EFFECT OF MILK AND DAIRY PRODUCTS CONSUMPTION ON ACNE RISK AND SEVERITY IN YOUNG ADULT PATIENTS WITH ACNE VULGARIS ATTENDING THE DERMATOLOGY CLINICS AT KING FAHD HOSPITAL OF THE UNIVERSITY IN ALKHOBAR , SAUDI ARABIA ©

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Methods
This is a case control study using interview questionnaire conducted at the dermatology clinics at King Fahd Hospital of the University in Alkhobar, Saudi Arabia during a period of one year (March 2015-April 2016). After acquiring the Institutional Review Board approval (license number IRB-2015-01-064) the study was initiated. All the information from the questionnaire was kept confidential. Written informed consent was taken before the respondent involvement in the study. Variable were adapted from previous study [5] and shown in Table 1. A total of 100 (27 male, 73 female) participants were involved in the study (50 cases and 50 controls). Our inclusion criteria was all adolescent and young adult patients (age 12-25 years) diagnosed with acne vulgaris at KFHU. Exclusion criteria included the presence of other medical conditions such poly cystic ovarian syndrome, Cushing syndrome, acne rosacea, steroid intake and incompletely answered questionnaire. Participants were interviewed using a food frequency questionnaire and asked how frequently they used a typical portion size of specified foods during the past 6 months, types of milk that was consumed and if they consumed other type of food with high glycemic index (Table 1). Clinical examination to assess the severity of acne was done by a dermatologist using the global acne grading system (Table 2).
Anthropometric measurements was taken using Seca digital scale with height rod. The raw data was processed and entered for data analysis as soon as it was collected from the participants. The collected data was entered into SPSS (Statistical Package for Social Sciences) version 16.0 for analysis. Descriptive statistics were reported using frequency and percentages for all categorical variables, and for continuous variables Mean± S. D were used for normally distributed data and median and interquartile range for skewed data. Chi-square test or a fisher's exact tests for categorical data were used to assess the association of the explanatory variables with cases and controls. Independent sample t test for con- tinuous data and Mann-Whitney U Test for skewed data were used to compare the difference in the explanatory variables between cases and control. Univariate logistic regression of all significant factors from the associations test were performed, followed by a multivariate logistic regression analysis on the all significant risk factors.

Results
There was similar gender distribution between the cases and controls. Their ages varied between 13 to 25 years. However, there was a statistically significant difference in the age, between the cases and the controls (p=0.005) showing that cases group had younger ages than the controls. In other words, the mean age of females in the case group was (20.5±3.2) which is significantly lower as compared to female in the control group (22.4±2.2) (p=0.004). No statistically significant difference (p<0.05) between the cases and control groups in weight body mass index and height for both sexes.
After adjusting for other predictors, the risk of acne increased with increasing age; OR (odds ratio) =1.39; 95 % CI (confidence interval: 1.14-1.68) (p=0.001). In case the subject consumes French fries, there is a fivefold greater risk for acne (OR=4.60; 95 % CI: 1.21-17.51) (p=0.025). If butter is consumed more than once a week the risk for acne increased (OR=3.76; 95 % CI: 1.21-11.62) (p=0.022). No statistically significant difference (P<0.05) was found between the severity of acne with all the dietary factors for the cases except for consumption of milk (p=0.033) ( Table 3). Table 3 The statistical significance between acne severity and dietary factors  Table 3 6. Discussion This case control study was conducted at the dermatology clinics at King Fahd Hospital of the University in Alkhobar, Saudi Arabia for a period of one year starting March 2015 to April 2016 to assess the relation between dairy products consumption and acne risk and severity in young adult patients with acne using interview questionnaires. After adjusting for other predictors, the risk of acne increased with increasing age (OR=1.39; 95 % CI: 1.14-1.68) (p=0.001). There was no statistically significant difference (P<0.05) found between the severity of acne with all the dietary factors including chocolate milk, ice cream, yogurt, halloumi cheese, cream cheese, hard cheese, milk shake, butter, type of milk, french fries, pizza, chocolate, rice, white bread except for consumption of milk which was χ 2 (3, 50)=8.479 (p=0.033). This contradicts the findings in other similar studies done in the world who found a strong correlation between milk and dairy product consumption and the risk of acne development [3,[5][6][7][8][9][10]. However, butter, rice and french fries were positively associated with increased risk for acne. Specifically patients consuming french fries had a fivefold greater risk (OR=4.60; 95 % CI: 1.21-17.51) (p=0.025) for acne compared to the controls. Pathophysiologically, milk consumption significantly elevates insulin and IGF-1 (Insulin growth factor 1 ) levels and decreases IG-FBP-3 levels [11]. it also contains bovine IGF-1, which is identical to human IGF-1 and binds with the same affinity to its receptor [12]. Increased insulin and IGF-1 signaling promote comedogenesis, sebaceous lipogenesis, follicular inflammation, and androgenic stimulation [13]. Milk also contains dihydrotestosterone precursors, including placenta-derived progesterone, 5a-pregnanedione, 5a-androstanedione, and numerous growth-related factors which in turn aggrevate acne [14]. Only the frequency of milk consumption was positively associated with acne severity while the type of milk made no statistically significant difference. This is partially similar to the findings in the Egyptian study done by saleh et al on a 100 acne patients assessing the relationship between the dietary intake of acne patients and acne severity [15]. The most notable limitations of this study were the retrospective self-reported dairy product consumption and data was not adjusted for some important confounding variables (such as stress, inadequate sleep, smoking, family history of acne). There are multiple randomized controlled trials that have shown the benefit of a low glycemic index/glycemic load diet in treating acne so this diet may be recommended to patients [16 -19]. While observational studies support the link between milk and acne, multiple randomized controlled trial are required before milk restriction diets can be recommended to acne patients.

Conclusion
1. Dairy products consumption does not seem to influence or aggravate acne development in our young adults who were Saudis except for milk.
2. Randomized controlled trials are highly recommended to establish a causal relationship between frequent milk consumption and acne severity and to assess the role of medical nutrition therapy (MNT) in acne management.
3. A practical approach is to address each acne patient individually and consider the possibility of dietary counseling.  Table 3 Scientific Journal «ScienceRise: Medical Science» № 4(12)2017