2 to 9 mm in diameter, and/or an ovarian volume greater than 10 ml without a dominant follicle or cyst. - Elevated AMH levels, now recognized as an alternative to ultrasound criteria for diagnosing PCOS. Dermatological issues, particularly acne and hirsutism, are among the primary reasons for medical consultations in women with PCOS [ 5 ]. Acne prevalence in the general population is estimated to range from 12–54% [ 7 ], with some studies indicating that nearly 43% of acne cases are associated with PCOS [ 8 ]. Acne is a multifactorial disease of the pilosebaceous unit, most commonly affecting the face [ 9 ]. It is caused by increased sebum production, hyperkeratosis of the follicular duct, and colonization by the bacterium Cutibacterium acnes, which may or may not be associated with inflammation [ 10 ]. Androgens play a significant role in acne pathogenesis, primarily by increasing sebaceous gland activity [ 9 ]. Most studies indicate that mild acne is frequently observed in women of childbearing age. However, inflammatory, treatment-resistant, moderate, or severe acne may suggest androgen excess and warrants investigation for underlying endocrinopathies, particularly PCOS [ 8 , 11 ]. The latest 2023 guidelines for managing acne in the context of PCOS emphasize the importance of a comprehensive hormonal evaluation at the initial presentation of acne to prevent misdiagnosis [ 12 ]. Despite being a common reason for dermatological consultations, acne in the context of PCOS is often overlooked and typically treated symptomatically, without investigating its underlying cause [ 13 ]. This is partly due to the challenges in diagnosing hormonal imbalances and the tendency of some physicians to manage all types of acne similarly. The global prevalence of PCOS-related acne remains underexplored, particularly in Africa, where no significant studies have been conducted despite the increasing incidence of PCOS in the region [ 14 ]. This study aims to assess the frequency of PCOS in patients primarily seeking treatment for acne. The secondary objective is to examine the clinical, metabolic, and hormonal characteristics of acne patients with and without a PCOS diagnosis. Patients and Methods This is a prospective analytical study, conducted in the Endocrinology Department of the university Hospital of Farhat Hached in Sousse. We collected data from all patients who visited the Endocrinology and Dermatology outpatient clinics for acne from January 2023 to January 2024. Written consent was obtained from the patients before the clinical and hormonal analysis. This study has been approved by the ethics committee of the faculty of medicine of Sousse. Patients’ selection: We conducted a sample size calculation using the formula appropriate for our study type: n = z². p (1 – p) / i² Where: n = sample size. z = confidence level: for a confidence level of 95%, z = 1.96. p = prevalence of PCOS in the Tunisian female population of reproductive age estimated at 4.73% (represents the prevalence of PCOS in Tunisia in 2019 among women aged 15 to 45 years). i = tolerated margin of error = precision: we want to know the true proportion within 5%. The calculation yields a sample size of n = 70 patients. Therefore, this threshold would be statistically representative of the population. Since recruitment took place over one year, we increased the final number due to the likely increase in PCOS prevalence since 2019. The final sample consisted of n = 139 patients in the PCOS group. Patients who have received hormonal treatment that may interfere with hormone dosage and ultrasound exploration within the last 3 months. We excluded patients with other conditions that could mimic the symptoms of PCOS, such as hyperprolactinemia, congenital adrenal hyperplasia, and thyroid disorders. All the hormonal assessment for these conditions were checked-up in all patients, and were normal. Additionally, patients on medications known to affect hormonal profiles were excluded, such as hormonal contraceptives, glucocorticoids, antipsychotics, and antiepileptic drugs. Patients with PCOS phenotype D (absence of clinical hyperandrogenism) were not included. Each patient underwent two separate appointments for a clinical examination and an ultrasound scan. Clinical, anamnestic, and ultrasonographic data were collected based on a predefined form. The clinical examination involved assessing acne using the Global Acne Evaluation (GEA) score, as well as evaluating other signs of hyperandrogenism such as hirsutism and androgenic alopecia. Additionally, anthropometric measurements including weight and height were taken, and the body mass index (BMI) was calculated. Metabolic and hormonal investigations Carbohydrate balance: Glycated hemoglobin (HbA1c) and fasting blood glucose (FBG) were measured after a minimum 8-hour fast. Hormonal profile: Hormonal treatment (cortisone, thyroxine, estrogen-progestin) was assessed, and hormone levels were measured using morning venipuncture samples at the beginning of the follicular phase (days 3–5) of the spontaneous menstrual cycle. Dry tubes were used for all hormonal samples. For all of our patients, the following hormones were measured: Follicle Stimulating Hormone (FSH), Luteinizing Hormone (LH), Total Testosterone, Estradiol (E2), Thyroid Stimulating Hormone (TSH), Free Thyroxine (FT4), Prolactin (PRL). Procedure: All examinations were conducted in a private room after obtaining the patient's consent. The examination took place between day 3 and day 5 of the menstrual cycle. PCOS diagnosis was confirmed if at least 2 out of 3 of the following criteria were present: - Clinical hyperandrogenism, which may include hirsutism, acne, and androgenic alopecia, or biological hyperandrogenism, indicated by Testosterone levels greater than 0.5 ng/mL, SDHEA (Dehydroepiandrosterone sulfate) levels exceeding 430 µg/dL, or Delta 4 androstenodione levels surpassing 3.5 ng/ml. - Oligo-anovulation, characterized by irregular or absent ovulation. Cycles shorter than 21 days or longer than 35 days are considered anovulatory. - On endovaginal ultrasound, the criteria include the presence of at least one ovary with more than 12 follicles ranging from 2 to 9 mm in diameter and/or an ovarian volume exceeding 10 ml. Group Analysis: In this study, the population was split into two groups based on the presence or absence of PCOS: - Group 1 (G1) consists of patients with acne and a confirmed diagnosis of PCOS based on at least two of the updated 2018 diagnostic criteria, which include clinical evidence of hirsutism, acne, androgenic alopecia, and/or biological evidence of hyperandrogenism, as well as evidence of oligo-anovulation (irregular or absent ovulation). - Group 2 (G2) comprises patients with isolated acne that does not fit the diagnosis of PCOS. Statistical Analysis: We used SPSS Ver 25.0 for data entry and analysis, and Endnote X6.5 for reference management. Categorical variables are described using absolute and relative numbers and percentages, while quantitative variables are described using means and standard deviations for normally distributed data. For non-normally distributed data, the median with extremes was used, and the normality of the distribution was verified using the Kolmogorov-Smirnov test. To compare the clinical, metabolic, and hormonal aspects of patients with acne in the context of PCOS with those without PCOS diagnosis, we used univariate analysis. We employed the Chi-squared test to compare percentages, and when this was not applicable, Fisher's exact test was used. For comparison of means, we used Student's t-test. Dosage results were expressed as mean ± SD for comparison of patients in the two subgroups. In our study, we utilized binary regression analysis to determine which factors could predict the severity of acne in women with PCOS. Binary regression is a statistical method used to analyze binary variables, such as the presence or absence of a specific medical condition. In our analysis, the severity of acne was the dependent variable, while the independent variables encompassed various hormonal and clinical characteristics of the participants. Through binary regression, we were able to calculate the regression coefficients for each independent variable and evaluate their impact on predicting acne severity. Additionally, we set the significance level (p) at 5%. Results Patients Our study included 212 patients followed for acne. Within this group, 139 patients (G1) had acne and were diagnosed with PCOS, while 73 patients (G2) had isolated acne without a PCOS diagnosis. The median age of the entire patient population was 24 years, with ages ranging from 18 to 44 years. The median age of the patients in both groups was 24 years, and the age distribution was similar in both groups (p = 0.46). In G1, familial hirsutism, Obstructive sleep apnea, and PCOS were present in 67.6%, 28.8%, and 40.3% of the cases, respectively, significantly higher than in G2, where these conditions were present in 37%, 15.1%, and 9.6% of the cases, respectively (p < 10 − 3 , p = 0.03, p < 10 − 3 , respectively). A personal history of obesity was reported in 56.1% of G1 cases, significantly higher than the 39.7% reported in G2 (p = 0.02). The mean BMI was 29.58 ± 7.44 in G1 and 26.07 ± 5.54 in G2, with a significant difference (p < 10 − 3 ) indicating that the mean BMI was lower in G2. Dermatological examination: Acne The average age of onset of acne was estimated at 13 years in G1 compared with 12 years in G2, with no significant difference between the two groups (p = 0.49). Stress and pollution were reported as triggers in 94.2% and 16.5% of G1, respectively, significantly more than in G2 (84.9% and 34.2% respectively) (p = 0.02, p = 0.003 respectively). Nodular lesions were present in 17.3% of G1, significantly more frequent than in G2, where they were present in only 5.5% of cases (p = 0.02). Hirsutism The frequency of hirsutism was 94.2% in G1, which was significantly higher than the 67.1% in G2 (p < 10 − 3 ). The rate of progression of hirsutism was significantly slower in group G2 than in G1 (p = 0.004). Moderate hirsutism was present in 36% of cases in group G1, significantly more than the 8.2% of cases in G2 (p < 10 − 3 ). The frequency of hirsutism was 94.2% in G1, significantly higher than in G2, which was around 67.1% (p < 10 − 3 ). Androgenic alopecia The prevalence of androgenic alopecia was 37.4% in G1, which was significantly higher than G2 which was 21.9% in (p = 0.02). Alopecia was grade 1 in 36% of cases, also significantly higher than in G2 (21.9%) (p = 0.04). Gynecological Examination: The average cycle length was 50 days in G1, which was significantly longer than in G2, where it was 31 days (p < 10 − 3 ). G1 showed significantly greater cycle disturbances compared to G2 (p < 10 − 3 ). G2 had a significantly higher cycle frequency, averaging 12 cycles per year compared to 9 cycles per year in G1 (p < 10 − 3 ). Metabolic Investigation: Median LDL-cholesterol, TG, and total cholesterol values in G1 were significantly higher than in G2 (p = 0.006, p = 0.04, p = 0.02 respectively). The median HDL-cholesterol value was significantly lower in G1 compared to G2 (p < 10 − 3 ). HyperTG and hypoHDL were significantly higher in G1 than in G2 (p < 10 − 3 ). Normal blood glucose was significantly less frequent in G1 compared to G2 (p < 10 − 3 ), while prediabetes was significantly more frequent in G1 than in G2 (p < 10 − 3 ). Hormonal Testing LH levels were 9.22 mU/ml [5.9–13] for G1, which was significantly higher than G2, where it was 5.65 mU/ml [4.87–7.21] (p < 10 − 3 ). The mean LH/FSH value was 1.65 ± 0.92 for G1, significantly higher than that of G2, which was 0.85 ± 0.45 (p < 10 − 3 ). The mean testosterone level was 0.72 ± 0.27 ng/mL for G1, significantly higher than 0.43 ± 0.15 ng/mL for G2 (p < 10 − 3 ). Hypotestosteronemia was present in 81.3% of patients in G1, significantly more than in G2, where it was present in 16.4% of cases (p < 10 − 3 ). The median PRL value was 23 ng/ml [ 16 – 35 ] for G1, significantly higher than G2, which was 18.3 ng/ml [ 12 – 22 ] (p = 10 − 3 ). Factors predicting severe acne in G1 In our study, the only independent risk factors associated with severe acne were: Hypertestosteronemia (OR = 6.526; 95% CI [1.025–25.325]; p = 0.046) Hyperprolactinemia (OR = 7.230; 95% CI [1.653–31.628]; p = 0.09) Phenotype A (OR = 5.011; 95% CI [1.022–24.562]; p = 0.047). Discussion In this study, we aimed to find out how common PCOS is among patients who have acne as their main skin concern. We also looked at the differences in clinical, metabolic, and hormonal profiles between two groups of acne patients: G1, who have both acne and PCOS, and G2, who have acne only. Acne is a complex condition that involves several interrelated factors: Excessive sebum production and changes in sebum quality: Sebum is produced in excess and its composition is changed, which weakens the skin barrier and leads to inflammation. Skin dysbiosis: This is characterized by disruption of the skin's bacterial flora, particularly by Cutibacterium acnes, and plays a significant role in acne development. Abnormalities in the growth and division of skin cells in the hair follicle: Cutibacterium acnes contributes to the formation of comedones by promoting the excessive production of skin cells, leading to blockage of the hair follicle and buildup of sebum. Inflammation and activation of the innate immune response play a key role in acne. The pilosebaceous follicle acts as an immune organ where immune cells detect pathogens and release inflammatory cytokines, sustaining the skin's dysbiosis and the inflammation process. [ 12 , 17 , 18 ]. Androgens are known to contribute to the development of acne. Sebocytes and keratinocytes have enzymes that can produce testosterone and dihydrotestosterone (DHT). Enzymes involved in androgenic hormone metabolism, such as 5-alpha reductase, 3-beta-OH steroid dehydrogenase, and 17-OH steroid dehydrogenase, display hyperactivity and abnormal behavior [ 19 ]. This results in increased turnover of prohormones like DHEAS, androstenedione, and testosterone, leading to the production of more potent androgenic hormones like testosterone and DHT [ 20 ]. Acne is a common skin condition, often affecting women. Its prevalence varies from 12–54% [ 7 ]. It usually starts during puberty, impacting up to 85% of teenagers, with the highest occurrence between the ages of 12 and 25 [ 21 ]. Acne can persist into adulthood. Several scales have been developed to classify the severity of acne, such as GEA scale, which was validated in 2011 [ 16 ] and used in our study. Different studies have reported varying prevalence of PCOS in acne patients. For example, Ramezani et al. stated that nearly 43% of acne cases are linked to PCOS [ 5 ], while others, such as Kelekci et al., found PCOS to be present in only 17–27% of acne-prone women [ 22 ]. Some studies have shown a higher prevalence in patients with severe acne, reaching up to 51% [ 23 ]. Timpatanapong et al.'s work revealed that PCOS was identified in 37.3% of acne patients [ 24 ]. In our study, we observed an even higher prevalence of PCOS in acne patients, estimated at 65.6%, which is consistent with the findings of other researchers such as Abusailik et al. and Gowri et al. [ 25 , 26 ]. Only a few studies have compared the characteristics of acne in patients with and without a confirmed diagnosis of PCOS. Persistent acne was the most commonly observed form, with an estimated prevalence of 53.2% in G1, and no significant difference between the two groups, consistent with the findings of Chanyachailert et al. [ 8 ]. In our study, among the 139 G1 patients, 96.4% reported the premenstrual phase as the most common trigger for acne, which is consistent with the findings of Poli et al and Chanyachailert et al [ 27 , 8 ]. Additionally, our study identified stress as a significant trigger for acne in PCOS patients, with 94.2% prevalence in G1, aligning with the findings of Chanyachailert et al [ 8 ]. These results highlight the substantial influence of psychosocial factors on the clinical presentation of acne in the context of PCOS. Comedone-type acne was observed in 89.1% of G1 in our study, consistent with the findings of Chanyachailert et al [ 8 ] and Feng et al [ 28 ], where the prevalence of comedonal acne was estimated at 80.6% and 67.7%, respectively, in PCOS patients. Hirsutism is considered to be the earliest cutaneous manifestation of PCOS [ 29 ] In our research, we found that hirsutism was prevalent in 94.2% of G1 compared to 67.1% in G2 (p < 10 − 3 ). These results support the findings of previous studies by Williamson et al [ 30 ], Chang et al [ 31 ], Legro et al [ 32 ], and Diamanti-Kandarakis et al [ 33 ], who also reported similar hirsutism prevalences. However, other studies, like the one by Chanyachailert et al [ 8 ] with 208 patients, found lower prevalences, with only 11.5% of patients being hirsute. Androgenic alopecia is less common and occurs later in PCOS, but it has significant psychological effects [ 15 ]. Studies by Hacivelioglu et al [ 34 ], Özdemir et al [ 35 ], and Keen et al [ 36 ] revealed alopecia prevalences similar to our study, ranging from 31–41.3%. However, a study by Feng et al [ 28 ] reported a lower prevalence of alopecia (23.1%) in PCOS patients with acne, which aligns with the results of Schmidt et al [ 37 ], where the alopecia rate was 22.4%. In our study, androgenic alopecia was estimated at 37.4% for G1, significantly higher than for G2, where it was 21.9% (p < 10 − 3 ). There is a strong connection between PCOS and obesity, and it is unclear whether one causes the other. The prevalence of this link is now very high, affecting up to 50% of women with PCOS [ 38 ]. In our study, we looked at the obesity history and weight of our patients. We found that the weight of women with acne and PCOS was significantly higher compared to healthy women (p = 0.02), which is consistent with existing data [ 39 ]. The average BMI of women with PCOS and acne in our study was 29.58 ± 7.44 for the first group (G1), significantly higher than the 26.07 ± 5.54 for the second group (G2) (p < 10 − 3 ). This average was notably higher than those reported in other studies, such as 21.14 ± 2.98 in a study by Kim et al [ 40 ], 25.5 ± 5.4 in a study by Hacivelioglu et al [ 34 ], and 24.6 ± 5.3 in a study by Franik et al [ 41 ]. Most women with PCOS and acne were either obese or overweight. The incidence of obesity was significantly higher in G1, at 44.6% compared to 18.1% in G2 (p < 10 − 3 ). These findings align with the results from studies by Sas et al [ 42 ], Franik et al [ 41 ], Alan et al [ 43 ], and Chanyachailert et al [ 8 ]. In our study, we found that the average level of testosterone was 0.72 ± 0.27 ng/mL for G1, which was significantly higher than the level for G2, which was 0.43 ± 0.15 ng/mL (p < 10 − 3 ). High testosterone levels were present in 81.3% of G1 patients, which was significantly higher than the 34% prevalence found by Hacivelioglu et al [ 34 ]. Similarly, other studies have also shown a similar trend. Studies of acne-prone PCOS patients by HAHN et al [ 44 ], Ozdemir et al [ 45 ], and Xu et al [ 46 ] reported significant high testosterone levels, with levels of 0.78 ng/ml ± 0.29, 0.73 ng/ml [0.51–0.91], and 0.75 ng/ml ± 0.23, respectively. Acne and obesity are frequently linked with PCOS. Research has shown that BMI is positively associated with the severity of acne in teenage girls and young adults [ 42 ]. Previous studies, such as those conducted by Alan et al [ 43 ], Franik et al [ 41 ], and Di Landro et al [ 47 ], have also demonstrated this connection. A study by Sas et al [ 42 ] suggests that higher BMI in teenage girls is linked to a greater risk of severe acne compared to those with a normal weight. Higher BMI values were also connected to a higher prevalence of acne with inflammatory lesions, while non-inflammatory lesions were more frequently observed in individuals with a lower BMI [ 42 ]. A high BMI can lead to increased secretion of Insulin Growth Factor (IGF1), which stimulates keratinocyte proliferation, sebaceous lipogenesis, and androgen synthesis. All of these processes can contribute to the development of acne in predisposed individuals [ 48 , 49 ]. Our study did not find a link between acne severity and higher BMI, which supports the findings of Lu et al. They reported no association between acne severity in Taiwanese women aged 25–45 years and higher mean BMI [ 50 ]. The absence of this association could be attributed to the use of a different acne scoring system in this study and the exclusion of acne patients with PCOS. Additionally, Snast et al [ 51 ] and Tsan et al [ 52 ] concluded that obesity might actually protect against acne, possibly due to increased aromatase activity and the peripheral conversion of androgens to estrogens in excess adipose tissue. The role of hyperprolactinemia in the development and worsening of acne is not well understood. Some studies have suggested that elevated PRL levels can lead to increased production of DHEAS by the adrenal glands, which may contribute to the development of acne [ 53 ]. Our study did show a positive association between hyperprolactinemia and severe acne. However, there are only a limited number of studies exploring this relationship, with some, such as those by Bansal et al [ 54 ] and Meena et al [ 53 ], failing to find an association between hyperprolactinemia and severe acne. Conclusion PCOS is the most common endocrine disorder affecting women of childbearing age and is becoming increasingly prevalent. It presents with a variety of clinical manifestations, including acne, which is one of the most frequently encountered dermatological manifestations. This highlights the importance of considering acne as a potential symptom of PCOS when assessing and managing these patients. In our study, PCOS was diagnosed in 65.6% of the acne patients. Our work has emphasized the hormonal and metabolic imbalances that may explain the association between PCOS and acne. The findings suggest a complex link between hormonal and metabolic disturbances in the development of acne. Acne in PCOS is most often nodular and inflammatory, and in our study, it is even more severe due to its association with high levels of testosterone and prolactin. According to our results, phenotype A was the most likely to cause severe acne compared with the other phenotypes. We highlighted the importance of conducting an initial hormonal assessment in all acne patients given the close relationship with PCOS. Our study is the first in Africa to emphasize the link between acne and PCOS. We encourage physicians to consider this endocrinopathy in all adult women seeking consultation for acne. This can lead to the development of new therapeutic approaches for managing PCOS-related acne and enabling the development of new therapeutic approaches in the management of PCOS acne. Declarations Declaration of interest The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported. Patient consent Written and informed consent was obtained from the patients for publication of the submitted article. Author contribution statement Dr Ben Abdessalem Fatma and Dr ACH Taieb drafted the manuscript. All authors helped in the patient care, read and approved the final manuscript. Funding No funding was received in the writing of this case. Author Contribution Dr Ben Abdessalem Fatma and Dr ACH Taieb drafted the manuscript. Dr Ben Abdessalem prepared tables 1-5.Dr Ghariani Nadia, Dr Mraihi Emna and Dr Ben Abdelkrim Asma collaborated closely on the study design, ensuring that the research objectives were clearly defined and methodologically sound. All authors helped in the patient care, read and approved the final manuscript. References Teede HJ et al (2023) Recommendations From the 2023 International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome. J Clin Endocrinol Metab 108(10):2447–2469 Escobar-Morreale HF (2018) Polycystic ovary syndrome: definition, aetiology, diagnosis and treatment. Nat Rev Endocrinol 14(5):270–284 Sadeghi HM et al (2022) Polycystic Ovary Syndrome: A Comprehensive Review of Pathogenesis, Management, and Drug Repurposing. Int J Mol Sci, 23(2) Lagana AS et al (2016) Metabolism and Ovarian Function in PCOS Women: A Therapeutic Approach with Inositols. 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Fertil Steril 83(6):1717–1723 Legro RS et al (2006) The Pregnancy in Polycystic Ovary Syndrome study: baseline characteristics of the randomized cohort including racial effects. Fertil Steril 86(4):914–933 Diamanti-Kandarakis E, Panidis D (2007) Unravelling the phenotypic map of polycystic ovary syndrome (PCOS): a prospective study of 634 women with PCOS. Clin Endocrinol (Oxf) 67(5):735–742 Hacivelioglu S et al (2013) Acne severity and the Global Acne Grading System in polycystic ovary syndrome. Int J Gynaecol Obstet 123(1):33–36 Ozdemir S et al (2010) Specific dermatologic features of the polycystic ovary syndrome and its association with biochemical markers of the metabolic syndrome and hyperandrogenism. Acta Obstet Gynecol Scand 89(2):199–204 Keen MA, Shah IH, Sheikh G (2017) Cutaneous Manifestations of Polycystic Ovary Syndrome: A Cross-Sectional Clinical Study. Indian Dermatol Online J 8(2):104–110 Schmidt TH et al (2016) Cutaneous Findings and Systemic Associations in Women With Polycystic Ovary Syndrome. JAMA Dermatol 152(4):391–398 Glueck CJ, Goldenberg N (2019) Characteristics of obesity in polycystic ovary syndrome: Etiology, treatment, and genetics. Metabolism 92:108–120 Naderpoor N et al (2015) Obesity and polycystic ovary syndrome. Minerva Endocrinol 40(1):37–51 Kim JH et al (2022) Body mass index, menstruation, acne, and hirsutism of polycystic ovary syndrome in women: A cross-sectional study. Health Care Women Int 43(1–3):85–97 Franik G et al (2018) Hormonal and metabolic aspects of acne vulgaris in women with polycystic ovary syndrome. Eur Rev Med Pharmacol Sci 22(14):4411–4418 Sas K, Reich A (2019) High Body Mass Index is a Risk Factor for Acne Severity in Adolescents: A Preliminary Report. Acta Dermatovenerol Croat 27(2):81–85 Alan S, Cenesizoglu E (2014) Effects of hyperandrogenism and high body mass index on acne severity in women. Saudi Med J 35(8):886–889 Hahn S et al (2005) Clinical and biochemical characterization of women with polycystic ovary syndrome in North Rhine-Westphalia. Horm Metab Res 37(7):438–444 Özdemir S et al (2010) Specific dermatologic features of the polycystic ovary syndrome and its association with biochemical markers of the metabolic syndrome and hyperandrogenism. Acta Obstet Gynecol Scand 89(2):199–204 Xu S et al (2022) Diagnostic value of total testosterone and free androgen index measured by LC-MS/MS for PCOS and insulin resistance. J Clin Lab Anal 36(11):e24739 Di Landro A et al (2012) Family history, body mass index, selected dietary factors, menstrual history, and risk of moderate to severe acne in adolescents and young adults. J Am Acad Dermatol 67(6):1129–1135 Seleit I et al (2014) Body mass index, selected dietary factors, and acne severity: are they related to in situ expression of insulin-like growth factor-1? Anal Quant Cytopathol Histpathol, 36(5): pp. 267 – 78 Rahaman SMA et al (2016) Association of insulin-like growth factor (IGF)-1 gene polymorphisms with plasma levels of IGF-1 and acne severity. J Am Acad Dermatol 75(4):768–773 Lu PH, Hsu CH (2015) Body mass index is negatively associated with acne lesion counts in Taiwanese women with post-adolescent acne. J Eur Acad Dermatol Venereol 29(10):2046–2050 Snast I et al (2019) Acne and obesity: A nationwide study of 600,404 adolescents. J Am Acad Dermatol 81(3):723–729 Liou TH et al (2009) Clinical and biochemical presentations of polycystic ovary syndrome among obese and nonobese women. Fertil Steril 92(6):1960–1965 Meena AK et al (2023) Biochemical and hormonal abnormalities in adult female acne. J Cosmet Dermatol 22(4):1392–1399 Bansal P et al (2021) A prospective study examining isolated acne and acne with hyperandrogenic signs in adult females. J Dermatolog Treat 32(7):752–755 Tables Tables 1 to 5 are available in the Supplementary Files section. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4889348","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":350106933,"identity":"493debce-7618-4985-92dc-87e8facb6d81","order_by":0,"name":"Fatma Ben 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20:06:43","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":23765,"visible":true,"origin":"","legend":"","description":"","filename":"Tableau5.docx","url":"https://assets-eu.researchsquare.com/files/rs-4889348/v1/7b900568becf82953cf8b10e.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Characterizing Clinical and Hormonal Profiles of Acne in North African Women with Polycystic Ovary Syndrome","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePolycystic ovary syndrome (PCOS) is the most common endocrine disorder among young women of childbearing age [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Its prevalence has risen sharply in recent years, with diagnostic criteria suggesting that up to 20% of the female population may be affected [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. PCOS is a complex condition resulting from hormonal imbalances involving both the ovaries and the central nervous system [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. This imbalance leads to an overproduction of androgens, particularly testosterone, which is typically produced in small amounts in women [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Although the precise pathophysiological mechanisms of PCOS remain incompletely understood, insulin resistance, along with resultant hyperinsulinism and hyperandrogenism, is believed to play a central role [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. PCOS is associated with multiple comorbidities, including metabolic, reproductive, neoplastic, and cardiovascular disorders, posing significant public health challenges and, in some cases, leading to severe outcomes. Therefore, early diagnosis and appropriate management are essential [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe latest guidelines, updated in 2023, recommend that PCOS be diagnosed based on the Rotterdam Consensus criteria of 2003, with the addition of Anti-M\u0026uuml;llerian Hormone (AMH) as a diagnostic marker [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Diagnosis requires the presence of at least two of the following criteria [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e- Clinical hyperandrogenism (manifesting as hirsutism, acne, or androgenic alopecia) or biochemical hyperandrogenism.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e- Oligo-anovulation (irregular or absent ovulation), where menstrual cycles shorter than 21 days or longer than 35 days are considered indicative of anovulation.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e- Polycystic ovarian morphology on endovaginal ultrasound, characterized by at least one ovary with more than 20 follicles measuring 2 to 9 mm in diameter, and/or an ovarian volume greater than 10 ml without a dominant follicle or cyst.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e- Elevated AMH levels, now recognized as an alternative to ultrasound criteria for diagnosing PCOS.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eDermatological issues, particularly acne and hirsutism, are among the primary reasons for medical consultations in women with PCOS [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Acne prevalence in the general population is estimated to range from 12\u0026ndash;54% [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], with some studies indicating that nearly 43% of acne cases are associated with PCOS [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Acne is a multifactorial disease of the pilosebaceous unit, most commonly affecting the face [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. It is caused by increased sebum production, hyperkeratosis of the follicular duct, and colonization by the bacterium Cutibacterium acnes, which may or may not be associated with inflammation [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Androgens play a significant role in acne pathogenesis, primarily by increasing sebaceous gland activity [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMost studies indicate that mild acne is frequently observed in women of childbearing age. However, inflammatory, treatment-resistant, moderate, or severe acne may suggest androgen excess and warrants investigation for underlying endocrinopathies, particularly PCOS [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The latest 2023 guidelines for managing acne in the context of PCOS emphasize the importance of a comprehensive hormonal evaluation at the initial presentation of acne to prevent misdiagnosis [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite being a common reason for dermatological consultations, acne in the context of PCOS is often overlooked and typically treated symptomatically, without investigating its underlying cause [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. This is partly due to the challenges in diagnosing hormonal imbalances and the tendency of some physicians to manage all types of acne similarly. The global prevalence of PCOS-related acne remains underexplored, particularly in Africa, where no significant studies have been conducted despite the increasing incidence of PCOS in the region [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study aims to assess the frequency of PCOS in patients primarily seeking treatment for acne. The secondary objective is to examine the clinical, metabolic, and hormonal characteristics of acne patients with and without a PCOS diagnosis.\u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThis is a prospective analytical study, conducted in the Endocrinology Department of the university Hospital of Farhat Hached in Sousse. We collected data from all patients who visited the Endocrinology and Dermatology outpatient clinics for acne from January 2023 to January 2024. Written consent was obtained from the patients before the clinical and hormonal analysis. This study has been approved by the ethics committee of the faculty of medicine of Sousse.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u0026rsquo; selection:\u003c/h2\u003e \u003cp\u003eWe conducted a sample size calculation using the formula appropriate for our study type:\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003en = z². p (1 – p) / i²\u003c/h3\u003e\n\u003cp\u003eWhere:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;sample size.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ez\u0026thinsp;=\u0026thinsp;confidence level: for a confidence level of 95%, z\u0026thinsp;=\u0026thinsp;1.96.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;prevalence of PCOS in the Tunisian female population of reproductive age estimated at 4.73% (represents the prevalence of PCOS in Tunisia in 2019 among women aged 15 to 45 years).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ei\u0026thinsp;=\u0026thinsp;tolerated margin of error\u0026thinsp;=\u0026thinsp;precision: we want to know the true proportion within 5%.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThe calculation yields a sample size of n\u0026thinsp;=\u0026thinsp;70 patients. Therefore, this threshold would be statistically representative of the population. Since recruitment took place over one year, we increased the final number due to the likely increase in PCOS prevalence since 2019. The final sample consisted of n\u0026thinsp;=\u0026thinsp;139 patients in the PCOS group.\u003c/p\u003e \u003cp\u003ePatients who have received hormonal treatment that may interfere with hormone dosage and ultrasound exploration within the last 3 months.\u003c/p\u003e \u003cp\u003eWe excluded patients with other conditions that could mimic the symptoms of PCOS, such as hyperprolactinemia, congenital adrenal hyperplasia, and thyroid disorders. All the hormonal assessment for these conditions were checked-up in all patients, and were normal. Additionally, patients on medications known to affect hormonal profiles were excluded, such as hormonal contraceptives, glucocorticoids, antipsychotics, and antiepileptic drugs. Patients with PCOS phenotype D (absence of clinical hyperandrogenism) were not included.\u003c/p\u003e \u003cp\u003eEach patient underwent two separate appointments for a clinical examination and an ultrasound scan. Clinical, anamnestic, and ultrasonographic data were collected based on a predefined form. The clinical examination involved assessing acne using the Global Acne Evaluation (GEA) score, as well as evaluating other signs of hyperandrogenism such as hirsutism and androgenic alopecia. Additionally, anthropometric measurements including weight and height were taken, and the body mass index (BMI) was calculated.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eMetabolic and hormonal investigations\u003c/h2\u003e \u003cp\u003eCarbohydrate balance: Glycated hemoglobin (HbA1c) and fasting blood glucose (FBG) were measured after a minimum 8-hour fast.\u003c/p\u003e \u003cp\u003eHormonal profile: Hormonal treatment (cortisone, thyroxine, estrogen-progestin) was assessed, and hormone levels were measured using morning venipuncture samples at the beginning of the follicular phase (days 3\u0026ndash;5) of the spontaneous menstrual cycle. Dry tubes were used for all hormonal samples.\u003c/p\u003e \u003cp\u003eFor all of our patients, the following hormones were measured: Follicle Stimulating Hormone (FSH), Luteinizing Hormone (LH), Total Testosterone, Estradiol (E2), Thyroid Stimulating Hormone (TSH), Free Thyroxine (FT4), Prolactin (PRL).\u003c/p\u003e \u003cp\u003eProcedure: All examinations were conducted in a private room after obtaining the patient's consent. The examination took place between day 3 and day 5 of the menstrual cycle.\u003c/p\u003e \u003cp\u003ePCOS diagnosis was confirmed if at least 2 out of 3 of the following criteria were present:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e- Clinical hyperandrogenism, which may include hirsutism, acne, and androgenic alopecia, or biological hyperandrogenism, indicated by Testosterone levels greater than 0.5 ng/mL, SDHEA (Dehydroepiandrosterone sulfate) levels exceeding 430 \u0026micro;g/dL, or Delta 4 androstenodione levels surpassing 3.5 ng/ml.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e- Oligo-anovulation, characterized by irregular or absent ovulation. Cycles shorter than 21 days or longer than 35 days are considered anovulatory.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e- On endovaginal ultrasound, the criteria include the presence of at least one ovary with more than 12 follicles ranging from 2 to 9 mm in diameter and/or an ovarian volume exceeding 10 ml.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eGroup Analysis:\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eIn this study, the population was split into two groups based on the presence or absence of PCOS:\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e- Group 1 (G1) consists of patients with acne and a confirmed diagnosis of PCOS based on at least two of the updated 2018 diagnostic criteria, which include clinical evidence of hirsutism, acne, androgenic alopecia, and/or biological evidence of hyperandrogenism, as well as evidence of oligo-anovulation (irregular or absent ovulation).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e- Group 2 (G2) comprises patients with isolated acne that does not fit the diagnosis of PCOS.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis:\u003c/h2\u003e \u003cp\u003eWe used SPSS Ver 25.0 for data entry and analysis, and Endnote X6.5 for reference management. Categorical variables are described using absolute and relative numbers and percentages, while quantitative variables are described using means and standard deviations for normally distributed data. For non-normally distributed data, the median with extremes was used, and the normality of the distribution was verified using the Kolmogorov-Smirnov test.\u003c/p\u003e \u003cp\u003eTo compare the clinical, metabolic, and hormonal aspects of patients with acne in the context of PCOS with those without PCOS diagnosis, we used univariate analysis. We employed the Chi-squared test to compare percentages, and when this was not applicable, Fisher's exact test was used.\u003c/p\u003e \u003cp\u003eFor comparison of means, we used Student's t-test. Dosage results were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD for comparison of patients in the two subgroups. In our study, we utilized binary regression analysis to determine which factors could predict the severity of acne in women with PCOS. Binary regression is a statistical method used to analyze binary variables, such as the presence or absence of a specific medical condition. In our analysis, the severity of acne was the dependent variable, while the independent variables encompassed various hormonal and clinical characteristics of the participants.\u003c/p\u003e \u003cp\u003eThrough binary regression, we were able to calculate the regression coefficients for each independent variable and evaluate their impact on predicting acne severity. Additionally, we set the significance level (p) at 5%.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003e Our study included 212 patients followed for acne. Within this group, 139 patients (G1) had acne and were diagnosed with PCOS, while 73 patients (G2) had isolated acne without a PCOS diagnosis. The median age of the entire patient population was 24 years, with ages ranging from 18 to 44 years. The median age of the patients in both groups was 24 years, and the age distribution was similar in both groups (p\u0026thinsp;=\u0026thinsp;0.46).\u003c/p\u003e \u003cp\u003eIn G1, familial hirsutism, Obstructive sleep apnea, and PCOS were present in 67.6%, 28.8%, and 40.3% of the cases, respectively, significantly higher than in G2, where these conditions were present in 37%, 15.1%, and 9.6% of the cases, respectively (p\u0026thinsp;\u0026lt;\u0026thinsp;10\u003csup\u003e\u0026minus;\u0026thinsp;3\u003c/sup\u003e, p\u0026thinsp;=\u0026thinsp;0.03, p\u0026thinsp;\u0026lt;\u0026thinsp;10\u003csup\u003e\u0026minus;\u0026thinsp;3\u003c/sup\u003e, respectively). A personal history of obesity was reported in 56.1% of G1 cases, significantly higher than the 39.7% reported in G2 (p\u0026thinsp;=\u0026thinsp;0.02). The mean BMI was 29.58\u0026thinsp;\u0026plusmn;\u0026thinsp;7.44 in G1 and 26.07\u0026thinsp;\u0026plusmn;\u0026thinsp;5.54 in G2, with a significant difference (p\u0026thinsp;\u0026lt;\u0026thinsp;10\u003csup\u003e\u0026minus;\u0026thinsp;3\u003c/sup\u003e) indicating that the mean BMI was lower in G2.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eDermatological examination:\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eAcne\u003c/strong\u003e \u003cp\u003eThe average age of onset of acne was estimated at 13 years in G1 compared with 12 years in G2, with no significant difference between the two groups (p\u0026thinsp;=\u0026thinsp;0.49). Stress and pollution were reported as triggers in 94.2% and 16.5% of G1, respectively, significantly more than in G2 (84.9% and 34.2% respectively) (p\u0026thinsp;=\u0026thinsp;0.02, p\u0026thinsp;=\u0026thinsp;0.003 respectively). Nodular lesions were present in 17.3% of G1, significantly more frequent than in G2, where they were present in only 5.5% of cases (p\u0026thinsp;=\u0026thinsp;0.02).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eHirsutism\u003c/strong\u003e \u003cp\u003eThe frequency of hirsutism was 94.2% in G1, which was significantly higher than the 67.1% in G2 (p\u0026thinsp;\u0026lt;\u0026thinsp;10\u003csup\u003e\u0026minus;\u0026thinsp;3\u003c/sup\u003e). The rate of progression of hirsutism was significantly slower in group G2 than in G1 (p\u0026thinsp;=\u0026thinsp;0.004). Moderate hirsutism was present in 36% of cases in group G1, significantly more than the 8.2% of cases in G2 (p\u0026thinsp;\u0026lt;\u0026thinsp;10\u003csup\u003e\u0026minus;\u0026thinsp;3\u003c/sup\u003e). The frequency of hirsutism was 94.2% in G1, significantly higher than in G2, which was around 67.1% (p\u0026thinsp;\u0026lt;\u0026thinsp;10\u003csup\u003e\u0026minus;\u0026thinsp;3\u003c/sup\u003e).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eAndrogenic alopecia\u003c/strong\u003e \u003cp\u003eThe prevalence of androgenic alopecia was 37.4% in G1, which was significantly higher than G2 which was 21.9% in (p\u0026thinsp;=\u0026thinsp;0.02). Alopecia was grade 1 in 36% of cases, also significantly higher than in G2 (21.9%) (p\u0026thinsp;=\u0026thinsp;0.04).\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eGynecological Examination:\u003c/h2\u003e \u003cp\u003eThe average cycle length was 50 days in G1, which was significantly longer than in G2, where it was 31 days (p\u0026thinsp;\u0026lt;\u0026thinsp;10\u003csup\u003e\u0026minus;\u0026thinsp;3\u003c/sup\u003e). G1 showed significantly greater cycle disturbances compared to G2 (p\u0026thinsp;\u0026lt;\u0026thinsp;10\u003csup\u003e\u0026minus;\u0026thinsp;3\u003c/sup\u003e). G2 had a significantly higher cycle frequency, averaging 12 cycles per year compared to 9 cycles per year in G1 (p\u0026thinsp;\u0026lt;\u0026thinsp;10\u003csup\u003e\u0026minus;\u0026thinsp;3\u003c/sup\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eMetabolic Investigation:\u003c/h2\u003e \u003cp\u003eMedian LDL-cholesterol, TG, and total cholesterol values in G1 were significantly higher than in G2 (p\u0026thinsp;=\u0026thinsp;0.006, p\u0026thinsp;=\u0026thinsp;0.04, p\u0026thinsp;=\u0026thinsp;0.02 respectively). The median HDL-cholesterol value was significantly lower in G1 compared to G2 (p\u0026thinsp;\u0026lt;\u0026thinsp;10\u003csup\u003e\u0026minus;\u0026thinsp;3\u003c/sup\u003e). HyperTG and hypoHDL were significantly higher in G1 than in G2 (p\u0026thinsp;\u0026lt;\u0026thinsp;10\u003csup\u003e\u0026minus;\u0026thinsp;3\u003c/sup\u003e). Normal blood glucose was significantly less frequent in G1 compared to G2 (p\u0026thinsp;\u0026lt;\u0026thinsp;10\u003csup\u003e\u0026minus;\u0026thinsp;3\u003c/sup\u003e), while prediabetes was significantly more frequent in G1 than in G2 (p\u0026thinsp;\u0026lt;\u0026thinsp;10\u003csup\u003e\u0026minus;\u0026thinsp;3\u003c/sup\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eHormonal Testing\u003c/h2\u003e \u003cp\u003eLH levels were 9.22 mU/ml [5.9\u0026ndash;13] for G1, which was significantly higher than G2, where it was 5.65 mU/ml [4.87\u0026ndash;7.21] (p\u0026thinsp;\u0026lt;\u0026thinsp;10\u003csup\u003e\u0026minus;\u0026thinsp;3\u003c/sup\u003e). The mean LH/FSH value was 1.65\u0026thinsp;\u0026plusmn;\u0026thinsp;0.92 for G1, significantly higher than that of G2, which was 0.85\u0026thinsp;\u0026plusmn;\u0026thinsp;0.45 (p\u0026thinsp;\u0026lt;\u0026thinsp;10\u003csup\u003e\u0026minus;\u0026thinsp;3\u003c/sup\u003e). The mean testosterone level was 0.72\u0026thinsp;\u0026plusmn;\u0026thinsp;0.27 ng/mL for G1, significantly higher than 0.43\u0026thinsp;\u0026plusmn;\u0026thinsp;0.15 ng/mL for G2 (p\u0026thinsp;\u0026lt;\u0026thinsp;10\u003csup\u003e\u0026minus;\u0026thinsp;3\u003c/sup\u003e). Hypotestosteronemia was present in 81.3% of patients in G1, significantly more than in G2, where it was present in 16.4% of cases (p\u0026thinsp;\u0026lt;\u0026thinsp;10\u003csup\u003e\u0026minus;\u0026thinsp;3\u003c/sup\u003e). The median PRL value was 23 ng/ml [\u003cspan additionalcitationids=\"CR17 CR18 CR19 CR20 CR21 CR22 CR23 CR24 CR25 CR26 CR27 CR28 CR29 CR30 CR31 CR32 CR33 CR34\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] for G1, significantly higher than G2, which was 18.3 ng/ml [\u003cspan additionalcitationids=\"CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] (p\u0026thinsp;=\u0026thinsp;10\u003csup\u003e\u0026minus;\u0026thinsp;3\u003c/sup\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eFactors predicting severe acne in G1\u003c/h2\u003e \u003cp\u003eIn our study, the only independent risk factors associated with severe acne were:\u003c/p\u003e \u003cp\u003eHypertestosteronemia (OR\u0026thinsp;=\u0026thinsp;6.526; 95% CI [1.025\u0026ndash;25.325]; p\u0026thinsp;=\u0026thinsp;0.046)\u003c/p\u003e \u003cp\u003eHyperprolactinemia (OR\u0026thinsp;=\u0026thinsp;7.230; 95% CI [1.653\u0026ndash;31.628]; p\u0026thinsp;=\u0026thinsp;0.09)\u003c/p\u003e \u003cp\u003ePhenotype A (OR\u0026thinsp;=\u0026thinsp;5.011; 95% CI [1.022\u0026ndash;24.562]; p\u0026thinsp;=\u0026thinsp;0.047).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we aimed to find out how common PCOS is among patients who have acne as their main skin concern. We also looked at the differences in clinical, metabolic, and hormonal profiles between two groups of acne patients: G1, who have both acne and PCOS, and G2, who have acne only.\u003c/p\u003e \u003cp\u003eAcne is a complex condition that involves several interrelated factors:\u003c/p\u003e \u003cp\u003eExcessive sebum production and changes in sebum quality: Sebum is produced in excess and its composition is changed, which weakens the skin barrier and leads to inflammation.\u003c/p\u003e \u003cp\u003eSkin dysbiosis: This is characterized by disruption of the skin's bacterial flora, particularly by Cutibacterium acnes, and plays a significant role in acne development.\u003c/p\u003e \u003cp\u003eAbnormalities in the growth and division of skin cells in the hair follicle: Cutibacterium acnes contributes to the formation of comedones by promoting the excessive production of skin cells, leading to blockage of the hair follicle and buildup of sebum.\u003c/p\u003e \u003cp\u003eInflammation and activation of the innate immune response play a key role in acne. The pilosebaceous follicle acts as an immune organ where immune cells detect pathogens and release inflammatory cytokines, sustaining the skin's dysbiosis and the inflammation process. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAndrogens are known to contribute to the development of acne. Sebocytes and keratinocytes have enzymes that can produce testosterone and dihydrotestosterone (DHT). Enzymes involved in androgenic hormone metabolism, such as 5-alpha reductase, 3-beta-OH steroid dehydrogenase, and 17-OH steroid dehydrogenase, display hyperactivity and abnormal behavior [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. This results in increased turnover of prohormones like DHEAS, androstenedione, and testosterone, leading to the production of more potent androgenic hormones like testosterone and DHT [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAcne is a common skin condition, often affecting women. Its prevalence varies from 12\u0026ndash;54% [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. It usually starts during puberty, impacting up to 85% of teenagers, with the highest occurrence between the ages of 12 and 25 [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Acne can persist into adulthood.\u003c/p\u003e \u003cp\u003eSeveral scales have been developed to classify the severity of acne, such as GEA scale, which was validated in 2011 [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] and used in our study.\u003c/p\u003e \u003cp\u003eDifferent studies have reported varying prevalence of PCOS in acne patients. For example, Ramezani et al. stated that nearly 43% of acne cases are linked to PCOS [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], while others, such as Kelekci et al., found PCOS to be present in only 17\u0026ndash;27% of acne-prone women [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Some studies have shown a higher prevalence in patients with severe acne, reaching up to 51% [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Timpatanapong et al.'s work revealed that PCOS was identified in 37.3% of acne patients [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our study, we observed an even higher prevalence of PCOS in acne patients, estimated at 65.6%, which is consistent with the findings of other researchers such as Abusailik et al. and Gowri et al. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOnly a few studies have compared the characteristics of acne in patients with and without a confirmed diagnosis of PCOS.\u003c/p\u003e \u003cp\u003ePersistent acne was the most commonly observed form, with an estimated prevalence of 53.2% in G1, and no significant difference between the two groups, consistent with the findings of Chanyachailert et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our study, among the 139 G1 patients, 96.4% reported the premenstrual phase as the most common trigger for acne, which is consistent with the findings of Poli et al and Chanyachailert et al [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Additionally, our study identified stress as a significant trigger for acne in PCOS patients, with 94.2% prevalence in G1, aligning with the findings of Chanyachailert et al [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. These results highlight the substantial influence of psychosocial factors on the clinical presentation of acne in the context of PCOS.\u003c/p\u003e \u003cp\u003eComedone-type acne was observed in 89.1% of G1 in our study, consistent with the findings of Chanyachailert et al [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] and Feng et al [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], where the prevalence of comedonal acne was estimated at 80.6% and 67.7%, respectively, in PCOS patients.\u003c/p\u003e \u003cp\u003eHirsutism is considered to be the earliest cutaneous manifestation of PCOS [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn our research, we found that hirsutism was prevalent in 94.2% of G1 compared to 67.1% in G2 (p\u0026thinsp;\u0026lt;\u0026thinsp;\u003cb\u003e10\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u0026minus;\u0026thinsp;3\u003c/b\u003e\u003c/sup\u003e). These results support the findings of previous studies by Williamson et al [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], Chang et al [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], Legro et al [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], and Diamanti-Kandarakis et al [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], who also reported similar hirsutism prevalences. However, other studies, like the one by Chanyachailert et al [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] with 208 patients, found lower prevalences, with only 11.5% of patients being hirsute.\u003c/p\u003e \u003cp\u003eAndrogenic alopecia is less common and occurs later in PCOS, but it has significant psychological effects [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Studies by Hacivelioglu et al [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], \u0026Ouml;zdemir et al [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], and Keen et al [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] revealed alopecia prevalences similar to our study, ranging from 31\u0026ndash;41.3%. However, a study by Feng et al [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] reported a lower prevalence of alopecia (23.1%) in PCOS patients with acne, which aligns with the results of Schmidt et al [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], where the alopecia rate was 22.4%. In our study, androgenic alopecia was estimated at 37.4% for G1, significantly higher than for G2, where it was 21.9% (p\u0026thinsp;\u0026lt;\u0026thinsp;\u003cb\u003e10\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u0026minus;\u0026thinsp;3\u003c/b\u003e\u003c/sup\u003e).\u003c/p\u003e \u003cp\u003eThere is a strong connection between PCOS and obesity, and it is unclear whether one causes the other. The prevalence of this link is now very high, affecting up to 50% of women with PCOS [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. In our study, we looked at the obesity history and weight of our patients. We found that the weight of women with acne and PCOS was significantly higher compared to healthy women (p\u0026thinsp;=\u0026thinsp;0.02), which is consistent with existing data [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe average BMI of women with PCOS and acne in our study was 29.58\u0026thinsp;\u0026plusmn;\u0026thinsp;7.44 for the first group (G1), significantly higher than the 26.07\u0026thinsp;\u0026plusmn;\u0026thinsp;5.54 for the second group (G2) (p\u0026thinsp;\u0026lt;\u0026thinsp;\u003cem\u003e10\u003c/em\u003e\u003csup\u003e\u003cem\u003e\u0026minus;\u0026thinsp;3\u003c/em\u003e\u003c/sup\u003e). This average was notably higher than those reported in other studies, such as 21.14\u0026thinsp;\u0026plusmn;\u0026thinsp;2.98 in a study by Kim et al [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], 25.5\u0026thinsp;\u0026plusmn;\u0026thinsp;5.4 in a study by Hacivelioglu et al [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], and 24.6\u0026thinsp;\u0026plusmn;\u0026thinsp;5.3 in a study by Franik et al [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMost women with PCOS and acne were either obese or overweight. The incidence of obesity was significantly higher in G1, at 44.6% compared to 18.1% in G2 (p\u0026thinsp;\u0026lt;\u0026thinsp;\u003cem\u003e10\u003c/em\u003e\u003csup\u003e\u003cem\u003e\u0026minus;\u0026thinsp;3\u003c/em\u003e\u003c/sup\u003e). These findings align with the results from studies by Sas et al [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e], Franik et al [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e], Alan et al [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e], and Chanyachailert et al [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our study, we found that the average level of testosterone was 0.72\u0026thinsp;\u0026plusmn;\u0026thinsp;0.27 ng/mL for G1, which was significantly higher than the level for G2, which was 0.43\u0026thinsp;\u0026plusmn;\u0026thinsp;0.15 ng/mL (p\u0026thinsp;\u0026lt;\u0026thinsp;\u003cb\u003e10\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u0026minus;\u0026thinsp;3\u003c/b\u003e\u003c/sup\u003e). High testosterone levels were present in 81.3% of G1 patients, which was significantly higher than the 34% prevalence found by Hacivelioglu et al [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSimilarly, other studies have also shown a similar trend. Studies of acne-prone PCOS patients by HAHN et al [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e], Ozdemir et al [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e], and Xu et al [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e] reported significant high testosterone levels, with levels of 0.78 ng/ml\u0026thinsp;\u0026plusmn;\u0026thinsp;0.29, 0.73 ng/ml [0.51\u0026ndash;0.91], and 0.75 ng/ml\u0026thinsp;\u0026plusmn;\u0026thinsp;0.23, respectively.\u003c/p\u003e \u003cp\u003eAcne and obesity are frequently linked with PCOS. Research has shown that BMI is positively associated with the severity of acne in teenage girls and young adults [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Previous studies, such as those conducted by Alan et al [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e], Franik et al [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e], and Di Landro et al [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e], have also demonstrated this connection. A study by Sas et al [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e] suggests that higher BMI in teenage girls is linked to a greater risk of severe acne compared to those with a normal weight. Higher BMI values were also connected to a higher prevalence of acne with inflammatory lesions, while non-inflammatory lesions were more frequently observed in individuals with a lower BMI [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. A high BMI can lead to increased secretion of Insulin Growth Factor (IGF1), which stimulates keratinocyte proliferation, sebaceous lipogenesis, and androgen synthesis. All of these processes can contribute to the development of acne in predisposed individuals [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur study did not find a link between acne severity and higher BMI, which supports the findings of Lu et al. They reported no association between acne severity in Taiwanese women aged 25\u0026ndash;45 years and higher mean BMI [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. The absence of this association could be attributed to the use of a different acne scoring system in this study and the exclusion of acne patients with PCOS. Additionally, Snast et al [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e] and Tsan et al [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e] concluded that obesity might actually protect against acne, possibly due to increased aromatase activity and the peripheral conversion of androgens to estrogens in excess adipose tissue.\u003c/p\u003e \u003cp\u003eThe role of hyperprolactinemia in the development and worsening of acne is not well understood. Some studies have suggested that elevated PRL levels can lead to increased production of DHEAS by the adrenal glands, which may contribute to the development of acne [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. Our study did show a positive association between hyperprolactinemia and severe acne. However, there are only a limited number of studies exploring this relationship, with some, such as those by Bansal et al [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e] and Meena et al [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e], failing to find an association between hyperprolactinemia and severe acne.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePCOS is the most common endocrine disorder affecting women of childbearing age and is becoming increasingly prevalent. It presents with a variety of clinical manifestations, including acne, which is one of the most frequently encountered dermatological manifestations. This highlights the importance of considering acne as a potential symptom of PCOS when assessing and managing these patients. In our study, PCOS was diagnosed in 65.6% of the acne patients.\u003c/p\u003e \u003cp\u003eOur work has emphasized the hormonal and metabolic imbalances that may explain the association between PCOS and acne. The findings suggest a complex link between hormonal and metabolic disturbances in the development of acne.\u003c/p\u003e \u003cp\u003eAcne in PCOS is most often nodular and inflammatory, and in our study, it is even more severe due to its association with high levels of testosterone and prolactin. According to our results, phenotype A was the most likely to cause severe acne compared with the other phenotypes.\u003c/p\u003e \u003cp\u003eWe highlighted the importance of conducting an initial hormonal assessment in all acne patients given the close relationship with PCOS.\u003c/p\u003e \u003cp\u003eOur study is the first in Africa to emphasize the link between acne and PCOS. We encourage physicians to consider this endocrinopathy in all adult women seeking consultation for acne. This can lead to the development of new therapeutic approaches for managing PCOS-related acne and enabling the development of new therapeutic approaches in the management of PCOS acne.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eDeclaration of interest\u003c/h2\u003e \u003cp\u003eThe authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003ePatient consent\u003c/h2\u003e \u003cp\u003e Written and informed consent was obtained from the patients for publication of the submitted article.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eAuthor contribution statement\u003c/strong\u003e \u003cp\u003eDr Ben Abdessalem Fatma and Dr ACH Taieb drafted the manuscript. All authors helped in the patient care, read and approved the final manuscript.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eNo funding was received in the writing of this case.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eDr Ben Abdessalem Fatma and Dr ACH Taieb drafted the manuscript. Dr Ben Abdessalem prepared tables 1-5.Dr Ghariani Nadia, Dr Mraihi Emna and Dr Ben Abdelkrim Asma collaborated closely on the study design, ensuring that the research objectives were clearly defined and methodologically sound. All authors helped in the patient care, read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eTeede HJ et al (2023) Recommendations From the 2023 International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome. 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J Clin Lab Anal 36(11):e24739\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDi Landro A et al (2012) Family history, body mass index, selected dietary factors, menstrual history, and risk of moderate to severe acne in adolescents and young adults. J Am Acad Dermatol 67(6):1129\u0026ndash;1135\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSeleit I et al (2014) \u003cem\u003eBody mass index, selected dietary factors, and acne severity: are they related to in situ expression of insulin-like growth factor-1?\u003c/em\u003e Anal Quant Cytopathol Histpathol, 36(5): pp. 267\u0026thinsp;\u0026ndash;\u0026thinsp;78\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRahaman SMA et al (2016) Association of insulin-like growth factor (IGF)-1 gene polymorphisms with plasma levels of IGF-1 and acne severity. J Am Acad Dermatol 75(4):768\u0026ndash;773\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLu PH, Hsu CH (2015) Body mass index is negatively associated with acne lesion counts in Taiwanese women with post-adolescent acne. J Eur Acad Dermatol Venereol 29(10):2046\u0026ndash;2050\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSnast I et al (2019) Acne and obesity: A nationwide study of 600,404 adolescents. J Am Acad Dermatol 81(3):723\u0026ndash;729\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiou TH et al (2009) Clinical and biochemical presentations of polycystic ovary syndrome among obese and nonobese women. Fertil Steril 92(6):1960\u0026ndash;1965\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeena AK et al (2023) Biochemical and hormonal abnormalities in adult female acne. J Cosmet Dermatol 22(4):1392\u0026ndash;1399\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBansal P et al (2021) A prospective study examining isolated acne and acne with hyperandrogenic signs in adult females. J Dermatolog Treat 32(7):752\u0026ndash;755\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 5 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"archives-of-dermatological-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Archives of Dermatological Research](https://www.springer.com/journal/403)","snPcode":"403","submissionUrl":"https://submission.nature.com/new-submission/403/3","title":"Archives of Dermatological Research","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Acne, Polycystic ovary syndrome, hirsutism, alopecia, androgens","lastPublishedDoi":"10.21203/rs.3.rs-4889348/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4889348/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIntroduction:\u003c/p\u003e \u003cp\u003ePolycystic ovary syndrome (PCOS) is the leading endocrine disorder in young women of childbearing age. Dermatological issues, particularly acne, are a major reason for medical consultations. This study seeks to establish the prevalence of PCOS among patients with acne and to compare the metabolic and hormonal clinical characteristics of acne patients with PCOS to those with isolated acne.\u003c/p\u003e \u003cp\u003ePatients and Methods:\u003c/p\u003e \u003cp\u003eThis was a prospective study conducted with analytical objectives at the Endocrinology Department and Dermatology Department of CHU Farhat Hached Sousse. The study included patients seeking treatment for acne from January 2023 to January 2024, divided into two groups: those with confirmed PCOS (G1) and those with isolated acne (G2). All patients underwent hormonal assessment and ovarian ultrasound.\u003c/p\u003e \u003cp\u003eResults:\u003c/p\u003e \u003cp\u003eWe conducted a study involving 212 patients. We found that 65.6% of acne patients had been diagnosed with PCOS. Nodular lesions were significantly more frequent in G1 (p\u0026thinsp;=\u0026thinsp;0.02). Acne was linked with hirsutism, which was more prevalent in G1 (94.2% G1 vs. 67.1% G2), as well as androgenic alopecia (51% G1 vs. 21.9% G2) (p\u0026thinsp;\u0026lt;\u0026thinsp;10\u003csup\u003e\u0026minus;\u0026thinsp;3\u003c/sup\u003e). G1 showed evidence of biological hyperandrogenism, with a mean testosterone level of 0.72\u0026thinsp;\u0026plusmn;\u0026thinsp;0.27 ng/mL, significantly higher than in G2. The LH/FSH ratio was greater than 1 in 72.7% of G1 cases, with a notable difference from G2. In our study, acne in G1 appeared to be more severe and was associated with hypertestosteronemia (p\u0026thinsp;=\u0026thinsp;0.041) and hyperprolactinemia (p\u0026thinsp;=\u0026thinsp;0.008).\u003c/p\u003e \u003cp\u003eAccording to our results, phenotype A was the most likely to cause severe acne (p\u0026thinsp;=\u0026thinsp;0.043).\u003c/p\u003e \u003cp\u003eConclusion:\u003c/p\u003e \u003cp\u003eOur work is unique in that it brings to light this hidden aspect of the dermatological impact of PCOS, prompting physicians to screen for this endocrine disorder in all adult women seeking acne treatment.\u003c/p\u003e","manuscriptTitle":"Characterizing Clinical and Hormonal Profiles of Acne in North African Women with Polycystic Ovary Syndrome","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-06 20:06:38","doi":"10.21203/rs.3.rs-4889348/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-09-14T15:19:16+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-05T15:30:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"330430911268508672091465052521716832179","date":"2024-09-05T13:17:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"260869074973756615313204911060240498860","date":"2024-09-03T00:59:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"22118657453644337954645342848324295640","date":"2024-08-31T21:03:31+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-08-15T01:19:46+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-10T15:52:16+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-10T15:51:52+00:00","index":"","fulltext":""},{"type":"submitted","content":"Archives of Dermatological Research","date":"2024-08-09T23:44:56+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"archives-of-dermatological-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Archives of Dermatological Research](https://www.springer.com/journal/403)","snPcode":"403","submissionUrl":"https://submission.nature.com/new-submission/403/3","title":"Archives of Dermatological Research","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"833c1d25-26b0-438c-b79a-62fbe41063ae","owner":[],"postedDate":"September 6th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-10-17T00:08:16+00:00","versionOfRecord":[],"versionCreatedAt":"2024-09-06 20:06:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4889348","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4889348","identity":"rs-4889348","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}