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ORIGINAL ARTICLE
The role of exposome in acne: results from an international
patient survey
B. Dreno,
1,
* J. Shourick,
2
D. Kerob,
3
A. Bouloc,
4
C. Ta
€
ıeb
5,6
1
Department of Dermato-Cancerology, CHU Nantes-H^
otel-Dieu CRCINA, Inserm 1232, CIC 1413, University of Nantes, Nantes,
France
2
Bio Informatics/statistics, University of Paris Sud, Paris, France
3
Vichy Laboratoire Internationale, Levallois-Perret, France
4
Private Practice, Paris, France
5
EMMA, Fontenay-sous-Bois, France
6
Sant
e Publique, CHU Necker-Enfants malades, Paris, France
*Correspondence: B. Dreno. E-mail: brigitte.dreno@atlanmed.fr
Abstract
Background Acne severity and its response to treatment may be influenced by internal and external factors: the
exposome.
Objectives The aim of this international real-life survey was to assess the most involved exposome factors in acne.
Methods Eleven thousand individuals, aged between 15 and 39 years, with clinically confirmed acne or without acne,
defined by age, gender and prevalence, were invited to participate in an Internet survey of 63 questions in order to
assess the frequency of identified acne exposome factors.
Results Data from 6679 questionnaires were used for statistical analysis purposes: 2826 from the acne group and
3853 from the control group. Nibbling, consumption of dairy products, sweets, alcohol or whey proteins, as well as expo-
sure to pollution, stress, certain mechanical factors and humid or hot weather or sun exposure, were significantly (all
P≤0.05) more frequently reported for the acne group than for the control group. This was not the case for tobacco con-
sumption. Data regarding the impact of cannabis consumption were insufficient for drawing any conclusions.
Conclusions Data from this international, anonymized Internet questionnaire conducted with more than almost 6700
participants add new arguments to assumptions made that certain exposome factors have an impact on acne. Nutrition,
pollution, stress and harsh skincare, as well as climate and sun exposure may be considered the most frequent factors
related to acne.
Received: 17 October 2019; Accepted: 13 November 2019
Conflict of interest
The authors have no conflict of interest to disclose.
Funding source
The study was financially supported by Vichy Laboratoire, France.
Introduction
Acne is inflammatory disease of the pilosebaceous follicle occur-
ring commonly in adolescents and sometimes in adults. It is
associated with hyperseborrhoea altering the epithelium of the
follicle with formation of comedones, a modification of the
microbiote called dysbiosis targeting mainly Propionibacterium
acnes (P. acnes) causing an activation of the innate immunity
and thus inflammation.
1
Skin is one of the major interfaces between the body and the
external environment and is one of the main routes for the pene-
tration of pathogens into the body.
2
The primary role of the skin
is to serve as a physical barrier, protecting our body from
potential assault from foreign organisms, toxic substances or any
other external physical, chemical or organic factors.
2,3
The term ‘exposome’ describes the sum of environmental
and internal exposures to which an individual is subjected
from conception to death.
4
The definition of exposome has
varied over time.
4–8
In 2017, a study evaluated the impact of
exposome on skin ageing for the first time and proposed the
following exposome categories: sun radiation [ultraviolet
(UV) radiation, visible light and infrared radiation], air pol-
lution, tobacco smoke, nutrition, a number of less well stud-
ied, miscellaneous factors, as well as cosmetic products and
aesthetic procedures.
9
©2019 European Academy of Dermatology and VenereologyJEADV 2020, 34, 1057–1064
DOI: 10.1111/jdv.16119 JEADV
In 2018, Dr
eno et al.
10
analysed the potential role of expo-
some in acne by means of a literature review. According to the
literature studied, nutrition, medication, occupational factors,
pollutants, weather factors as well as psychosocial and lifestyle
factors impact the course and severity of the disease and treat-
ment efficacy. Moreover, the authors pointed out that external
exposome factors act on the natural skin barrier and on the skin
microbiota, resulting in increased sebum production, hyperkera-
tinisation, modification of the microbiote and activation of the
innate immunity, resulting in the exacerbation of acne.
11,12
They
concluded that identifying the most frequent exposome factors
that trigger acne and reducing their impact is mandatory for
adequate acne management.
The aim of the present large international real-life survey was
to confirm from a patient prospect, the influence of the most
frequent internal and external exposome factors involved in acne
described by Dreno et al.
10
Methodology
This international, anonymized survey was conducted between
December 2018 and January 2019 via Internet in France, Ger-
many, Italy, Brazil, Canada and Russia, with 11 000 participants
with clinically confirmed acne or without acne (control group)
and who agreed to participate in Internet surveys. The acne
group was defined as the individuals with clinically diagnosed
acne through auto-questioning: subjects had to confirm that
their acne was clinically confirmed by a physician. Moreover,
individuals had to confirm that they used a prescribed acne
treatment or a recommended acne care at the time the question-
naire was completed.
The survey was conducted by means of local databases of
Internet users who agreed to participate in surveys. It com-
plied with local data protection laws and did not require inde-
pendent review board or independent ethics committee
approvals. Participants did not provide written informed con-
sent for participation. The survey was comprised of 63 ques-
tions and was compiled by the authors, based on the article
by Dr
eno et al.
10
It assessed age, gender, socio-economic fea-
tures, skin types, presence of acne and current acne treatment,
as well as 6 internal and external exposome factors (nutrition
and nutritional supplements, occupational factors, medica-
tions, pollutants, psychosocial and modern lifestyle factors,
weather conditions) as defined by Dr
eno et al.
10
; the different
chapters of the survey are presented in Table 1. A modified
version of a previously used algorithm to define the two study
groups was applied.
13
Briefly, a polling institute (H. Chevalier
Conseil, Paris France, supported by Quantar Health Care,
Paris, France, both specialized in the conduct of health-related
surveys) conducted the survey. A sample of the target study
population aged 15–39 years in both groups was recruited
using the stratified random sampling method. Based on local
databases of Internet users, fixed quotas of subjects fulfilling
predefined criteria were recruited. Drawing on national popu-
lation data, these quotas were based on the following aspects:
age, gender and acne prevalence, thereby ensuring the accurate
representation of the sample population and the same repre-
sentation in the acne and control groups.
Statistical analyses were performed using R software version
3.5.1 (The R Project for Statistical Computing, The R Founda-
tion, Vienna, Austria).
Data concerning individuals between 15 and 39 years of age
were extracted from the survey database. Quantitative variables
were expressed as means and standard deviations. Qualitative
variables were expressed as frequencies and percentages. Com-
parisons between both groups were performed using the Wil-
coxon test in the case of quantitative variables; for categorical
variables, intergroup comparisons were carried out with the chi-
squared test. The level of significance was set at 5%. Each vari-
able was evaluated in a univariate analysis adjusted for age, in
order to identify factors associated with acne. Then, all variables
associated with acne at a probability threshold of 0.1 were
entered into a multiple logistic regression analysis. With this
model, variables were retained in a stepwise manner in order to
determine those variables that were independently associated
with acne at a probability threshold of 0.05. Odds ratios (OR)
were consequently generated.
Results
Demographic and socio-economic data
In total, 11 000 individuals participated in the survey and data
from 6679 were usable for statistical analysis purposes: 2826
(42.3%) in the acne group and 3853 (57.7%) in the control
group. The remaining 4321 questionnaires were incomplete,
started, but not validated, or were completed but not validated
by the users. Mean age, gender distribution and phototype were
similar in both groups; the body mass index (BMI) was signifi-
cantly higher (P<0.001) in participants with acne (24.90) than
in those without acne (23.99). Details regarding patient demo-
graphics are provided in Table 2.
Table 1 Survey structure
1 Introduction
2 Screening
3 Quotas et socio-economic information
4 Phototype
5 Nutrition and nutritional supplements
6 Occupational factors: cosmetics and mechanical factors
7 Medications: contraception, anabolic steroids testosterone
8 Pollutants: industrial and air pollutants, tobacco, cannabis and alco-
hol consumption
9 Psychosocial and modern lifestyle factors: stress, emotions, sleep
deprivation, socio-economic pressures, excessive artificial light
exposure (tablets, smartphones, computers)
10 Weather conditions: heat, humidity, ultraviolet radiation
©2019 European Academy of Dermatology and VenereologyJEADV 2020, 34, 1057–1064
1058 Dreno et al.
Nutrition and nutritional supplements
The data analysis regarding nutrition and nutritional supple-
ments showed that significantly more (P<0.001) individuals
with acne (48.2%, 1362/2826) consumed dairy products on a
daily basis compared to individuals who did not (38.8%, 1494/
3853). The difference was also statistically significant (all
P<0.001) for soft drinks, fruit juices or syrups, pastry, choco-
late and sweets.
Significantly more (P<0.001) participants in the acne group
(61.9%, 1748/2826) than in the non-acne group (43.2%, 1665/
3853) reported frequent and regular nibbling during the
12 months preceding the survey and significantly more
(P<0.001) individuals in the acne (11.0%, 311/2826) than in the
acne-free group (7.3%, 281/3853) reported the regular consump-
tion of whey proteins during the 12 months preceding the survey.
Probiotic consumption was significantly (P<0.001) higher
in individuals with acne (16.4%, 464/2826) than in acne-free
individuals (5.2%, 202/3853).
Detailed results including OR are provided in Fig. 1.
Medication
The use of contraceptives was significantly higher (P<0.001) in
individuals with acne (39.0%, 677/1746) than in acne-free indi-
viduals (30.5%, 743/2436). Oral contraceptives were perceived as
reducing acne in 42.7% (286/677) of individuals with acne, while
26.5% (247/677) declared that they had no influence on their
acne. 20.8% (141/677) declared that they increased their acne.
In acne-free individuals, a large majority (79.5%) declared
that their contraception had no influence on their skin.
Three times more individuals with acne (12.0%, 338/2826)
than acne-free individuals (3.8%, 122/3853) declared the regular
use of anabolic drugs during the 12 months preceding the sur-
vey, the difference was statistically significant (P<0.001).
Significantly more (P<0.001) individuals with acne than
without reported the intake of anti-depressants, anti-epileptics
or corticoids.
Table 3 provides detailed results.
Occupational factors
More than one-third of individuals with acne (35.4%, 999/2826)
compared to 16.7% (645/3 853) without used an electric brush
to clean their face (P<0.001; the OR was: 0.44, CI 95%: (0.39;
0.48), P<0.0001].
Significantly more (P<0.001) individuals with acne (56.5%,
1596/2826) than those without (36.3%, 1397/3853) applied
essential or plant oils to their face and 71.05% (2008/2826) of
the first group compared to 43.2% (1664/3853) of the latter
declared using scrubs [OR: 4.99, CI 95%: (4.28; 5.81),
P<0.0001] or peelings [57.8%, 1633/2826 vs 33.1%, 1275/3853;
OR: 3.35, CI 95%: (2.95; 3.81), P<0.0001] at least or even daily
on their face. Differences were all statistically significant
(P<0.001).
Pollutants
Significantly more (P<0.001) individuals with acne than acne-
free individuals reported living close to an airport (10.9%, 308/
2826 vs 7.2%, 276/3853), to an industrial site (15.6%, 428/2826
vs 9.9%, 380/3853) or to cultivated land (21.2%, 598/2826 vs
Table 2 Demographic and socio-economic data
Without acne
n=3853
With acne
n=2826
P-value
Gender (n,%)
Female (n, %) 2436 63.22 1746 61.78 0.26
Male (n, %) 1417 36.78 1080 38.22
Age (years SD) 25.73 7.26 25.47 7.42 NS
Distribution according to age
15–19 years (n, %) 705 24.9% 1127 29.2% <0.001
20–24 years (n, %) 863 30.5% 1127 29.2%
25–39 years (n, %) 1258 44.5% 1599 41.5%
Weight (kg) 67.93 18.32 69.21 16.02 NS
Body Mass Index 24.90 23.99 <0.001
Socio-economic category
Upper category (n, %) 969 34.3% 1021 26.5% <0.001
Lower category (n, %) 1181 41.8% 1659 43.1%
Unemployed (n, %) 676 23.9% 1173 30.4%
Residence (n,%)
Urban (n, %) 1668 59.0% 1874 48.6% <0.001
Suburban. mid-size town (n, %) 691 24.5% 957 24.8%
Countryside, small-size town (n, %) 467 16.5% 1022 26.5%
NS, not significant.
©2019 European Academy of Dermatology and VenereologyJEADV 2020, 34, 1057–1064
The role of exposome in acne 1059
19.21%, 740/3853). A large majority of individuals with acne
compared to those without were exposed significantly more
often to tar (9.3%, 262/2826 vs 2.3%, 164/3853; P<0.001),
solvent emanation and crude oil (10.7%, 301/2826 vs 4.7%,
182/3853) or oil emanation (13.1%, 371/2826 vs 7.8%, 301/
3853). A statistically significant difference (P<0.001) for
anthropic pollutants (tobacco, cannabis or alcohol consump-
tion) between both groups was only shown for alcohol con-
sumption: (56.5%, 1597/2826 vs 43.0%, 1656/3853). No
significant difference was shown for tobacco consumption. Due
to legal restrictions in certain countries concerning cannabis
consumption, the available sample size of individuals consum-
ing cannabis was insufficient for making any statistically vali-
dated observation.
Detailed results for all sub-factors including OR are provided
in Table 4.
Psychosocial and modern lifestyle
When rating the level of stress on a visual analogue scale ranging
from 0 (none) to 10 (very high), a significantly higher
(P<0.001) mean score was observed in individuals with acne
(5.9 2.3) compared to those without (5.0 2.7).
The prevalence of individuals suffering from important and
extremely high-stress levels was significantly higher (P<0.001)
in individuals with acne (51.0%, 1440/2826) than in acne-free
individuals (29.0%, 1118/3853).
Significantly more (P<0.001) individuals with acne (54.6%,
1542/2826) than without (47.6%, 1834/3853) reported lacking
sleep and significantly more (P<0.001) individuals without
acne (52.4%, 2020/3853) than those with (50.3%, 1420/2826)
reported restful sleep.
In both groups, the exposure to screens and tablets just before
falling asleep was reported by a large majority of individuals with
significantly more individuals (P<0.001) in the acne (91.3%,
2580/2826) than in the acne-free group (85.2%, 3281/3853).
Detailed results including OR are provided in Table 5.
Weather factors
There was no significant difference in prevalence of individuals
with or without acne living in temperate or cold regions. Con-
versely, acne was significantly more frequent in hot [24.6% (696/
2826) vs 17.1% (659/3853)] or humid regions [13.0% (367/2826)
vs 11.5% (442/3853); P<0.001 and P<0.03, respectively].
Acne was significantly (P<0.01) more frequent in individu-
als with moderate or intensive sun exposure due to their work or
daily activities [42.8% (1208/2826) vs 31.6% (1216/3853)].
Details are given in Table 6.
Discussion
Data from this international, anonymized Internet questionnaire
conducted with almost 6700 participants add new arguments to
assumptions made that certain exposome factors have an impact
on acne.
The survey showed that significantly more individuals with
acne live in an urban area have an upper socio-economic cate-
gory and a significantly higher BMI (all P<0.001).
Nibbling and the consumption of dairy products, sweets,
alcohol or whey proteins were reported significantly more often
38.80%
48.20%
31.00%
35.60%
28.60%
39.90%
27.80%
37.00%
19.10%
29.70%
43.20%
61.90%
7.30%
11.00%
5.20%
16.40%
Consumption of probiotics
OR 1.65 [1.44;1.89], P <0.0001
Consumption of whey protein
OR 3.94 [3.29;4.71], P <0.0001
Consumption of sweets
OR 0.47 [0.42;0.52], P <0.0001
Consumption of chocolate
OR 1.79 [1.62;1.7], P <0.0001
Consumption of sodas juices or syrups
OR 1.66 [1.5;1.84], P <0.0001
Daily consumption of dairy products
OR 1.21 [1.1;1.35], P <0.0001
Consumption of pastry
OR 1.52 [1.38;1.69], P <0.0001
Nibbling: frequency and regurlarly
OR 3.57 [3.0;4.25], P <0.0001
0 10 20304050 6070
Percentage (%)
Figure 1 Impact of nutrition and nutritional supplements during the 12 months preceding the survey. OR, odds ratio, (confidence
interval) 95%, P=P-value.
©2019 European Academy of Dermatology and VenereologyJEADV 2020, 34, 1057–1064
1060 Dreno et al.
(all P≤0.05) by individuals with acne and confirmed observa-
tions previously made.
14–36
Not surprisingly, the intake of probi-
otics was significantly (P<0.001) higher in individuals with
acne. This may be due to the fact that probiotics are becoming
more and more popular and that their use is encouraged more
and more via social networks and Internet blogs than by derma-
tologists or other physicians, even though promising study
results exist.
37,38
The survey further confirms that individuals with acne con-
sider that oral contraception significantly reduces their acne
(P<0.001). Despite this, almost 21% of individuals in this
group reported that they consider that their contraception had
worsened their acne. This observation may be explained by the
use of 1st or 2nd generation contraceptive pills, a phenomenon
already described in 2016 by Leclerc-Mercier et al.
39
and who
also reported that the use of 3rd or 4th generation contraceptive
pills improve acne as these contraceptives contain the most often
low or non-androgenic progestin (desogestrel, gestodene) not
activating the androgen receptors of sebaceous glands and even
blocking this receptor for certain HCPs. However, we were not
able to confirm this allegation using the data collected.
Moreover, three times more individuals with acne regularly used
anabolic steroids, indirectly confirming scientific data suggesting
an acne-stimulating action of these molecules.
40–42
Use of cer-
tain other medications, such as anti-depressants, anti-epileptics
or corticoids, was more frequently observed in individuals with
acne, confirming their role in the induction of acne-like lesions,
according to Dr
eno et al.
10
According to the participants, hot and humid climates, as well
as sun exposure, play a significant role in acne. These findings
confirm observations made in the past and also very recently by
Narang et al.
43–47
One of the lipids produced by human seba-
ceous glands on the face and torso is squalene. This unsaturated
fatty acid represents ~10–15% of sebum and is readily oxidized by
ozone, long UV rays and tobacco smoke.
48
These oxidized sebum
lipids cause keratinocyte hyperproliferation and inflammatory
cytokine release, leading ultimately to the onset or worsening of
acne. However, in acne, the association between sebum oxidation
and comedogenesis has not been investigated thoroughly.
49
The survey also confirmed that exposure to pollution or to
stress and to certain mechanical factors, such as the use of a
dermo-roller or harsh cleansing of the face, is more frequently
Table 3 Impact of medication
Without acne
n=2436
With acne
n=1746
P-value
Use of oral contraceptive (n,%) 743 30.5 677 39.0 <0.001
The oral contraceptive n=187 n=677
Increased acne (n, %) 0 0 141 20.8
Reduced acne (n, %) 0 0 289 42.7
Impact (n, %) 187 4.6 247 36.5
The contraceptive had an impact on the skin n=741 n=430
Yes (n, %) 150 20.2 141 20.8
No (n, %) 591 79.5 289 42.7
Intake of a hormonal treatment based on
steroids or testosterone during the last 12
months (n,%)
n=3853 n=2826
122 3.2 338 12.0 <0.001
OR 3.03
CI 95% (2.27; 4.03)
P-value <0.0001
Intake during the last 12 months of (n,%)
An antidepressant 338 8.8 472 16.7 <0.001
OR 0.35
CI 95% (0.3; 0.42)
P-value <0.0001
An antiepileptic 71 1.8 153 5.4 <0.001
OR 3.93
CI 95% (3.17; 4.88)
P-value <0.0001
Oral or IV Corticodes 120 3.1 319 11.3 <0.001
OR 4.9
CI 95% (3.54; 6.79)
P-value <0.0001
CI, confidence interval; IV, intravenous; OR, odd ratio.
©2019 European Academy of Dermatology and VenereologyJEADV 2020, 34, 1057–1064
The role of exposome in acne 1061
observed in individuals with acne.
48,50–58
It did not confirm the
link between acne and tobacco, thereby endorsing the data of
the literature with divergent results reported in a recent paper
with by Wolkenstein et al.
13,59
Due to legal constraints concerning the consumption of can-
nabis in certain countries, we were unable to assess the link of
cannabis consumption in a sufficiently large study population,
thereby not providing any conclusions.
Table 4 Impact of pollution factors
Without acne
n=3853
With acne
n=2826
P-value
Lives close to
An airport (n, %) 276 7.2 308 11.0 <0.001
OR (CI 95%) P-value 0.37 (0.33; 0.41) <0.0001
An industry facility (n, %) 380 9.9 428 15.2 <0.001
OR (CI 95%) P-value 1.58 (1.33; 1.87) <0.0001
Cultivated land (n, %) 740 19.2 598 21.2 <0.001
OR (CI 95%) P-value 1.63 (1.4; 1.89) <0.0001
Exposure during work to
Tar (n, %) 164 4.3 262 9.3 <0.001
OR (CI 95%) P-value 1.44 (1.31; 1.59) <0.0001
Solvent emanations, crude oil (n, %) 182 4.7 301 10.7 <0.001
OR (CI 95%) P-value 2.29 (1.87; 2.81) <0.0001
Oil emanations (n, %) 301 7.8 371 13.1 <0.001
OR (CI 95%) P-value 2.39 (1.97; 2.89) <0.0001
Tobacco consumption
Does not smoke (n, %) 2722 70.7 2033 71.9 <0.001
Smokes occasionally or daily (n, %) 1131 29.4 793 28.1
OR (CI 95%) P-value 4.14 (3.35; 5.13) <0.0001
Alcohol consumption (n,%) N= 3853 N= 2826
1656 43.0 1597 56.5 <0.001
OR (CI 95%) P-value 1.34 (1.05; 1.7) <0.0001
Cannabis consumption (n,%) N= 1016 N= 740
169 16.6 156 21.1 NS
CI, confidence interval; NS, not significant; OR, odd ratio.
Table 5 Impact of psychosocial and modern lifestyle factors
Without acne
n=3853
With acne
n=2826
P-value
Stress felt
Score expressed on VAS (meanSD) 5 2.7 5.9 2.3 <0.001
OR (CI 95%) P-value 1.78 (1.52; 2.09) <0.0001
Stress felt
No or moderate stress (n, %) 2735 18.9 1386 12.1 <0.001
Important or extreme stress (n, %) 1118 29.0 1440 51.0
OR (CI 95%) P-value 1.15 (1.12; 1.17) <0.0001
Lacking sleep (n, %) 1834 47.6 1542 54.6 <0.001
OR (CI 95%) P-value 1.79 (1.62–1.98) <0.0001
Repairing sleep (n,%)
Yes 2020 52.4 1420 50.3 <0.001
No 1833 47.6 1406 49.8
OR (CI 95%) P-value 1.33 (1.21–1.47) <0.0001
Looking at a screen/tablet the hour before falling asleep
Several times per week or every evening (n, %) 3281 85.2 2580 91.3 <0.001
Rarely or never (n, %) 572 14.9 246 8.7
OR (CI 95%) P-value 1.83 (1.56–2.14) <0.0001
CI, confidence interval; OR, odd ratio; VAS, visual analogue scale (0–10).
©2019 European Academy of Dermatology and VenereologyJEADV 2020, 34, 1057–1064
1062 Dreno et al.
Our study has several limitations. Patients reported themselves
that they suffered from acne. Even though the questionnaire
requested that acne had to be confirmed by a clinician prior to
participation, the design of the study, using an anonymous Inter-
net questionnaire did not allow to confirm the inclusion criteria.
Thus potentially, patients with rosacea, erythema or other acne-
like conditions could have participated. Moreover, products used
to manage their acne might not have been described or recom-
mended by a physician. Despite these limitations and the poten-
tial bias due to the Internet study design, our results confirm for
the first time and on a large international level, assumptions
made and presented by Dr
eno et al. in 2018.
10
Our data confirm that among the questioned internal and
external exposome factors, nutrition, pollution, stress, harsh
skincare, temperature, humidity and sun exposure had a signifi-
cant impact on acne, thereby confirming published results and
allegations, our methodological approach and that a holistic
approach is necessary for the efficient management of acne.
Acknowledgements
The authors acknowledge the participants of this survey and the
writing and editing support of Karl Patrick G€
oritz, SMWS –Sci-
entific and Medical Writing Services, France.
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Table 6 Impact of weather factors and sun exposure
Without acne
n=3853
With acne
n=2826
P-value
Do you or have you lived during the last 12 months in a region or country with
Temperate weather 1989 51.62% 1428 50.53% NS
Particularly hot weather 659 17.10% 696 24.63% <0.001
Particularly cold weather 581 15.08% 446 15.78% NS
Particularly humid weather 442 11.47% 367 12.99% 0.03
Due to your job or your daily activities or exposure to sun light is
Intense or moderate 1216 31.56% 1208 42.75% <0.001
Low or none 2637 68.44% 1618 57.25%
NS, not significant.
©2019 European Academy of Dermatology and VenereologyJEADV 2020, 34, 1057–1064
The role of exposome in acne 1063
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