Assessment of plasma testosterone, estradiol, and progesterone levels in Vietnam female patients with&nbsp;moderate to severe&nbsp;acne vulgaris

Phu Cuong Nguyen; Hoang Van Nguyen; Van Tien Vu; Van Tran Pham; Dang Quyet Tran; Thanh Tung Nguyen

doi:10.12688/f1000research.75617.5

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Revised

Assessment of plasma testosterone, estradiol, and progesterone levels in Vietnam female patients with moderate to severe acne vulgaris

[version 5; peer review: 1 approved, 1 approved with reservations, 2 not approved]

Previously titled: Assessment of serum hormone levels in female patients with acne vulgaris

Phu Cuong Nguyen¹, Hoang Van Nguyen¹, Van Tien Vu¹, Van Tran Pham², Dang Quyet Tran¹, Thanh Tung Nguyen³

Phu Cuong Nguyen¹, Hoang Van Nguyen¹, [...] Van Tien Vu¹, Van Tran Pham², Dang Quyet Tran¹, Thanh Tung Nguyen³

PUBLISHED 19 Jan 2023

Author details Author details

¹ Department of Dermatology and Venereology, Military Hospital 103, Vietnam Military Medical University, HaNoi, Ha Dong, 100000, Vietnam
² Department of Biochemistry, Military Hospital 103, Vietnam Military Medical University, Hanoi, Ha Dong, 100000, Vietnam
³ Military Institute of Clinical Embryology and Histology, Vietnam Military Medical University, Hanoi, Ha Dong, 100000, Vietnam

Phu Cuong Nguyen
Roles: Data Curation, Formal Analysis, Investigation, Software, Writing – Review & Editing

Hoang Van Nguyen
Roles: Data Curation, Investigation, Writing – Original Draft Preparation

Van Tien Vu
Roles: Data Curation, Investigation, Visualization, Writing – Original Draft Preparation

Van Tran Pham
Roles: Data Curation, Methodology, Resources, Supervision

Dang Quyet Tran
Roles: Project Administration, Resources, Supervision, Visualization

Thanh Tung Nguyen
Roles: Investigation, Supervision, Visualization

OPEN PEER REVIEW

REVIEWER STATUS

Abstract

Introduction: Acne is a chronic inflammatory disorder of the pilosebaceous unit with differential pathogenesis. To elucidate the roles of hormones in acne pathogenesis, we conducted a study to evaluate the plasma testosterone, estradiol, and progesterone levels in women with acne vulgaris.
Methods: We conducted a cross-sectional descriptive study, and 140 women with acne vulgaris were examined; their plasma estradiol, progesterone, and testosterone were analyzed by chemiluminescence technique and compared with the healthy control group.
Results: Increased plasma hormone levels in women with acne vulgaris accounted for 33.57%, and hyperandrogenism accounted for 20.71% of cases. We found significant differences in testosterone levels (mean value, 56.92 ± 27.64ng/dL, 60.71± 25.85ng/dL versus 38.35 ± 10.09ng/dL, p<0.01), respectively, in the moderate to severe acne group and the control group. However, the estradiol level of the moderate and severe acne groups (325.12 ± 91.79 and 305.26 ± 83.01pmol/l) was lower than the control group (368.6 ± 58.34pmol/l), with p-value under 0.05. No statistically significant differences were found for progesterone levels.
Conclusion: Female patients with moderate to severe acne vulgaris had abnormalities in plasma testosterone and estradiol levels. These abnormalities might be part roles in the pathogenesis of acne vulgaris, even when the mean levels were in the normal range.

Keywords

Acne vulgaris, hormone

Corresponding author: Thanh Tung Nguyen

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2023 Nguyen PC et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Nguyen PC, Nguyen HV, Vu VT et al. Assessment of plasma testosterone, estradiol, and progesterone levels in Vietnam female patients with moderate to severe acne vulgaris [version 5; peer review: 1 approved, 1 approved with reservations, 2 not approved]. F1000Research 2023, 11:23 (https://doi.org/10.12688/f1000research.75617.5) First published: 11 Jan 2022, 11:23 (https://doi.org/10.12688/f1000research.75617.1) Latest published: 19 Jan 2023, 11:23 (https://doi.org/10.12688/f1000research.75617.5)

Revised Amendments from Version 4

Based on the opinions of the reviewers, we decided to change some information in our article:
About the title, we focused on analyzing the data in moderate to severe acne patients. Therefore, the title was changed to “Vietnam patients with moderate to severe acne vulgaris”.
Regarding our data, we recruited more healthy volunteers (35 cases) and took more blood tests. Therefore, new data were collected and input to excel files. These documents were updated and uploaded to the web database (DOI: https://doi.org/10.5061/dryad.bvq83bk9z). Moreover, the data was re-analyzed and presented in new tables. These tables were the same structure as the previous version, except for table no.2. We added new information about the clinical manifestation and related factors to acne vulgaris, shown in table 2. The others kept the old structure with updated statistics.
Furthermore, we explained more about the results and pointed out some limitations of our study in the content of our article.

See the authors' detailed response to the review by Berna Aksoy
See the authors' detailed response to the review by Jerry Tan
See the authors' detailed response to the review by Mohamed Badawy Hassan Tawfik Abdel-Naser

Introduction

Acne is a chronic inflammatory disorder of the pilosebaceous unit with various manifestations, including non-inflammation and inflammation lesions. Collier et al. (2008) investigated 1013 Americans aged 20 years and older; 73.3% (744) reported ever having acne, and more women suffer from acne than men.¹ Four major factors involved in acne pathogenesis are excessive sebum production, follicular hyperkeratinization, hyper-colonization of the duct by Cutibacterium acnes (formerly Propionibacterium acnes), and the production of inflammation.² Moreover, the hormone plays a part role in the pathogenesis of acne. Some studies found that acne had a relationship with hyperandrogenemia in female patients.³ Estradiol, the primary female sex hormone known as the major active estrogen, forms in absolute plasma levels and estrogenic activity during human female reproductive years. Supplying sufficient amounts of estrogens will decrease sebum production and may act by suppressing androgen production by inhibiting the pituitary from secreting gonadotropin.⁴ The effect of progesterone on sebaceous glands was still disputed. Some authors have blamed progesterone for the change in sebum production in females during the menstrual cycle. However, this theory has not been proved experimentally.⁵ Therefore, we conducted this study to evaluate the plasma testosterone, estradiol, and progesterone levels and the correlation of hormonal alterations with the severity of acne in women with acne vulgaris.

Materials and methods

The cross-sectional study was conducted on 140 female patients diagnosed with acne vulgaris and 70 healthy females. Patients were recruited from the clinic of the Dermatology and Venereology department, Military hospital 103, VMMU, from January to October 2019. Approval was obtained from the ethics committee of the Hanoi Department of Science and Technology. Written informed consent for publication of the patients’ details was obtained from the patients.

We selected female acne patients aged between 16 and 25 who had not received drugs causing acne (glucocorticoids, lithium, isoniazid, phenytoin, selective reuptake serotonin inhibitors) or hormonal therapy (hormonal contraceptive and anti-androgen therapy) for at least three months before joining the study. Healthy volunteers without acne, pregnancy, or lactation served as the control group. None of the participants had been treated with hormonal treatment at this time of the study. All patients of each group were asked about history taken, throughout local and general clinical examinations, to rule out any suspected similar diagnosis or other local and systemic disorders which contraindicate the patients from participating in this study. PCOS was also excluded by the manifestation of hyperandrogenism (hirsutism, oligomenorrhea) and confirmed with transvaginal and pelvic ultrasound.

Acne severity grading

The severity of acne was determined according to the Global Acne Grading System (GAGS).⁶ Each type of acneiform lesion has a gravity score: no lesions: 0; comedones: 1; papules: 2; pustules: 3; and nodules: 4. The local score was calculated using factor × grade 0-4. Depending on the acne lesion location, the factor had the following values: forehead: 2; right cheek: 2; left cheek: 2; chin: 1; thorax and upper torso: 1. The sum of the local scores was the global score which settled acne severity. In our study, a global score of 1-18 signified mild acne, 19-30 was moderate acne, and a global score > 31 was severe.

Endocrine evaluation

Each patient performed a hormonal profile, including testosterone, estradiol, and progesterone. Blood samples were collected at 08:00 am on the second to the fourth day of menses (the follicular phase of the menstrual cycle). Each 4 mL of venous blood was centrifuged and plasma was stored at -20°C. Hormone levels were measured by using direct chemiluminescent technology in the Unicel^® DXI800 machine. Units: testosterone for ng/dL, estradiol for pmol/L, progesterone for ng/mL. Women’s testosterone normal levels were considered as ≤0.86 ng/mL; estradiol ranged from 74–532 pmol/L; progesterone was ≤1 ng/mL.

Data analysis

Statistical analyses were done by using SPSS software version 22.0. Data were presented as percentages for qualitative variables and mean and standard deviation for quantitative variables. Comparing two means using the student t-test. The relationship between categorical variables was analyzed by using the Chi-square test. P values of less than 0.05 were considered to be significant.

Results

The study was conducted at OPD of the Dermatology and Venereology department, Military hospital 103, VMMU, Vietnam. The healthy volunteers were recruited from the community, and female patients with acne vulgaris were selected randomly as the study group. Two hundred and ten female participants were enrolled and divided into three groups, including moderate acne, severe acne groups, and healthy control. The mean age of patients for the acne group was 21.03±2.47 years; for the controls, it was 20.68±2.57 years ranging from 18 to 25 years (Table 1).

Table 1. Age and BMI features of acne vulgaris group and control group.

Characteristics	Acne group (n=140)	Control group (n=70)	p-value	Normal range
Average age (years)	21.03±2.47	20.68±2.57	>0.05
BMI (kg/m²)	19.27±1.63	19.15±1.72	>0.05	18.5–24.9

Data showed that sixty-five percent had a duration from one to two years. Meanwhile, patients suffering from acne for more than two years accounted for 2.86 percent. Most patients (50.71%) occurred acne from 20-24 years old. All cases presented comedones, followed by 80.71% of cases that had papules, and 61.43% had pustules. The highest percentage of acne lesion locations were on the cheek and forehead, with 67.86% and 53.57%, respectively. It was found that moderate and severe acne groups accounted for an equal percentage of 50% (Table 2).

Table 2. Characteristics of female patients with acne vulgaris.

Characteristics		Number of cases (n=140)	Percentage
Duration	Less than 1 year	45	32.40
	1-2 years	91	65.00
	Above 2 years	04	2.86
Age of onset	16-19 years old	57	40.71
	20-24 years old	71	50.71
	Above 24 years old	12	8.58
Site	Cheek	95	67.86
	Forehead	75	53.57
	Chin	67	47.86
	Nose	50	35.71
	Jaw corner	72	51.43
	Chest	45	32.14
	Back	52	37.14
Lesions	Comedones	140	100
	Papules	113	80.71
	Pustules	86	61.43
Severity	Moderate	70	50.00
Severity	Severe	70	50.00

Plasma testosterone concentrations in moderate and severe groups were 56.92±27.64 ng/dL and 60.71±25.85 ng/dL, respectively. Although the mean concentrations were all in the normal range, they were statistically significantly higher than the controls at 38.35±10.09 ng/dL. Plasma estradiol levels in moderate and severe groups were 325.12±91.79 pmol/l and 305.26±83.01 pmol/l subsequently, and in the healthy group, were 368.6±58.34 pmol/l. This reduction of estradiol level in female acne patients was statistically significant. Plasma progesterone concentrations in moderate, severe acne and control groups were 0.59±0.39 ng/mL, 0.65±0.40 ng/mL, and 0.58±0.11 ng/mL, respectively. The mean levels in female acne patients were higher than in controls; however, the difference was not significant. It was not found the different in mean plasma hormonal levels between moderate and severe acne groups (Table 3).

Table 3. Plasma hormonal levels in acne groups and healthy control.

Parameters		N	Mean	IR	p-value
Testosterone (ng/dL)	Control (1)	70	38.35±10.09	(35.94,40.75)	p21<0.01 p31<0.01 p32>0.05
	Moderate (2)	70	56.92±27.64	(50.33,63.51)
	Severe (3)	70	60.71± 25.85	(54.55,66.88)
Estradiol (pmol/l)	Control (1)	70	368.6±58.34	(354.66,382.48)	p21<0.05* p31<0.01** p32>0.05
	Moderate (2)	70	325.12±91.79	(303.24,347.01)
	Severe (3)	70	305.26±83.01	(285.47,325.05)
Progesterone (ng/mL)	Control (1)	70	0.58±0.11	(0.56,0.61)	p21>0.05 p31>0.05 p32>0.05
	Moderate (2)	70	0.59±0.39	(0.50,0.69)
	Severe (3)	70	0.65±0.40	(0.55,0.75)

* p-value<0.05 was considered statistically significant.

** p-value<0.01 was considered statistically significant.

Regarding hormonal alterations, 33.57 percent of female acne patients had abnormal plasma hormonal levels of more than one biochemical parameter. 20.71% had plasma testosterone levels increase, 2.14% were a rise in estradiol levels, and 11.43% for progesterone elevation (Table 4).

Table 4. Plasma hormonal alterations in female acne patients.

Parameters		Testosterone (n=140)		Estradiol (n=140)		Progesterone (n=140)		Total (n=140)
Parameters		No.	%	No.	%	No.	%	No.	%
Normal		111	79.29	137	97.86	124	88.57	93	66.43
Increase	Moderate	11	7.86	2	1.43	9	6.43	21	15.00
	Severe	18	12.86	1	0.71	7	5.00	26	18.57
	Total	29	20.71	3	2.14	16	11.43	47	33.57

Discussion

In this study, the mean age in the acne groups was 21.03±2.47 years, younger than the previous study, with a mean of 26.64 years.⁵ Most patients (50.71%) occurred acne from 20-24 years old with a duration between 1-2 years, accounting for the highest percentage with 65%. It was found that 32.4% had a duration of less than one year, and 2.86 percent suffered from acne for more than two years.

In literature, acne lesions often occur at sites with a risk of the pilosebaceous unit. In our study, the cheek and forehead were involved with the highest percentage (67.86% and 53.57%, respectively). Lesions on the chest and back accounted for 32.14% and 37.14%. Regarding fundamental lesions, both inflammatory and non-inflammatory lesions were all seen. Comedones were found in all patients, followed by 80.71% suffering from papules and 61.43% having pustules.

Plasma testosterone levels were significantly increased in female patients with moderate to severe acne vulgaris compared to the controls. Although the mean testosterone level was in the normal range, this elevation was statistically significant. It can be explained that androgen bioactivity depends on the amount of plasma hormonal levels and the affinity to specific receptors, the number of receptors, or metabolism in binding sites. Our result was corroboration by the study done by Wei et al.⁷ However, in the study by Cetinozman⁸ and Akdogan,⁹ no significant change in testosterone levels was found between the acne and control groups. The discrepancy among the research results can be explained that the numbers of samples of the previous authors were not large enough, and the method of grading the severity of acne disease between the studies was based on different scales. Furthermore, anti-androgen therapy improved acne lesions in patients with polycystic ovary syndrome,¹⁰ which shows the critical role of androgen in the pathogenesis of acne.

In our study, the percentage of hormonal alteration in at least one parameter in female patients with acne vulgaris was 33.57%. 20.71% had plasma testosterone levels increase, 2.14% were a rise in estradiol concentrations and 11.43% for progesterone elevation (Table 4). In 2013, da Cunha et al. found that 56.52% of cases changed at least one androgen hormone, and the rate of androgenism was 10.77%.⁵ The literature reveals that hormonal disorders such as PCOS have a relationship with acne as the clinical manifestation of this disease. In our study, all patients were examined to rule out hirsutism and took transvaginal and pelvic ultrasounds to find any changes in ovaries. However, the limitation of our study was that patients were screened at one point without follow-up hormonal disorders. Therefore, we theorized that hyperandrogenism without hirsutism might be a subclinical sign for early diagnosis of hormonal disorders.

The role of estradiol in the pathogenesis of acne vulgaris is not elucidated. We hypothesize that estrogens might impact sebum secretion by three mechanisms: the opposition of androgens within the sebaceous glands, inhibition of gonadal androgen production via a negative feedback mechanism on gonadotropin release, and affects genes that play a role in sebaceous gland growth and lipid production.¹¹ In our study, plasma estradiol levels in moderate and severe groups were significantly decreased compared to the healthy group. This result was in accordance with the observation of the study done by Wei et al.⁷

The progesterone effect on acne remains unclear. However, some studies show that progesterone can reduce androgen effects by inhibiting the 5-ARD enzyme or androgen receptors.¹² The fluctuation of sebum production in women during the menstrual cycle and premenstrual cyclic flare has partly been associated with progesterone. Some progestins lead to an exacerbation of acne by interacting with androgen receptors.¹²^,¹³ In our study, there was no statically significant difference between moderate to severe acne groups and controls in terms of plasma progesterone levels. In contrast to our study, Bakry et al. claimed that the progesterone levels in female acne patients were higher than in the control group.² It was similar to the study by Arora et al.¹⁴ The difference in results between our study and other studies can be explained by the different days of hormone tests in the menstrual cycle and different inclusion criteria. Arora¹⁴ and Bakry² investigated plasma hormones during the luteal phase of menses. Meanwhile, we performed in the follicular phase of menses.

Our study had some limitations. As literature reviews, plasma salivary hormone levels such as progesterone and estradiol fluctuate during menstrual cycles. To minimize these effects, we took samples at 8 a.m. on the 2-4^th day of menses, the early follicular phase of the menstrual cycle, during which plasma hormonal levels remain relatively stable. In our study, hormonal alterations showed a relationship with acne vulgaris. Therefore, large-scale cross-sectional studies are needed to confirm the correlation between acne and hormonal abnormalities. Further prospective studies are to follow up on acne cases having plasma hormonal alterations without clinical presentation, as well as evaluate the clinical outcomes of targeted therapies.

Conclusion

Our study showed that female patients with moderate to severe acne vulgaris had abnormalities in plasma testosterone and estradiol levels. These abnormalities might be part of the pathogenesis of acne vulgaris, even when the mean levels were in the normal range.

Data availability

Underlying data

Dryad: Underlying data for ‘Assessment of plasma testosterone, estradiol, and progesterone levels in Vietnam female patients with moderate to severe acne vulgaris’. https://doi.org/10.5061/dryad.bvq83bk9z ¹⁵

The project contains the following underlying data:

• DATA.xlsx

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

Ethics approval

Approval was obtained from the ethics committee of Hanoi Department of Science and Technology with the code: 01C-08/14-2017-3. The procedures used in this study adhere to the tenets of the Declaration of Helsinki.

Consent to participate

Written informed consent for publication of the patients’ details was obtained from the patients.

Acknowledgments

The authors would like to thank the Department of Dermatology and Venereology, Military hospital 103, Vietnam Military Medical University, for their support during the study and the patients for their voluntary participation in this research.

References

1. Collier CN, et al.: The prevalence of acne in adults 20 years and older. J. Am. Acad. Dermatol. 2008; 58(1): 56–59. PubMed Abstract
2. Bakry OA, et al.: Role of hormones and blood lipids in the pathogenesis of acne vulgaris in non-obese, non-hirsute females. Indian Dermatol. Online J. 2014; 5(1): S9–S16.
3. Placzek M, et al.: Elevated 17-hydroxyprogesterone serum values in male patients with acne. J. Am. Acad. Dermatol. 2005; 53(6): 955–958. PubMed Abstract
4. Thiboutot D: Acne: hormonal concepts and therapy. Clin. Dermatol. 2004; 22(5): 419–428. PubMed Abstract
5. da Cunha MG , Fonseca FL, Machado CD: Androgenic hormone profile of adult women with acne. Dermatology. 2013; 226(2): 167–171. PubMed Abstract
6. Doshi A, Zaheer A, Stiller MJ: A comparison of current acne grading systems and proposal of a novel system. Int. J. Dermatol. 1997; 36(6):416–418. PubMed Abstract | Publisher Full Text
7. Wei B, et al.: Higher 17alpha-hydroxyprogesterone levels aggravated the severity of male adolescent acne in Northeast China. Dermatology. 2014; 229(4): 359–362. PubMed Abstract
8. Cetinözman F, et al.: Insulin sensitivity, androgens and isotretinoin therapy in women with severe acne. J. Dermatol. Treat. 2014; 25(2):119–122. PubMed Abstract | Publisher Full Text
9. Akdogan N, et al.: Association of serum hormone levels with acne vulgaris: Low estradiol level can be a pathogenetic factor in female acne. Our Dermatology Online .2018; 9(3):249–256. Publisher Full Text
10. de Gonçalves MHH , et al.: Síndrome do ovário policístico: abordagem dermatológica.An. Bras. Dermatol.2011; 86: 111–119. Publisher Full Text
11. Ian Mason J: The 3beta-hydroxysteroid dehydrogenase gene family of enzymes. Trends Endocrinol. Metab. 1993; 4(6): 199–203.
12. Rabe T, et al.: Inhibition of skin 5 alpha-reductase by oral contraceptive progestins in vitro. Gynecol. Endocrinol. 2000; 14(4): 223–230. PubMed Abstract
13. Bitzer J, Tschudin S, Alder J: Acceptability and side-effects of Implanon in Switzerland: a retrospective study by the Implanon Swiss Study Group. Eur. J. Contracept. Reprod. Health Care. 2004; 9(4): 278–284. PubMed Abstract
14. Arora MK, Seth S, Dayal S: The relationship of lipid profile and menstrual cycle with acne vulgaris. Clin. Biochem. 2010; 43(18):1415–1420. PubMed Abstract | Publisher Full Text
15. Nguyen PC, et al.: Assessment of serum hormone levels in female patients with acne vulgaris. Dryad, Dataset. 2022. Publisher Full Text

Comments on this article Comments (0)

Version 5

VERSION 5 PUBLISHED 11 Jan 2022

Author details Author details

Phu Cuong Nguyen
Roles: Data Curation, Formal Analysis, Investigation, Software, Writing – Review & Editing

Hoang Van Nguyen
Roles: Data Curation, Investigation, Writing – Original Draft Preparation

Van Tien Vu
Roles: Data Curation, Investigation, Visualization, Writing – Original Draft Preparation

Van Tran Pham
Roles: Data Curation, Methodology, Resources, Supervision

Dang Quyet Tran
Roles: Project Administration, Resources, Supervision, Visualization

Thanh Tung Nguyen
Roles: Investigation, Supervision, Visualization

Competing interests

No competing interests were disclosed.

Grant information

The author(s) declared that no grants were involved in supporting this work.

Article Versions (5)

version 5

Revised

Published: 19 Jan 2023, 11:23

https://doi.org/10.12688/f1000research.75617.5

version 4

Revised

Published: 22 Apr 2022, 11:23

https://doi.org/10.12688/f1000research.75617.4

version 3

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Published: 04 Apr 2022, 11:23

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version 2

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https://doi.org/10.12688/f1000research.75617.2

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https://doi.org/10.12688/f1000research.75617.1

© 2023 Nguyen PC et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Nguyen PC, Nguyen HV, Vu VT et al. Assessment of plasma testosterone, estradiol, and progesterone levels in Vietnam female patients with moderate to severe acne vulgaris [version 5; peer review: 1 approved, 1 approved with reservations, 2 not approved]. F1000Research 2023, 11:23 (https://doi.org/10.12688/f1000research.75617.5)

NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.

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ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions

Version 5

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PUBLISHED 19 Jan 2023

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Reviewer Report 16 Sep 2024

Dalia Rifaat Al-Sharaky, Pathology Department, Faculty of Medicine, Menoufia University, Shebin El Kom, Egypt

Approved with Reservations

https://doi.org/10.5256/f1000research.142367.r163603

Although the title is consistent with the presented problem and reflects the main message of the study. The aim of the study is well established by previous studies that conducted the role of hormones in female acne patients.

Regarding the title it emphasizes Vietnam female however, in general this probably diminishes the impact of the paper, as readers may assume that these findings are not able to be extrapolated to other populations. Unless there are special risk factors or absence of them in Vietnam. I prefer that this could be emphasized less and leave the readers to make their own conclusions regarding the Vietnamese female acne patients.

In the materials and methods; what are the local and systemic disorders which contraindicate the patients from participating in this study? Please state them.

The female acne patients were selected aged between 16 and 25, why this age group?

In the characteristics displayed in table 2, the age of onset was categorized into 3 groups 16 to 19, 20 to 24 and older than 24, doesn’t this compromise the third group (older than 24 years) for the eldest range of age selected is 25 years old?

In the materials and methods, the authors stated that the Women’s testosterone normal levels were considered as ≤0.86 ng/mL; estradiol ranged from 74–532 pmol/L; progesterone was ≤1 ng/mL. What is the reference for these ranges.

There are other factors that may play a role in the etiopathogenesis of acne, such as stress, diet and smoking, how did the study deal with them.

In the results section you stated that female patients with acne vulgaris were selected randomly, I believe those group were selected based on a specific criteria and not randomly. Can the authors please clarify this.

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

I cannot comment. A qualified statistician is required.
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: GIT pathology and immunohistochemistry

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

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Version 4

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PUBLISHED 22 Apr 2022

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Reviewer Report 28 Oct 2022

Mohamed Badawy Hassan Tawfik Abdel-Naser, Bawabet Al Hayah Medical Center, Cairo, Egypt

Not Approved

https://doi.org/10.5256/f1000research.130606.r152628

The authors stated that the acne group and the normal control are age-matched. You may kindly avoid this term, because they are not matched.

In the title, abstract and material and methods, the authors used the term "serum"; most importantly they collected sera, whereas in the table and also in the text they used the term "plasma". What is the reason for this?

In general, several researchers do not recommend assessment of androgens, LH, etc., in acne patients because of the hormonal circadian fluctuation unless there is clinical evidence of hormonal disturbance. There are also several confounding variables. This may provide an explanation for the inconsistent results of hormonal assessment studies that the authors of the present study referred to.¹

Another explanation for the inconsistent results is inadequate study design. In the present study authors assessed serum testosterone, estradiol and progesterone in females with acne vulgaris (n=175). Hormones levels were compared with the healthy control (n=35) of similar age. Students' test is used for the comparisons. Clearly, the control group is inadequate as it has an inacceptable large margin of error (roughly 1/√ 35 = 17%). On the other hand, the test group has less margin of error but still large (roughly 1/√175=7.5%). Accordingly, unpaired t test may return erroneous/misleading results. In addition, and considering estradiol as an example, its reference range is 74–532 pmol/L, in the test group the mean + SD is 323.15+93.31 and in the healthy control the mean + SD is 370.94+58.88. Ninety five percent (95%) of the healthy normal population will have estradiol levels in the range of 74-532 pmol/L as previously mentioned. By analogy and in this study, 95% (mean+2 SD) of females with acne have estradiol levels in the range of 136.53 – 509.78 and the healthy control group in the range of 253.15-488.7. Note that these ranges in both acne group and control group are within the normal reference range, i.e., they are normal. Accordingly, the mentioned statistical significance (p<0.05) is of no particular scientific (medical) relevance. The same concept (analysis) can also be applied on all assessed hormones.

The authors stated that 16% (n=28) of females with acne have increased testosterone level but no symptoms or signs of virilism. Was this increase above the upper limit of the lab reference range (6-86 ng/ml) or in comparison with the control group (n=35)?. This is again of no particular relevance not only because the control group is inadequate but also due to possible confounding factors. Based on the aforementioned arguments the provided statistical evaluation is misleading. There are several other similar but complex issues regarding the study design.

Some of the terms, phrases and sentences are not easy to comprehend.

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

No
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

No
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

No

References

1. Hedayat K, Lapraz J: Acne: Disorder of luteal androgen management. 2019. 165-183 Publisher Full Text

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Acne, pigmentary disorders

I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.

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Author Response 19 Jan 2023

NGUYEN CUONG, Department of Dermatology and Venereology, 103 Military Hospital, Vietnam Military Medical University, HaNoi, 100000, Vietnam

19 Jan 2023

Author Response

1. The authors stated that the acne group and the normal control are age-matched. You may kindly avoid this term because they are not matched.

=>Thank you for your ... Continue reading 1. The authors stated that the acne group and the normal control are age-matched. You may kindly avoid this term because they are not matched.

=>Thank you for your valuable comments on your study. As per your opinions, we also recognized the sample sizes of the acne group and control group were asymmetrical. Therefore, we continued to recruit more healthy volunteers to take blood tests. The comparison of age variables between the two groups was shown in a new version.

2. In the title, abstract and material, and methods, the authors used the term "serum"; most importantly they collected sera, whereas in the table and also in the text they used the term "plasma". What is the reason for this?

=>We conducted hormonal evaluation tests with plasma. And we corrected this tissue.

3. In general, several researchers do not recommend the assessment of androgens, LH, etc., in acne patients because of hormonal circadian fluctuation unless there is clinical evidence of hormonal disturbance. There are also several confounding variables. This may provide an explanation for the inconsistent results of hormonal assessment studies that the authors of the present study referred to.¹

=> Some studies show that hormonal alteration has a role in female acne vulgaris. However, there is no strict guideline yet. And hormonal therapies for adult acne treatment were conducted without requiring hormonal abnormalities recently. Therefore, we conducted this study to investigate the hormonal profiles of female acne patients in Vietnam. Our result also partly contributed to the reference hormonal range in acne patients in our country. As literature reviews, plasma salivary hormone levels such as progesterone and estradiol fluctuate during menstrual cycles. To minimize these effects, we took samples at 8 a.m. on the 2-4th day of menses, the early follicular phase of the menstrual cycle, during which plasma hormonal levels remain relatively stable.

4. Another explanation for the inconsistent results is inadequate study design. In the present study authors assessed serum testosterone, estradiol and progesterone in females with acne vulgaris (n=175). Hormones levels were compared with the healthy control (n=35) of similar age. Students' test is used for the comparisons. Clearly, the control group is inadequate as it has an inacceptable large margin of error (roughly 1/√ 35 = 17%). On the other hand, the test group has less margin of error but still large (roughly 1/√175=7.5%). Accordingly, unpaired t test may return erroneous/misleading results. In addition, and considering estradiol as an example, its reference range is 74–532 pmol/L, in the test group the mean + SD is 323.15+93.31 and in the healthy control the mean + SD is 370.94+58.88. Ninety five percent (95%) of the healthy normal population will have estradiol levels in the range of 74-532 pmol/L as previously mentioned. By analogy and in this study, 95% (mean+2 SD) of females with acne have estradiol levels in the range of 136.53 – 509.78 and the healthy control group in the range of 253.15-488.7. Note that these ranges in both acne group and control group are within the normal reference range, i.e., they are normal. Accordingly, the mentioned statistical significance (p<0.05) is of no particular scientific (medical) relevance. The same concept (analysis) can also be applied on all assessed hormones.

=> Thank you for your excellent opinion. As we mentioned above, we focused on analyzing data in female patients with moderate and severe acne vulgaris (70 patients for each group) and then comparing it to the healthy control (70 participants). Although the mean hormonal level was in the normal range, this elevation was statistically significant. It can be explained that androgen bioactivity depends on the amount of plasma hormonal levels and the affinity to specific receptors, the number of receptors, or metabolism in binding sites.

5. The authors stated that 16% (n=28) of females with acne have increased testosterone level but no symptoms or signs of virilism. Was this increase above the upper limit of the lab reference range (6-86 ng/ml) or in comparison with the control group (n=35)?. This is again of no particular relevance not only because the control group is inadequate but also due to possible confounding factors. Based on the aforementioned arguments the provided statistical evaluation is misleading. There are several other similar but complex issues regarding the study design.

=> That’s a valuable finding. We meant that 16% of female acne patients had plasma testosterone levels increase above the normal range.

6. Some of the terms, phrases, and sentences are not easy to comprehend.

=> Thank you for your comment. With the new version, sentences and grammar were checked and re-written to more comprehend. After all, we would like to express our special thanks to you for your valuable comments.
1. The authors stated that the acne group and the normal control are age-matched. You may kindly avoid this term because they are not matched.

=>Thank you for your valuable comments on your study. As per your opinions, we also recognized the sample sizes of the acne group and control group were asymmetrical. Therefore, we continued to recruit more healthy volunteers to take blood tests. The comparison of age variables between the two groups was shown in a new version.

2. In the title, abstract and material, and methods, the authors used the term "serum"; most importantly they collected sera, whereas in the table and also in the text they used the term "plasma". What is the reason for this?

=>We conducted hormonal evaluation tests with plasma. And we corrected this tissue.

3. In general, several researchers do not recommend the assessment of androgens, LH, etc., in acne patients because of hormonal circadian fluctuation unless there is clinical evidence of hormonal disturbance. There are also several confounding variables. This may provide an explanation for the inconsistent results of hormonal assessment studies that the authors of the present study referred to.¹

=> Some studies show that hormonal alteration has a role in female acne vulgaris. However, there is no strict guideline yet. And hormonal therapies for adult acne treatment were conducted without requiring hormonal abnormalities recently. Therefore, we conducted this study to investigate the hormonal profiles of female acne patients in Vietnam. Our result also partly contributed to the reference hormonal range in acne patients in our country. As literature reviews, plasma salivary hormone levels such as progesterone and estradiol fluctuate during menstrual cycles. To minimize these effects, we took samples at 8 a.m. on the 2-4th day of menses, the early follicular phase of the menstrual cycle, during which plasma hormonal levels remain relatively stable.

4. Another explanation for the inconsistent results is inadequate study design. In the present study authors assessed serum testosterone, estradiol and progesterone in females with acne vulgaris (n=175). Hormones levels were compared with the healthy control (n=35) of similar age. Students' test is used for the comparisons. Clearly, the control group is inadequate as it has an inacceptable large margin of error (roughly 1/√ 35 = 17%). On the other hand, the test group has less margin of error but still large (roughly 1/√175=7.5%). Accordingly, unpaired t test may return erroneous/misleading results. In addition, and considering estradiol as an example, its reference range is 74–532 pmol/L, in the test group the mean + SD is 323.15+93.31 and in the healthy control the mean + SD is 370.94+58.88. Ninety five percent (95%) of the healthy normal population will have estradiol levels in the range of 74-532 pmol/L as previously mentioned. By analogy and in this study, 95% (mean+2 SD) of females with acne have estradiol levels in the range of 136.53 – 509.78 and the healthy control group in the range of 253.15-488.7. Note that these ranges in both acne group and control group are within the normal reference range, i.e., they are normal. Accordingly, the mentioned statistical significance (p<0.05) is of no particular scientific (medical) relevance. The same concept (analysis) can also be applied on all assessed hormones.

=> Thank you for your excellent opinion. As we mentioned above, we focused on analyzing data in female patients with moderate and severe acne vulgaris (70 patients for each group) and then comparing it to the healthy control (70 participants). Although the mean hormonal level was in the normal range, this elevation was statistically significant. It can be explained that androgen bioactivity depends on the amount of plasma hormonal levels and the affinity to specific receptors, the number of receptors, or metabolism in binding sites.

5. The authors stated that 16% (n=28) of females with acne have increased testosterone level but no symptoms or signs of virilism. Was this increase above the upper limit of the lab reference range (6-86 ng/ml) or in comparison with the control group (n=35)?. This is again of no particular relevance not only because the control group is inadequate but also due to possible confounding factors. Based on the aforementioned arguments the provided statistical evaluation is misleading. There are several other similar but complex issues regarding the study design.

=> That’s a valuable finding. We meant that 16% of female acne patients had plasma testosterone levels increase above the normal range.

6. Some of the terms, phrases, and sentences are not easy to comprehend.

=> Thank you for your comment. With the new version, sentences and grammar were checked and re-written to more comprehend. After all, we would like to express our special thanks to you for your valuable comments.
Competing Interests: No competing interests were disclosed. Close
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Author Response 19 Jan 2023

NGUYEN CUONG, Department of Dermatology and Venereology, 103 Military Hospital, Vietnam Military Medical University, HaNoi, 100000, Vietnam

19 Jan 2023

Author Response

1. The authors stated that the acne group and the normal control are age-matched. You may kindly avoid this term because they are not matched.

=>Thank you for your ... Continue reading 1. The authors stated that the acne group and the normal control are age-matched. You may kindly avoid this term because they are not matched.

=>Thank you for your valuable comments on your study. As per your opinions, we also recognized the sample sizes of the acne group and control group were asymmetrical. Therefore, we continued to recruit more healthy volunteers to take blood tests. The comparison of age variables between the two groups was shown in a new version.

2. In the title, abstract and material, and methods, the authors used the term "serum"; most importantly they collected sera, whereas in the table and also in the text they used the term "plasma". What is the reason for this?

=>We conducted hormonal evaluation tests with plasma. And we corrected this tissue.

3. In general, several researchers do not recommend the assessment of androgens, LH, etc., in acne patients because of hormonal circadian fluctuation unless there is clinical evidence of hormonal disturbance. There are also several confounding variables. This may provide an explanation for the inconsistent results of hormonal assessment studies that the authors of the present study referred to.¹

=> Some studies show that hormonal alteration has a role in female acne vulgaris. However, there is no strict guideline yet. And hormonal therapies for adult acne treatment were conducted without requiring hormonal abnormalities recently. Therefore, we conducted this study to investigate the hormonal profiles of female acne patients in Vietnam. Our result also partly contributed to the reference hormonal range in acne patients in our country. As literature reviews, plasma salivary hormone levels such as progesterone and estradiol fluctuate during menstrual cycles. To minimize these effects, we took samples at 8 a.m. on the 2-4th day of menses, the early follicular phase of the menstrual cycle, during which plasma hormonal levels remain relatively stable.

4. Another explanation for the inconsistent results is inadequate study design. In the present study authors assessed serum testosterone, estradiol and progesterone in females with acne vulgaris (n=175). Hormones levels were compared with the healthy control (n=35) of similar age. Students' test is used for the comparisons. Clearly, the control group is inadequate as it has an inacceptable large margin of error (roughly 1/√ 35 = 17%). On the other hand, the test group has less margin of error but still large (roughly 1/√175=7.5%). Accordingly, unpaired t test may return erroneous/misleading results. In addition, and considering estradiol as an example, its reference range is 74–532 pmol/L, in the test group the mean + SD is 323.15+93.31 and in the healthy control the mean + SD is 370.94+58.88. Ninety five percent (95%) of the healthy normal population will have estradiol levels in the range of 74-532 pmol/L as previously mentioned. By analogy and in this study, 95% (mean+2 SD) of females with acne have estradiol levels in the range of 136.53 – 509.78 and the healthy control group in the range of 253.15-488.7. Note that these ranges in both acne group and control group are within the normal reference range, i.e., they are normal. Accordingly, the mentioned statistical significance (p<0.05) is of no particular scientific (medical) relevance. The same concept (analysis) can also be applied on all assessed hormones.

=> Thank you for your excellent opinion. As we mentioned above, we focused on analyzing data in female patients with moderate and severe acne vulgaris (70 patients for each group) and then comparing it to the healthy control (70 participants). Although the mean hormonal level was in the normal range, this elevation was statistically significant. It can be explained that androgen bioactivity depends on the amount of plasma hormonal levels and the affinity to specific receptors, the number of receptors, or metabolism in binding sites.

5. The authors stated that 16% (n=28) of females with acne have increased testosterone level but no symptoms or signs of virilism. Was this increase above the upper limit of the lab reference range (6-86 ng/ml) or in comparison with the control group (n=35)?. This is again of no particular relevance not only because the control group is inadequate but also due to possible confounding factors. Based on the aforementioned arguments the provided statistical evaluation is misleading. There are several other similar but complex issues regarding the study design.

=> That’s a valuable finding. We meant that 16% of female acne patients had plasma testosterone levels increase above the normal range.

6. Some of the terms, phrases, and sentences are not easy to comprehend.

=> Thank you for your comment. With the new version, sentences and grammar were checked and re-written to more comprehend. After all, we would like to express our special thanks to you for your valuable comments.
1. The authors stated that the acne group and the normal control are age-matched. You may kindly avoid this term because they are not matched.

=>Thank you for your valuable comments on your study. As per your opinions, we also recognized the sample sizes of the acne group and control group were asymmetrical. Therefore, we continued to recruit more healthy volunteers to take blood tests. The comparison of age variables between the two groups was shown in a new version.

2. In the title, abstract and material, and methods, the authors used the term "serum"; most importantly they collected sera, whereas in the table and also in the text they used the term "plasma". What is the reason for this?

=>We conducted hormonal evaluation tests with plasma. And we corrected this tissue.

3. In general, several researchers do not recommend the assessment of androgens, LH, etc., in acne patients because of hormonal circadian fluctuation unless there is clinical evidence of hormonal disturbance. There are also several confounding variables. This may provide an explanation for the inconsistent results of hormonal assessment studies that the authors of the present study referred to.¹

=> Some studies show that hormonal alteration has a role in female acne vulgaris. However, there is no strict guideline yet. And hormonal therapies for adult acne treatment were conducted without requiring hormonal abnormalities recently. Therefore, we conducted this study to investigate the hormonal profiles of female acne patients in Vietnam. Our result also partly contributed to the reference hormonal range in acne patients in our country. As literature reviews, plasma salivary hormone levels such as progesterone and estradiol fluctuate during menstrual cycles. To minimize these effects, we took samples at 8 a.m. on the 2-4th day of menses, the early follicular phase of the menstrual cycle, during which plasma hormonal levels remain relatively stable.

4. Another explanation for the inconsistent results is inadequate study design. In the present study authors assessed serum testosterone, estradiol and progesterone in females with acne vulgaris (n=175). Hormones levels were compared with the healthy control (n=35) of similar age. Students' test is used for the comparisons. Clearly, the control group is inadequate as it has an inacceptable large margin of error (roughly 1/√ 35 = 17%). On the other hand, the test group has less margin of error but still large (roughly 1/√175=7.5%). Accordingly, unpaired t test may return erroneous/misleading results. In addition, and considering estradiol as an example, its reference range is 74–532 pmol/L, in the test group the mean + SD is 323.15+93.31 and in the healthy control the mean + SD is 370.94+58.88. Ninety five percent (95%) of the healthy normal population will have estradiol levels in the range of 74-532 pmol/L as previously mentioned. By analogy and in this study, 95% (mean+2 SD) of females with acne have estradiol levels in the range of 136.53 – 509.78 and the healthy control group in the range of 253.15-488.7. Note that these ranges in both acne group and control group are within the normal reference range, i.e., they are normal. Accordingly, the mentioned statistical significance (p<0.05) is of no particular scientific (medical) relevance. The same concept (analysis) can also be applied on all assessed hormones.

=> Thank you for your excellent opinion. As we mentioned above, we focused on analyzing data in female patients with moderate and severe acne vulgaris (70 patients for each group) and then comparing it to the healthy control (70 participants). Although the mean hormonal level was in the normal range, this elevation was statistically significant. It can be explained that androgen bioactivity depends on the amount of plasma hormonal levels and the affinity to specific receptors, the number of receptors, or metabolism in binding sites.

5. The authors stated that 16% (n=28) of females with acne have increased testosterone level but no symptoms or signs of virilism. Was this increase above the upper limit of the lab reference range (6-86 ng/ml) or in comparison with the control group (n=35)?. This is again of no particular relevance not only because the control group is inadequate but also due to possible confounding factors. Based on the aforementioned arguments the provided statistical evaluation is misleading. There are several other similar but complex issues regarding the study design.

=> That’s a valuable finding. We meant that 16% of female acne patients had plasma testosterone levels increase above the normal range.

6. Some of the terms, phrases, and sentences are not easy to comprehend.

=> Thank you for your comment. With the new version, sentences and grammar were checked and re-written to more comprehend. After all, we would like to express our special thanks to you for your valuable comments.
Competing Interests: No competing interests were disclosed. Close
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Version 2

VERSION 2

PUBLISHED 09 Feb 2022

Revised

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Reviewer Report 08 Mar 2022

Jerry Tan, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada

Not Approved

https://doi.org/10.5256/f1000research.121108.r126046

Most importantly, there is inadequate detail on the acne and control cohorts. In the former, it is important to ensure selection criteria are detailed as it is not stated. How will the reader know that these patients were not pre-selected based on a history or physical findings of virilism or other hyper-androgenic features? In the latter, most significant are age matching and ensuring that controls were not on birth control pills or other hormonal therapies that may confound hormonal test results.

Secondly, determination of acne severity uses a scale not typical for clinical or epidemiological acne research.

Furthermore, there are prior studies showing no association between hormonal abnormalities and acne in women – these should be referenced.

Finally, there is awkward sentence structure, syntax and word choice leading to difficulty in my comprehension.

Is the work clearly and accurately presented and does it cite the current literature?

No
Is the study design appropriate and is the work technically sound?

No
Are sufficient details of methods and analysis provided to allow replication by others?

No
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

No

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Acne

CITE

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Author Response 04 Apr 2022

NGUYEN CUONG, Department of Dermatology and Venereology, 103 Military Hospital, Vietnam Military Medical University, HaNoi, 100000, Vietnam

04 Apr 2022

Author Response
- We added the inclusion and exclusion criteria in detail for the control and acne groups in the new version of our article.
- In the previous
... Continue reading
We added the inclusion and exclusion criteria in detail for the control and acne groups in the new version of our article.

In the previous article, we based on the acne grading score by Karen Mckoy. This score was not used widely in other studies, and we adjusted and fixed them suitable with the Global Acne Grading System. In our research, a global score of 1-18 signified mild acne, 19‐30 was moderate acne, and a global score > 31 was severe acne.

Some authors found no relationship between hormone disorders and acne in female patients in the literature. And we added the results of these studies and gave our discussion about this difference.
We added the inclusion and exclusion criteria in detail for the control and acne groups in the new version of our article.

In the previous article, we based on the acne grading score by Karen Mckoy. This score was not used widely in other studies, and we adjusted and fixed them suitable with the Global Acne Grading System. In our research, a global score of 1-18 signified mild acne, 19‐30 was moderate acne, and a global score > 31 was severe acne.

Some authors found no relationship between hormone disorders and acne in female patients in the literature. And we added the results of these studies and gave our discussion about this difference.
Competing Interests: No competing interests were disclosed. Close
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COMMENTS ON THIS REPORT

Author Response 04 Apr 2022

NGUYEN CUONG, Department of Dermatology and Venereology, 103 Military Hospital, Vietnam Military Medical University, HaNoi, 100000, Vietnam

04 Apr 2022

Author Response
- We added the inclusion and exclusion criteria in detail for the control and acne groups in the new version of our article.
- In the previous
... Continue reading
We added the inclusion and exclusion criteria in detail for the control and acne groups in the new version of our article.

In the previous article, we based on the acne grading score by Karen Mckoy. This score was not used widely in other studies, and we adjusted and fixed them suitable with the Global Acne Grading System. In our research, a global score of 1-18 signified mild acne, 19‐30 was moderate acne, and a global score > 31 was severe acne.

Some authors found no relationship between hormone disorders and acne in female patients in the literature. And we added the results of these studies and gave our discussion about this difference.
We added the inclusion and exclusion criteria in detail for the control and acne groups in the new version of our article.

In the previous article, we based on the acne grading score by Karen Mckoy. This score was not used widely in other studies, and we adjusted and fixed them suitable with the Global Acne Grading System. In our research, a global score of 1-18 signified mild acne, 19‐30 was moderate acne, and a global score > 31 was severe acne.

Some authors found no relationship between hormone disorders and acne in female patients in the literature. And we added the results of these studies and gave our discussion about this difference.
Competing Interests: No competing interests were disclosed. Close
Report a concern

Views

Reviewer Report 16 Feb 2022

Berna Aksoy, Department of Dermatology, Faculty of Medicine, Bahcesehir University, Istanbul, Turkey

Approved

https://doi.org/10.5256/f1000research.121108.r122986

The article is satisfactory ... Continue reading

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Version 1

VERSION 1

PUBLISHED 11 Jan 2022

Views

Reviewer Report 02 Feb 2022

Berna Aksoy, Department of Dermatology, Faculty of Medicine, Bahcesehir University, Istanbul, Turkey

Approved with Reservations

https://doi.org/10.5256/f1000research.79509.r119712

This manuscript evaluates serum hormone levels in women, comparing with a control group. The manuscript evaluated 3 hormones at menstruation period. However, themanuscript needs revision as:

Progesterone 0,5 vs 0,6 may be better analysed by increasing control size, which is too small (175 vs 35). Additionally severe acne vs control group progesterone levels are significantly different. For a better statistical analysis the control group should be nearly half, and I think, therefore, that increasing control size will be meaningful statistically. The same is applicable to progesterone levels.

Acne vulgaris is a term up to age 25, what is the rationale that you choose 30 years? Acne adultorum is supposed to be related to hormonal disturbances. Many acne adultorum patients are stressful working women, there is an increased rate of stress hormones such as prolactin and cortisol. It is better you exclude women over 25.

Estradiol, progesterone and testosterone levels are in fact not enough for hormonal evaluation in women.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

No
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Partly
Are all the source data underlying the results available to ensure full reproducibility?

No source data required
Are the conclusions drawn adequately supported by the results?

No

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Acne

CITE

Report a concern

Author Response 09 Feb 2022

NGUYEN CUONG, Department of Dermatology and Venereology, 103 Military Hospital, Vietnam Military Medical University, HaNoi, 100000, Vietnam

09 Feb 2022

Author Response

1. Progesterone 0,5 vs 0,6 may be better analysed by increasing control size, which is too small (175 vs 35). Additionally severe acne vs control group progesterone levels are significantly ... Continue reading 1. Progesterone 0,5 vs 0,6 may be better analysed by increasing control size, which is too small (175 vs 35). Additionally severe acne vs control group progesterone levels are significantly different. For a better statistical analysis the control group should be nearly half, and I think, therefore, that increasing control size will be meaningful statistically. The same is applicable to progesterone levels.

- This article studied the relationship between acne vulgaris with three degrees of disease and hormone levels. And mild acne was found not in relation to sex hormone disorders. This study tried to find this relationship in the moderate and severe groups, with 35 patients in each group. So we decided to choose the control group of around 35 patients. To be more meaningful statistically, we will increase the number of patients in the control group.

2. Acne vulgaris is a term up to age 25, what is the rationale that you choose 30 years? Acne adultorum is supposed to be related to hormonal disturbances. Many acne adultorum patients are stressful working women, there is an increased rate of stress hormones such as prolactin and cortisol. It is better you exclude women over 25.

Acne that occurs in patients over 25 years old is called post-adolescent acne, and the hormone levels in these patients will be affected by external factors such as stress. And Our study first chooses female acne patients ranging from 16 to 30. When we checked our data and found that patients over 25 years old had no change in my statistical data, we could replace the inclusive criteria field that we chose the patients from 16 to 25 years old.

3. Estradiol, progesterone, and testosterone levels are in fact not enough for hormonal evaluation in women.

- Thank you for your comment. We will consider changing the article to “Assessment of serum testosterone, estradiol, and progesterone levels in female patients with acne”.
1. Progesterone 0,5 vs 0,6 may be better analysed by increasing control size, which is too small (175 vs 35). Additionally severe acne vs control group progesterone levels are significantly different. For a better statistical analysis the control group should be nearly half, and I think, therefore, that increasing control size will be meaningful statistically. The same is applicable to progesterone levels.

- This article studied the relationship between acne vulgaris with three degrees of disease and hormone levels. And mild acne was found not in relation to sex hormone disorders. This study tried to find this relationship in the moderate and severe groups, with 35 patients in each group. So we decided to choose the control group of around 35 patients. To be more meaningful statistically, we will increase the number of patients in the control group.

2. Acne vulgaris is a term up to age 25, what is the rationale that you choose 30 years? Acne adultorum is supposed to be related to hormonal disturbances. Many acne adultorum patients are stressful working women, there is an increased rate of stress hormones such as prolactin and cortisol. It is better you exclude women over 25.

Acne that occurs in patients over 25 years old is called post-adolescent acne, and the hormone levels in these patients will be affected by external factors such as stress. And Our study first chooses female acne patients ranging from 16 to 30. When we checked our data and found that patients over 25 years old had no change in my statistical data, we could replace the inclusive criteria field that we chose the patients from 16 to 25 years old.

3. Estradiol, progesterone, and testosterone levels are in fact not enough for hormonal evaluation in women.

- Thank you for your comment. We will consider changing the article to “Assessment of serum testosterone, estradiol, and progesterone levels in female patients with acne”.
Competing Interests: Author Close
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COMMENTS ON THIS REPORT

Author Response 09 Feb 2022

NGUYEN CUONG, Department of Dermatology and Venereology, 103 Military Hospital, Vietnam Military Medical University, HaNoi, 100000, Vietnam

09 Feb 2022

Author Response

1. Progesterone 0,5 vs 0,6 may be better analysed by increasing control size, which is too small (175 vs 35). Additionally severe acne vs control group progesterone levels are significantly ... Continue reading 1. Progesterone 0,5 vs 0,6 may be better analysed by increasing control size, which is too small (175 vs 35). Additionally severe acne vs control group progesterone levels are significantly different. For a better statistical analysis the control group should be nearly half, and I think, therefore, that increasing control size will be meaningful statistically. The same is applicable to progesterone levels.

- This article studied the relationship between acne vulgaris with three degrees of disease and hormone levels. And mild acne was found not in relation to sex hormone disorders. This study tried to find this relationship in the moderate and severe groups, with 35 patients in each group. So we decided to choose the control group of around 35 patients. To be more meaningful statistically, we will increase the number of patients in the control group.

2. Acne vulgaris is a term up to age 25, what is the rationale that you choose 30 years? Acne adultorum is supposed to be related to hormonal disturbances. Many acne adultorum patients are stressful working women, there is an increased rate of stress hormones such as prolactin and cortisol. It is better you exclude women over 25.

Acne that occurs in patients over 25 years old is called post-adolescent acne, and the hormone levels in these patients will be affected by external factors such as stress. And Our study first chooses female acne patients ranging from 16 to 30. When we checked our data and found that patients over 25 years old had no change in my statistical data, we could replace the inclusive criteria field that we chose the patients from 16 to 25 years old.

3. Estradiol, progesterone, and testosterone levels are in fact not enough for hormonal evaluation in women.

- Thank you for your comment. We will consider changing the article to “Assessment of serum testosterone, estradiol, and progesterone levels in female patients with acne”.
1. Progesterone 0,5 vs 0,6 may be better analysed by increasing control size, which is too small (175 vs 35). Additionally severe acne vs control group progesterone levels are significantly different. For a better statistical analysis the control group should be nearly half, and I think, therefore, that increasing control size will be meaningful statistically. The same is applicable to progesterone levels.

- This article studied the relationship between acne vulgaris with three degrees of disease and hormone levels. And mild acne was found not in relation to sex hormone disorders. This study tried to find this relationship in the moderate and severe groups, with 35 patients in each group. So we decided to choose the control group of around 35 patients. To be more meaningful statistically, we will increase the number of patients in the control group.

2. Acne vulgaris is a term up to age 25, what is the rationale that you choose 30 years? Acne adultorum is supposed to be related to hormonal disturbances. Many acne adultorum patients are stressful working women, there is an increased rate of stress hormones such as prolactin and cortisol. It is better you exclude women over 25.

Acne that occurs in patients over 25 years old is called post-adolescent acne, and the hormone levels in these patients will be affected by external factors such as stress. And Our study first chooses female acne patients ranging from 16 to 30. When we checked our data and found that patients over 25 years old had no change in my statistical data, we could replace the inclusive criteria field that we chose the patients from 16 to 25 years old.

3. Estradiol, progesterone, and testosterone levels are in fact not enough for hormonal evaluation in women.

- Thank you for your comment. We will consider changing the article to “Assessment of serum testosterone, estradiol, and progesterone levels in female patients with acne”.
Competing Interests: Author Close
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Berna Aksoy, Bahcesehir University, Istanbul, Turkey
Jerry Tan, University of Western Ontario, London, Canada
Mohamed Badawy Hassan Tawfik Abdel-Naser, Bawabet Al Hayah Medical Center, Cairo, Egypt
Dalia Rifaat Al-Sharaky, Menoufia University, Shebin El Kom, Egypt

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Reviewer Report

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16 Sep 2024 | for Version 5

Dalia Rifaat Al-Sharaky, Pathology Department, Faculty of Medicine, Menoufia University, Shebin El Kom, Egypt

2 Views Cite this report Responses(0)

Approved With Reservations

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

I cannot comment. A qualified statistician is required.
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

GIT pathology and immunohistochemistry

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Reviewer Report

36 Views

28 Oct 2022 | for Version 4

Mohamed Badawy Hassan Tawfik Abdel-Naser, Bawabet Al Hayah Medical Center, Cairo, Egypt

36 Views Cite this report Responses(1)

Not Approved

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

No
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

No
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

No

References

1. Hedayat K, Lapraz J: Acne: Disorder of luteal androgen management. 2019. 165-183 Publisher Full Text

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No competing interests were disclosed.

Reviewer Expertise

Acne, pigmentary disorders

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Author Response

19 Jan 2023

NGUYEN CUONG, Department of Dermatology and Venereology, 103 Military Hospital, Vietnam Military Medical University, HaNoi, 100000, Vietnam

1. The authors stated that the acne group and the normal control are age-matched. You may kindly avoid this term because they are not matched.

=>Thank you for your valuable comments on your study. As per your opinions, we also recognized the sample sizes of the acne group and control group were asymmetrical. Therefore, we continued to recruit more healthy volunteers to take blood tests. The comparison of age variables between the two groups was shown in a new version.

2. In the title, abstract and material, and methods, the authors used the term "serum"; most importantly they collected sera, whereas in the table and also in the text they used the term "plasma". What is the reason for this?

=>We conducted hormonal evaluation tests with plasma. And we corrected this tissue.

3. In general, several researchers do not recommend the assessment of androgens, LH, etc., in acne patients because of hormonal circadian fluctuation unless there is clinical evidence of hormonal disturbance. There are also several confounding variables. This may provide an explanation for the inconsistent results of hormonal assessment studies that the authors of the present study referred to.¹

=> Some studies show that hormonal alteration has a role in female acne vulgaris. However, there is no strict guideline yet. And hormonal therapies for adult acne treatment were conducted without requiring hormonal abnormalities recently. Therefore, we conducted this study to investigate the hormonal profiles of female acne patients in Vietnam. Our result also partly contributed to the reference hormonal range in acne patients in our country. As literature reviews, plasma salivary hormone levels such as progesterone and estradiol fluctuate during menstrual cycles. To minimize these effects, we took samples at 8 a.m. on the 2-4th day of menses, the early follicular phase of the menstrual cycle, during which plasma hormonal levels remain relatively stable.

4. Another explanation for the inconsistent results is inadequate study design. In the present study authors assessed serum testosterone, estradiol and progesterone in females with acne vulgaris (n=175). Hormones levels were compared with the healthy control (n=35) of similar age. Students' test is used for the comparisons. Clearly, the control group is inadequate as it has an inacceptable large margin of error (roughly 1/√ 35 = 17%). On the other hand, the test group has less margin of error but still large (roughly 1/√175=7.5%). Accordingly, unpaired t test may return erroneous/misleading results. In addition, and considering estradiol as an example, its reference range is 74–532 pmol/L, in the test group the mean + SD is 323.15+93.31 and in the healthy control the mean + SD is 370.94+58.88. Ninety five percent (95%) of the healthy normal population will have estradiol levels in the range of 74-532 pmol/L as previously mentioned. By analogy and in this study, 95% (mean+2 SD) of females with acne have estradiol levels in the range of 136.53 – 509.78 and the healthy control group in the range of 253.15-488.7. Note that these ranges in both acne group and control group are within the normal reference range, i.e., they are normal. Accordingly, the mentioned statistical significance (p<0.05) is of no particular scientific (medical) relevance. The same concept (analysis) can also be applied on all assessed hormones.

=> Thank you for your excellent opinion. As we mentioned above, we focused on analyzing data in female patients with moderate and severe acne vulgaris (70 patients for each group) and then comparing it to the healthy control (70 participants). Although the mean hormonal level was in the normal range, this elevation was statistically significant. It can be explained that androgen bioactivity depends on the amount of plasma hormonal levels and the affinity to specific receptors, the number of receptors, or metabolism in binding sites.

5. The authors stated that 16% (n=28) of females with acne have increased testosterone level but no symptoms or signs of virilism. Was this increase above the upper limit of the lab reference range (6-86 ng/ml) or in comparison with the control group (n=35)?. This is again of no particular relevance not only because the control group is inadequate but also due to possible confounding factors. Based on the aforementioned arguments the provided statistical evaluation is misleading. There are several other similar but complex issues regarding the study design.

=> That’s a valuable finding. We meant that 16% of female acne patients had plasma testosterone levels increase above the normal range.

6. Some of the terms, phrases, and sentences are not easy to comprehend.

=> Thank you for your comment. With the new version, sentences and grammar were checked and re-written to more comprehend. After all, we would like to express our special thanks to you for your valuable comments.

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Reviewer Report

37 Views

08 Mar 2022 | for Version 2

Jerry Tan, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada

37 Views Cite this report Responses(1)

Not Approved

Is the work clearly and accurately presented and does it cite the current literature?

No
Is the study design appropriate and is the work technically sound?

No
Are sufficient details of methods and analysis provided to allow replication by others?

No
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

No

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Acne

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Author Response

04 Apr 2022

NGUYEN CUONG, Department of Dermatology and Venereology, 103 Military Hospital, Vietnam Military Medical University, HaNoi, 100000, Vietnam

We added the inclusion and exclusion criteria in detail for the control and acne groups in the new version of our article.
In the previous article, we based on the acne grading score by Karen Mckoy. This score was not used widely in other studies, and we adjusted and fixed them suitable with the Global Acne Grading System. In our research, a global score of 1-18 signified mild acne, 19‐30 was moderate acne, and a global score > 31 was severe acne.
Some authors found no relationship between hormone disorders and acne in female patients in the literature. And we added the results of these studies and gave our discussion about this difference.

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Reviewer Report

17 Views

16 Feb 2022 | for Version 2

Berna Aksoy, Department of Dermatology, Faculty of Medicine, Bahcesehir University, Istanbul, Turkey

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Approved

The article is satisfactory in its revised form: approved.

Competing Interests

No competing interests were disclosed.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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Reviewer Report

35 Views

02 Feb 2022 | for Version 1

Berna Aksoy, Department of Dermatology, Faculty of Medicine, Bahcesehir University, Istanbul, Turkey

35 Views Cite this report Responses(1)

Approved With Reservations

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

No
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Partly
Are all the source data underlying the results available to ensure full reproducibility?

No source data required
Are the conclusions drawn adequately supported by the results?

No

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Acne

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Responses (1)

Author Response

09 Feb 2022

NGUYEN CUONG, Department of Dermatology and Venereology, 103 Military Hospital, Vietnam Military Medical University, HaNoi, 100000, Vietnam

1. Progesterone 0,5 vs 0,6 may be better analysed by increasing control size, which is too small (175 vs 35). Additionally severe acne vs control group progesterone levels are significantly different. For a better statistical analysis the control group should be nearly half, and I think, therefore, that increasing control size will be meaningful statistically. The same is applicable to progesterone levels.

- This article studied the relationship between acne vulgaris with three degrees of disease and hormone levels. And mild acne was found not in relation to sex hormone disorders. This study tried to find this relationship in the moderate and severe groups, with 35 patients in each group. So we decided to choose the control group of around 35 patients. To be more meaningful statistically, we will increase the number of patients in the control group.

2. Acne vulgaris is a term up to age 25, what is the rationale that you choose 30 years? Acne adultorum is supposed to be related to hormonal disturbances. Many acne adultorum patients are stressful working women, there is an increased rate of stress hormones such as prolactin and cortisol. It is better you exclude women over 25.

Acne that occurs in patients over 25 years old is called post-adolescent acne, and the hormone levels in these patients will be affected by external factors such as stress. And Our study first chooses female acne patients ranging from 16 to 30. When we checked our data and found that patients over 25 years old had no change in my statistical data, we could replace the inclusive criteria field that we chose the patients from 16 to 25 years old.

3. Estradiol, progesterone, and testosterone levels are in fact not enough for hormonal evaluation in women.

- Thank you for your comment. We will consider changing the article to “Assessment of serum testosterone, estradiol, and progesterone levels in female patients with acne”.

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Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

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Assessment of plasma testosterone, estradiol, and progesterone levels in Vietnam female patients with moderate to severe acne vulgaris

Abstract

Keywords

Revised Amendments from Version 4

Introduction

Materials and methods

Acne severity grading

Endocrine evaluation

Data analysis

Results

Table 1. Age and BMI features of acne vulgaris group and control group.

Table 2. Characteristics of female patients with acne vulgaris.

Table 3. Plasma hormonal levels in acne groups and healthy control.

Table 4. Plasma hormonal alterations in female acne patients.

Discussion

Conclusion

Data availability

Underlying data

Ethics approval

Consent to participate

Acknowledgments

References

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