studies that have investigated the relationship between and Lien.

Drafting of the manuscript: Halvorsen and Vleu-

acne and BMI. gels. Critical revision of the manuscript for important in-
Strengths of this study are the many participants and tellectual content: Vleugels, Bjertness, and Lien. Statisti-
the high participation rate, and thus its representative- cal analysis: Halvorsen. Obtained funding: Halvorsen and
ness. An additional strength is the inclusion of relevant Bjertness. Administrative, technical, and material sup-
variables in the adjusted analyses, especially mental dis- port: Halvorsen and Bjertness. Study supervision: Vleu-
tress, which reflects symptoms of depression and anxi- gels, Bjertness, and Lien.
ety, and dietary parameters. In addition; the results in Financial Disclosure: None reported.
both girls and boys were the same when overweight and Funding/Support: This study was supported in part by The
obesity were defined as being above the 85th percentile. University of Oslo and Norwegian Institute of Public
Limitations of the study include the cross-sectional Health, The Regional Center for Child and Adolescent Men-
design, which makes interpretation of causality diffi- tal Health, Eastern and Southern Norway; The University
cult, and the use of self-reported data on BMI and acne, of Oslo and Norwegian Institute of Public Health for Plan-
which can allow for measurement errors. However, the ning, Conducting and Funding of Youth 2004.
acne question used has been previously validated, and Role of the Sponsors: The sponsors had no role in the
the BMI prevalences were similar to findings among 18- design and conduct of the study; in the collection, analy-
year-old adolescents from the United Kingdom and the sis, and interpretation of data; or in the preparation, re-
United States.3,7,8 Another limitation is that there were view, or approval of the manuscript.
no data available on total caloric intake in this popula- Additional Contributions: Florence Dalgard, MD, PhD,
tion. Finally, despite the ability to control for age at men- helped collect data and reviewed the article.
arche, which is known to be related to hormonal status
1. Burton JL, Cunliffe WJ, Stafford I, Shuster S. The prevalence of acne vul-
and development of polycystic ovarian syndrome garis in adolescence. Br J Dermatol. 1971;85(2):119-126.
(PCOS),13 it was not possible to directly control for se- 2. Kilkenny M, Merlin K, Plunkett A, Marks R. The prevalence of common skin
rum hormone levels or for a diagnosis of PCOS, which conditions in Australian school students: 3, acne vulgaris. Br J Dermatol. 1998;
139(5):840-845.
has a known association with acne and obesity in ado- 3. Halvorsen JA, Stern RS, Dalgard F, Thoresen M, Bjertness E, Lien L. Sui-
lescents.13,14 Despite the findings demonstrating a rela- cidal ideation, mental health problems, and social impairment are in-
creased in adolescents with acne: a population-based study. J Invest Dermatol.
tionship between acne and overweight and obesity in girls 2011;131(2):363-370.
aged 18 and 19 years, the study limitations do not allow 4. Spencer EH, Ferdowsian HR, Barnard ND. Diet and acne: a review of the
the straightforward interpretation that obesity causes acne. evidence. Int J Dermatol. 2009;48(4):339-347.
5. Halvorsen JA, Dalgard F, Thoresen M, Bjertness E, Lien L. Is the association
To our knowledge, this is the first population-based between acne and mental distress influenced by diet? results from a cross-
study of acne and BMI in adolescents. Given the impor- sectional population study among 3775 late adolescents in Oslo, Norway.
tance of this common skin problem, along with the in- BMC Public Health. 2009;9:340.
6. Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence and trends in
creasing prevalence of both overweight and obesity in chil- overweight among US children and adolescents, 1999-2000. JAMA. 2002;
dren and adolescents, further exploration is warranted into 288(14):1728-1732.
7. Halvorsen JA, Braae Olesen A, Thoresen M, Holm JO, Bjertness E, Dalgard
the association between BMI and acne in this age group. F. Comparison of self-reported skin complaints with objective skin signs among
adolescents. Acta Derm Venereol. 2008;88(6):573-577.
Jon Anders Halvorsen, MD, PhD 8. Cole TJ, Bellizzi MC, Flegal KM, Dietz WH. Establishing a standard defini-
tion for child overweight and obesity worldwide: international survey. BMJ.
Ruth Ann Vleugels, MD, MPH 2000;320(7244):1240-1243.
Espen Bjertness, PhD 9. World Health Organization. BMI classification. http://apps.who.int/bmi
/index.jsp?introPage=intro_3.html. Accessed February 8, 2010.
Lars Lien, MD, PhD 10. Tsai MC, Chen W, Cheng YW, Wang CY, Chen GY, Hsu TJ. Higher body
mass index is a significant risk factor for acne formation in schoolchildren.
Author Affiliations: Department of Dermatology, Oslo Uni- Eur J Dermatol. 2006;16(3):251-253.
11. Borgia F, Cannavò S, Guarneri F, Cannavò SP, Vaccaro M, Guarneri B.
versity Hospitalet, Faculty of Medicine (Dr Halvorsen), De- Correlation between endocrinological parameters and acne severity in adult
partment of Community Medicine (Drs Halvorsen and women. Acta Derm Venereol. 2004;84(3):201-204.
Bjertness), and Department of Mental Health and Addic- 12. Bourne S, Jacobs A. Observations on acne, seborrhoea, and obesity. Br Med
J. 1956;1(4978):1268-1270.
tion (Dr Lien), University of Oslo, Oslo, Norway; Depart- 13. Rosenfield RL. Clinical review: Identifying children at risk for polycystic ovary
ment of Dermatology, Brigham and Women’s Hospital, and syndrome. J Clin Endocrinol Metab. 2007;92(3):787-796.
Division of Allergy and Immunology, Children’s Hospi- 14. Pfeifer SM, Kives S. Polycystic ovary syndrome in the adolescent. Obstet Gy-
necol Clin North Am. 2009;36(1):129-152.
tal Boston, Harvard Medical School, Boston, Massachu-
setts (Dr Vleugels); Tibet University Medical College, Lhasa,
Tibet (Dr Bjertness); and Department of Research, Hos- COMMENTS AND OPINIONS
pital Innlandet Trust, Brumundal, Norway (Dr Lien).
Correspondence: Dr Halvorsen, Department of Derma-
tology, Oslo University Hospitalet, Faculty of Medicine,
N-0027, Oslo, Norway (j.a.halvorsen@medisin.uio.no or Narrowband UV-B Phototherapy During
jander-h@online.no). Pregnancy and Folic Acid Depletion
Author Contributions: Drs Halvorsen, Bjertness, and Lien
had full access to all of the data in the study and take re-
sponsibility for the integrity of the data and the accu-
racy of the data analysis. Study concept and design:
Halvorsen and Bjertness. Acquisition of data: Bjertness.
Analysis and interpretation of data: Halvorsen, Vleugels,
W e read with interest Zeichner’s1 case report
of acne vulgaris during pregnancy treated
successfully with narrowband UV-B (NB-
UV-B) therapy. Generally, UV-B is considered a safe form
of psoriasis therapy during pregnancy, and this may ap-

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 ply to acne treatment as well. However, it is of utmost Author Affiliations: Department of Dermatology, Uni-
importance not to overlook the photodegradation of fo- versity of California, San Francisco, San Francisco, Cali-
lic acid associated with light therapy. fornia (Drs Park Murase); Department of Dermatology,
Folic acid deficiency is associated with the develop- Palo Alto Foundation Medical Group, Mountain View,
ment of neural tube defects, which complicate 1 in ev- California (Dr Murase).
ery 1000 pregnancies and can be detected early in the Correspondence: Dr Murase, Department of Dermatol-
second trimester. There is new evidence in patients with ogy, Palo Alto Foundation Medical Group, 701 E El
psoriasis that high cumulative NB-UV-B doses cause a Camino Real (31-104), Mountain View, CA 94040
proportionate decrease in serum folic acid levels (ⱖ118.16 (jemurase@gmail.com).
J/cm2 in 36 treatments).2 Previous studies found insig- Financial Disclosure: None reported.
nificant decreases in serum folic acid; however, these stud-
1. Zeichner JA. Narrowband UV-B phototherapy for the treatment of acne vul-
ies had smaller numbers of treatments and had lower total garis during pregnancy. Arch Dermatol. 2011;147(5):537-539.
cumulative doses (6.9 J/cm2 in 9-15 sessions in 19 pa- 2. El-Saie LT, Rabie AR, Kamel MI, Seddeik AK, Elsaie ML. Effect of narrow-
tients; 2.3 J/cm2 in 18-20 treatments in 35 patients).2 Fur- band ultraviolet B phototherapy on serum folic acid levels in patients with
psoriasis. Lasers Med Sci. 2011;26(4):481-485.
thermore, a more recent pilot study found that patients’ 3. Juzeniene A, Stokke KT, Thune P, Moan J. Pilot study of folate status in healthy
folic acid levels decreased after broadband UV-B therapy volunteers and in patients with psoriasis before and after UV exposure. J Pho-
tochem Photobiol B. 2010;101(2):111-116.
(110-220 mJ/cm2 in 7-22 treatments).3 In addition, there 4. Lapunzina P. Ultraviolet light-related neural tube defects? Am J Med Genet.
was a case report in Buenos Aires of 3 unrelated patients 1996;67(1):106.
who had sunbed exposure in early pregnancy; their in- 5. Murase JE, Koo JY, Berger TG. Narrowband ultraviolet B phototherapy in-
fluences serum folate levels in patients with vitiligo. J Am Acad Dermatol. 2010;
fants all developed neural tube defects, which may have 62(4):710-711.
resulted from folic acid depletion.4 6. DUSA Pharmaceuticals Inc. Light dose ranging study of photodynamic
To address this practice gap, dermatologists should therapy (PDT) with levulan ⫹ blue light versus vehicle ⫹ blue light in
severe facial acne. http://www.clinicaltrials.gov/ct2/show/results/NCT00706433
consider measuring folic acid levels periodically or con- ?term=DUSA+Pharmaceuticals&rank=1. Accessed August 30, 2011.
sulting with the patient’s obstetrician to determine ap-
propriate folic acid supplementation in their pregnant
UV-B phototherapy patients, particularly during the first
trimester. In female patients undergoing phototherapy
Interferon-␥ Release Assay
who may become pregnant or who are planning a preg-
nancy, folic acid supplementation should be encour-
aged. In a normal pregnancy, about 0.5 mg/d of folic acid
is recommended. High-risk patients can take as much as
4 to 5 mg/d, but it is necessary to rule out vitamin B12
deficiency when prescribing over 1 mg/d.5
R eaders of a recent article published in the Ar-
chives about the usefulness of an interferon-␥
release assay in diagnosing erythema indura-
tum1 might like to put that work in historical and tech-
nical perspective. Many years ago, a medical student
Interestingly, patients with fairer skin types tend to
experience decreased folic acid levels after UV expo- (L.M.M.), wondering why lymphocytes infiltrated vi-
sure. Pigment in darker skin types may also confer pro- rus-infected tissues, teamed up with an immunologist
tection against the photolysis of folic acid. Because the (B.H.W.) working in the emerging field of lympho-
patient in Zeichner’s1 case report had type III skin, fo- kines. They hypothesized that sensitized lymphocytes
late supplementation might have been less of a concern. challenged by a specific antigen might release an inhibi-
Furthermore, Zeichner1 mentions several other light- tor of viral replication. Since tuberculin reactivity was a
based therapies for acne and comments on the lack of standard (and nonviral) manifestation of delayed-type
reliable randomized controlled trials for these thera- hypersensitivity, they took lymphocytes from mice im-
pies. Blue light (BLU-U; DUSA Pharmaceuticals Inc) is munized with PPD (purified protein derivative, used in
approved by the US Food and Drug Administration for tuberculosis skin testing), challenged them in vitro
the treatment of moderate inflammatory acne vulgaris. with PPD, and found that those lymphocytes secreted
A phase 2 randomized, controlled, investigator- an inhibitor of vesicular stomatitis virus growth.2 That
blinded, clinical trial of moderate to severe facial acne secreted inhibitor eventually became known as inter-
in 266 patients was previously performed, but the data feron-␥, and the basics of that original test have been re-
remain unpublished.6 The objective was to determine the capitulated in several interferon-␥ release assays for tu-
safety and efficacy of blue light monotherapy compared berculosis.3
with combination blue light and aminolevulinic acid Leonard M. Milstone, MD
therapy. Both the blue light monotherapy and combina- Byron H. Waksman, MD
tion groups demonstrated a statistically significant re-
duction in the number of inflammatory lesions (41.7% Author Affiliations: Department of Dermatology, Yale
and 37.5%, respectively) (P ⬍.001 for both). This study University School of Medicine, New Haven, Connecti-
further reinforces the author’s suggestion that different cut (Dr Milstone). Dr Waksman retired, formerly affili-
forms of light therapy may be helpful in treating acne dur- ated with Yale University School of Medicine.
ing pregnancy, when other forms of therapy may be con- Correspondence: Dr Milstone, Department of Derma-
traindicated. tology, Yale University School of Medicine, PO Box
208059, New Haven, CT 06520 (leonard.milstone@yale
Kelly K. Park, MD .edu).
Jenny E. Murase, MD Financial Disclosure: None reported.

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