MINISTRY OF EDUCATION AND TRAINING MINISTRY OF DEFENCE 108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES PHAM THI BICH NA STUDY OF SERUM VITAMIN D AND IL 17 LEVELS IN ACNE VULGARIS PATIENT[.]
MINISTRY OF EDUCATION AND TRAINING MINISTRY OF DEFENCE 108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES PHAM THI BICH NA STUDY OF SERUM VITAMIN D AND IL-17 LEVELS IN ACNE VULGARIS PATIENTS BEFORE AND AFTER TREATMENT WITH ORAL ISOTRETINOIN AND VITAMIN D Major/Specialization: Internal Medicine/Dermatology Code: 9720107 ABSTRACT OF MEDICAL PH.D THESIS Hanoi – 2023 THE THESIS WAS DONE IN: 108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES Supervisor: Reviewer 1: Reviewer 2: Reviewer 3: This thesis will be presented at Institute Council at: Day Month Year The thesis can be found at: National Library of Vietnam Library of 108 Institute of Clinical Medical and Pharmaceutical Sciences INTRODUCTION Acne vulgaris are common skin diseases in the clinical practice of dermatologists Disease usually does not effect on general health but has a detrimental impact on the person’s psychology and social communication In addition to a number of pathogenic mechanisms that are well-known as the basis for treatment, many other factors are also thought to be associated with the onset and severity of disease, including serum vitamin D and IL-17 levels Numerous studies around the world have shown a statistically significant association between serum vitamin D and IL-17 levels with severity and clinical manifestations of patients, as well as demonstrating that C acnes is a bacterium that can stimulate the expression of IL-17 in areas of skin damaged by disease Clinical trials on the role of vitamin D in the treatment of disease have also been conducted for the results of supplementing vitamin D into the fish egg treatment regimen producing statistically significant improvements when compared to the placebo-controlled group Furthermore, studies around the world have also demonstrated the inhibitory effect of Isotretinoin and Vit D on the production of IL-17 due to the stimulation of C acnes In Vietnam, no studies have been conducted on serum levels of vitamin D and IL-17 in acnes vulgaris patients That’s why we decided to conduct the theme “Study of serum vitamin D and IL-17 levels in acne vulgaris patients before and after treatment with oral Isotretinoin and vitamin D” with the following objectives: Survey of related factors and clinical features of acnes vulgaris at Ho Chi Minh City Hospital of DermatoVenereology Study of serum vitamin D and IL-17 levels before and after treatment and their relationships with clinical features in patients with moderate and severe acne vulgaris Study the results of Acne Vulgaris treatment with oral Isotretioin and Vitamin D CHAPTER 1: LITERATURE REVIEW 1.1 Overview of acne vulgaris Acne vulgaris is a very common disease of the sebaceous hair follicles, affecting up to 80% of adults In which, many cases need treatment because the disease has progressed for too long, due to complications or other accompanying disorders 1.1.1 The pathogenesis of acne vulgaris Acne vulgaris is formed by the influence of many factors, of which the main mechanism is the increase in sebum secretion, the keratinization of the hair follicle neck and the proliferation of inflammatory bacteria Keratinization of hair follicles is the source of the initial damage of acne vulgaris, that is comedone This clogged hair follicle horn causes keratin, sebum, and bacteria to be trapped in the hair follicle All of the above substances clump together, causing dilatio n of hair follicles and the formation of acne micronuclei The process of keratinization of the neck of the sebaceous hair follicles is influenced by a number of factors: androgen hormone, increased activity of Interleukin-1α (IL-1α), linoleic acid deficiency, increased free fatty acids in the sebaceous glands, bacteria, Overproduction of sebum from the sebaceous glands is also one of the causes of acne vulgaris, a process that is influenced by androgen hormones Inflammation is noted in both early and late stages of acne C acnes and the sebum component plays a very important role in the inflammatory process of acne vulgaris and some proliferative factors such as androgens, growth factors, IL-1α, are also present can directly cause inflammation Several recent studies have demonstrated that C acnes is a strong Th17-mediated inducer, and that Vitamin D inhibits the expression of Th17 induced by C acnes, thus can be considered an effective tool in the treatment of acne vulgaris In acne vulgaris, the factors in the above pathogenesis also interact with each other, so the treatment of acne vulgaris needs multi-mechanical action to bring optimal effect 1.1.2 Clinical features of acne vulgaris The most common location of acne vulgaris is on the face, then on the chest, back, and shoulders Primary lesions are classified into non-inflammatory lesions (whiteheads, blackheads) and inflammatory lesions (papules, pustules, nodules, cysts, tunnels) Common accompanying lesions are concave scars, post- inflammatory hyperpigmentation, keloid scars, vasodilating redness, hypopigmentation, The diagnostic criteria of acne vulgaris are based on basic clinical lesions, especially the expression of the caviar nucleus There are many different scales used for grading acne vulgaris The most commonly used system in research is the Global Acne Classification System (GAGS) The evaluation method is based on regions (5 regions on the face and region on the upper back/chest) Each of these regions is related to a multiplier of to (1 point each for the nose and chin; points each for the forehead, left cheek, and right cheek; and points each for the chest and upper back) The degree of damage in each area is divided proportionally: if there is more than acne nucleus, if there is more than pustule, if there is more than pustule, and if there is more than cyst/mass If there is no acne damage in any area, the score is The severity score for each area will be given based on the injury type with the highest score This score will be multiplied by the score for each region The sum of all regions will give a GAGS score: light ≤ GS ≤ 18; Average 19 ≤ GS ≤ 30; Weight 31 ≤ GS ≤ 38; Very heavy GS>38 The advantages of this scale are high accuracy, relatively simple, easy to apply, low time consumption, and the ability to evaluate back and chest injuries Therefore, we chose this scale for our research 1.1.2 Elements related to acne vulgaris Age: Acne can appear at different ages, but the incidence rate is the highest among adolescents Recently, due to the influence of skincare products and stressful lifestyles, this disease often occurs more frequently in adults Gender: Most studies have shown that women have a higher proportion of vulvar acne than men, but men have more severe clinical manifestations than women Family factors: Many studies have shown that genetic factors play an important role in the development of acne vulgaris People with a family history of "acne vulva" are related to the early appearance of the disease, the increase of pathological changes, the possibility of recurrence and the difficulty of treatment Skin color factor: "Acne" appears in all people, races, and other skin types around the world Regardless of race or ethnicity, this disease is considered the most common type of skin disease Endocrine factors: acne vulgaris can be associated with a variety of unusual endocrine disorders Endocrine disorders, such as polycystic ovary syndrome (including hyperandrogenism, insulin resistance, acanthosis nigricans), CAH, and adrenal and ovarian neoplasia may be associated with the acne vulgaris condition Psychological factors: Psychological factors induce the release of neuropeptides and hormones that activate cells involved in the pathogenesis of acne vulgaris Many patients report that their acne vulgaris flares up when they are stressed Diet: Although there is no clear answer regarding the relationship between diet and acne vulgaris, the results of several studies suggest that a high carbohydrate, milk, and fat diet may be associated with and exacerbate acne vulgaris Environmental factors, drug use, cosmetics, and mechanical effects: According to some medical literature, they are also related to the onset and severity of acne vulgaris 1.2 The role of IL-17 in acne vulgaris IL-17 is a cytokine family composed of six individuals, among which IL-17A, IL-17F, and their IL-17A/F isoforms have varying levels of inflammatory effects IL-17 is mainly produced by type 17 (Th17) helper T cells In addition, it is also produced together with other cells such as CD8+T cells, gamma delta T cells, natural killer T cells (iNKT), natural killer T cells (NK), and lymphoid tissue inducible cells (LTi) IL-17 has various physiological functions, including neutrophil motility, stimulation of Th2 cell expression in response to microorganisms, and stimulation of macrophage production of IL-1 β and TNF α Th17 and IL-17 cells have been identified to be associated with the incidence rate of a variety of human autoimmune diseases, such as rheumatoid arthritis, multiple sclerosis, inflammatory bowel disease, systemic sclerosis, primary Sjogren's syndrome, plaque alopecia, and vitiligo Several studies have shown that the presence of T cells producing IL-17A and cytokines involved in Th17 pathway activation in acne vulgaris lesions may play an important role in the disease process Agak et al.'s 2014 study showed that Clostridium acnes can stimulate Th17 and Th1 cells in human peripheral blood monocytes (PBMCs) to produce IL-17 and INF Some authors from around the world have concluded that drugs such as vitamin D3, retinoic acid, vitamin A, and zinc may play important roles in the treatment of acne vulgaris disease by inhibiting inflammatory expression of the Th17 pathway and increasing regulatory T cell activity 1.2 The role of vitamin D in the disease acne vulgaris Overview of vitamin D: vitamin D is the common name for a group of substances with the structure secosterol, which is a vitamin in oil Vitamin D is divided into two main forms: Vitamin D2 (ergocalciferol) and Vitamin D3 (cholecalciferol) There are main sources to help the body supplement vitamin D: Synthesized on the skin when exposed to sunlight, supplementing vitamin D from foods and supplementing vitamin D from functional tablets Both forms of vitamin D2 and D3 are diffused through the intestinal mucosa along with fats and oils during meals, transported in the blood to adipose tissue and skeletal muscle, vitamin D partly accumulates here, the other part binds with proteins that move in the blood Calcitriol is the active form of vitamin D in the body, and is regulated by blood calcium levels The Calcidiol form, which is bound to plasma proteins and circulates in the blood, is the form used to quantify serum vitamin D levels The function of vitamin D for physiological activities of the body includes balancing calcium and phosphorus levels in the blood, regulating genes and participating in the immune system The role of Vit D in the skin includes the role of skin differentiation, antibacterial effects, participation in the activity of the innate translational system and the adaptive immune system According to the American Food and Nutrition Board (FNB), the risk of vitamin D deficiency is less than 30 to 50 nmol/l in serum The role of vitamin D in acne vulgaris: Vitamin D deficiency is associated with various skin diseases and pathologies, including skin cancer, psoriasis, autoimmune skin diseases such as vitiligo, scleroderma, and systemic lupus erythematosus, as well as atopic dermatitis and hair loss, Skin infections Based on recent systematic reviews, including 290 pre study studies and 172 randomized trials, it has been concluded that vitamin D deficiency appears to be a related marker of skin pathology through inflammatory reactions, including acne Research has also shown that Clostridium acnes is a powerful Th17 mediated inducer, and vitamin D inhibits Th17 expression induced by Clostridium acnes, making it an effective tool for treating acne vulgaris in acne The usual therapeutic dosage for adults with Vitamin D deficiency is 1000 international units once daily Taking vitamin D usually doesn't cause side effects However, taking vitamin D for a long time or taking an overdose of vitamin D can cause some of the following side effects: increased blood pressure, high fever, irregular heartbeat, abdominal pain, bone pain, constipation, diarrhea, thirst, increased frequency of urination, loss of appetite, metallic taste in the mouth 1.4 Studies on Vitamin D and Isotretinoin in acne vulgaris disease 1.4.1 Isotretinoin Isotretinoin acts on all the pathogenesis of acne vulgaris, making it the drug of choice for the treatment of moderate and severe acne vulgaris, individual cystic acne, eel acne, and resistant acne, recurrent acne or acne with accompanying complications The recommended dosage of isotretinoin is 0.5-1 mg/kg/day However, this dose often causes undesirable effects, so in clinical practice, many physicians tend to choose a lower dose in treatment, usually 20 mg/day Regarding the effectiveness of Isotretinoin, many domestic and international studies have shown that this is an interventional treatment on all mechanisms of acne vulgaris disease, thus promoting a good treatment effect The majority of patients improve between 9-12 weeks of treatment Regarding the adverse effects of isotretinoin in clinical, the most common manifestations are dry lips, dry skin and mucous membranes, other side effects occur with less frequency but are worth noting signs of flare-ups acne vulgaris during the initial period of treatment Undesirable effects on liver function, kidney function, blood fat after using isotretinoin in the treatment of acne have been monitored by many domestic and foreign authors, most of them have not been seen or seen a very small percentage with increases in AST, ALT or increase cholesterol, triglycerides at a mild level and then return to normal The drug is contraindicated for pregnant women 1.4.2 Vitamin D The study on the role of vitamin D in hepatitis can be explained by the relationship between vitamin D and the reduction of IL-6, IL8 and metalloproteinase-9 (MMP-9) synthesis In addition, a study published by Agak and colleagues in 2014 showed that vitamin D affects the expression of IL-17 by inhibiting Th17 cell activity In addition, a study published by Agak and colleagues in 2014 showed that vitamin D affects the expression of IL-17 by inhibiting Th17 cell activity A study by Zouboulis et al described the effect of vitamin D on the sebaceous glands, as well as the increase in fat production during vitamin D deficiency, which promotes inflammatory expression in VULGARIS ACNE disease On the other hand, a considerable number of studies around the world have shown that there is a statistically significant difference in serum vitamin D levels among acne vulgaris patients compared to the normal population without acne vulgaris A study published by Ghadah Alhetheli et al in 2020 found that acne vulgaris patients had more frequent vitamin D deficiency, but there was no significant correlation between serum vitamin D levels and the severity of acne vulgaris A study published by Mostafa Yildizgore and colleagues in 2015 found that the average serum vitamin D levels in patients with nodular follicular caviar were significantly lower than those in healthy individuals In 2016, a study conducted by Seul Ki Lim and colleagues in South Korea found that 48.8% of acne vulgaris patients had vitamin D deficiency, but only 22.5% of healthy controls had a negative correlation between vitamin D levels and the severity of acne vulgaris There is a significant negative correlation with inflammatory damage In subsequent clinical intervention trials, taking a vitamin D supplement of 1000 IU per day for months resulted in a statistically significant increase in vitamin D levels and clinical improvement compared to placebo A study published by El Hamd MA and colleagues in 2019 found that serum vitamin D levels in acne vulgaris patients were significantly higher than those in the control group There is a statistically significant negative correlation between serum vitamin D levels and the severity of acne vulgaris disease before treatment After treatment with isotretinoic acid, serum vitamin D levels significantly increased From the above research, the author concludes that vitamin D may play an important role in the pathogenesis of acne vulgaris disease, or acne vulgaris disease may have a negative impact on serum vitamin D synthesis CHAPTER 2: MATERIALS AND METHODS 2.1 Study objects and materials 2.1.1 Study subjects 119 moderate and severe acne vulgaris patients treated at Ho Chi Minh City Dermatology Hospital from March 2021 to December 2021 Diagnostic criteria: - Diagnostic criteria for acne vulgaris: comedones, papules, pustules, cysts, and lumps - Diagnostic criteria for moderate and severe acne vulgaris disease according to the GAGS scale Criteria for selecting patients: - For objective 1: The patient who came to the hospital for examination and treatment at Ho Chi Minh City Dermatology Hospital was diagnosed as a acne vulgaris vulgaris disease, aged from 18 years old and the patient agreed to participate in the study - For goal 2: • Group of diseases: Patients were clinically diagnosed with moderate and severe acne vulgaris disease, aged from 18 years old and the patients agreed to participate in the study • Healthy group: Healthy people similar to the disease group in terms of gender and age, aged from 18 years old, currently free of acne vulgaris disease and agreed to participate in the study - For target 3: Moderate and severe acne vulgaris disease aged 18 years, consent to participate in the study, no contraindications to Isotretinoin and oral serum vitamin D, divided into study group and control group Control group: frequency (n) percent(%) > 30 31 26,0 The average age 27,3 ± 6,1 (X±SD) Comment: the proportion of women is higher than that of men, the average age of acne vulgaris group of patients is 27.3 ± 6.1 in which the majority is concentrated in the 18-25 age group, accounting for 43.7% Table 3.2: Clinical features of acne vulgaris disease (n = 119) frequency (n) percent(%) Basic lesions Whitehead 119 100 Blackhead 118 99,2 Papule 110 92,4 Pustule 107 89,9 Zits 29 24,4 Cyst 15 12,6 other lesions hyperpigmented 66 55,5 hypopigmented 2,5 Telengiectasia 15 12,6 atrophic scar 54 45,4 Keloid scar 1,7 disease severity Light 49 41,2 Medium 51 42,8 Heavy 19 16,0 Comment: The most common types of acne vulgaris disease are whiteheads, blackheads, papules, and pustules, respectively The most common accompanying lesions are hyperpigmentation and concave scars Lesions are most distributed on the face, followed by the back, chest and outer arm Mild and moderate acne vulgaris disease accounted for the majority of the study 3.2 Serum vitamin D and IL-17 concentrations of moderate and severe acne vulgaris patients before and after treatment with isotretinoin combined with vitamin D Table 3.3: Comparison of serum Vit D and IL-17 levels of the patient group (n = 70) and healthy group (n = 70) patient group healthy group p (n = 70) (n = 70) Vit D (ng/ml) IL-17 (pg/ml) 17,3 ± 4,8 20,2 ± 6,4 0,003 8,3 (6,5 – 6,1 (4,8 – 13,5) 0,024 14,4) Comment: The serum concentration of Vit D in the disease group was lower than that of the healthy group and the serum IL-17 concentration of the disease group was statistically significant higher than that of the healthy group Table 3.4: Relationship between serum Vit D and IL-17 levels with some factors (n = 70) n Levels Vit D p Levels IL-17 p (X ± SD) (TV(KTV)) Gender Male 15 20,5 ± 6,2 0,00 10,8 (6,5 – 19,0) 0,42 Female 55 16,4 ± 4,0 8,3 (6,1 – 12,6) Age group ≤ 25 31 18,0 ± 5,4 11,1 (7,5 – 19,0) 0,199 7,9 (6,1 – 11,9) 0,02 26 – 30 23 15,8 ± 4,2 > 30 16 17,8 ± 4,1 6,5 (4,3 – 11,3) use sunscreen 0,00 0,00 Yes 41 15,9 ± 3,6 7,2 (5,4 – 11,9) 6 No 29 19,1 ± 5,7 11,1 (7,9 – 15,1) disease severity 0,422 0,57 Medium 51 17,5 ± 4,8 8,3 (6,5 – 13,3) Heavy 19 16,5 ± 4,8 8,3 (6,1 – 15,4) Comments: Vit D levels in moderate and severe acne vulgaris patients are statistically significant with gender, while IL-17 levels were statistically significant with age group Both Vit D and IL-17 concentrations were significantly different according to sunscreen use habits (KCN), but not according to disease severity Table 3.5: Serum Vit D and IL-17 levels before and after treatment in moderate and severe acne vulgaris patients (n = 70) Research time vit D Levels (X ±SD) p IL-17 levels (TV(KTV)) p Research group Before treatment 17,0 ± 3,9 After treatment 23,5 ± 6,3 < 0,001 8,3 (6,5 – 15,4) < 0,001 9,0 (6,1 – 13,3) 4,4 (3,1 – 10,1) 0,011 Control group Before treatment 17,5 ± 5,6 After treatment 23,8 ± 5,7 pNNCvsNĐC 0,702 4,8 (3,5 – 10,1) < 0,001 0,119 Comments: serum levels of Vit D and IL-17 after treatment changed statistically significantly compared to before treatment in both groups However, serum levels of Vit D and IL-17 after treatment were not different when comparing the groups 3.3 Effectiveness of treating moderate and severe acne vulgaris with Isotretinoin and oral Vitamin D GEE: pRESEARCH GROUP < 0,001 pCONTROL GROUP < 0,001 pRESEARCH GROUPvsCONTROL GROUP = 0,218 Điểm GAGS 30 25 20 15 10 Nhóm nghiên cứu Nhóm đối chứng Trước can thiệp 28.3 26.2 Sau tháng Sau tháng Sau tháng 21.4 20.3 13.1 11.6 4.4 4.5 Chart 3.1: Comparison of GAGS scores of groups by treatment time (n = 70) Comments: in both RESEARCH GROUP and CONTROL GROUP, the GAGS score after treatment was significantly reduced compared to before treatment with p < 0.001 However, this GAGS score was not significantly different when comparing the two groups (p = 0.218) Table 3.6 Comparison of disease improvement of groups by treatment time disease After month After months After months improve NNC NDC NNC NDC NNC NDC ment n (%) n (%) n (%) n(%) n (%) n (%) Excellent 0 0 16 (45,7) 13 (37,1) Very good (11,4) (22,9) 12 (34,3) 18 (51,4) 12 (34,3) 17 (48,6) Good 18 (51,4) (25,7) 18 (51,4) 12 (34,3) (11,4) (8,6) Average (22,9) (25,7) (14,3) (14,3) (8,6) (5,7) Weak (14,3) (25,7) 0 0 p 0,137 0,301 0,742 Comments: there is no statistically significant difference in disease improvement when comparing RESEARCH GROUP and CONTROL GROUP after 1, and months of treatment treat Table 3.7: Comparison of adverse effects of the groups by treatment time adverse effects Dry lips dry mucous membranes Dry skin exfoliative skin acne outbreaks Headache musculoskeletal pain constipated After month After months After months NNC NDC NNC NDC NNC NDC n(%) n (%) n (%) n (%) n (%) n (%) 22 23 24 28 24 23 (62,9) (65,7) (68,6) (80,0) (68,6) (65,7) 20 22 18 14 12 16 (57,1) (62,8) (51,4) (40,0) (34,2) (45,7) 18 20 11 12 10 (22,8) (51,4) (57,1) (31,4) (34,2) (28,6) (11,4) (2,9) (20,0) (11,4) (8,6) (5,7) (14,3) (22,8) (5,7) (2,9) (5,7) (2,9) (2,9) (5,7) (2,9) (2,9) (2,9) (5,7) (8,6) (8,6) (11,4) (14,3) (8,6) (5,7) (14,3) (11,4) (17,1) (11,4) 18 11 thirsty (20) 14 (40) (14,3) (11,4) (51,4) (31,4) Comments: dry lips, dry mucous membranes, dry skin and thirst are the most common side effects in both groups Acne outbreaks occurred less frequently in RESEARCH GROUP than in CONTROL GROUP CHAPTER – DISCUSSION 4.1 Some related factors and clinical characteristics acne vulgaris Gender: According to the literature, acne vulgaris disease is a very common condition in young men and women with little difference in frequency between the sexes In our study, female accounted for 82.3% higher than male accounted for 17.7% This is consistent with some previous studies of the authors Duong Thi Lan, Nguyen Thanh Hung, Trinh Tien Thanh, Tchiu Bich Xuan, Nguyen Thi Tra My Can explain the higher proportion of female patients in the study Our study and other authors' research is because the need to visit and improve cosmetic problems of women is higher than that of men, which does not reflect the prevalence of diseases by sex in the population Age: In our study, acne vulgaris disease was most concentrated in the 18-25 age group, accounting for 43.7% Our results are consistent with previous studies by authors Nguyen Thanh Hung, Duong Thi Lan, Nguyen Thi Tra My, Nguyen Thi Hong Nhung, Phuong Quynh Hoa This is also consistent with the literature that recognizes acne vulgaris disease as a disease of the sebaceous hair follicles and is most concentrated in adolescents Our mean age of disease was 27.3 ± 6.1, similar to the study of author Nguyen Dieu Thuan of 25.7 ± 10.4, and higher than most studies of other authors , which can be explained by our inclusion criteria not including acne vulgaris patients under 18 years of age Basic lesions and other lesions of acne vulgaris disease: Regarding the basic lesions of acne vulgaris disease, the most common are whiteheads (100%), blackheads (99.2%), papules (92) .4%), pustules (89.9%) This result is similar to the study of the authors Trinh Tien Thanh, Nguyen Thi Minh Hong, Vo Nguyen Thuy Anh In our study, hyperpigmented skin (55.5%) and concave scars (45.4%) were the two most common types of lesions in acne vulgaris disease This rate is similar to domestic studies and higher than foreign studies, possibly due to the climate in Ho Chi Minh City with strong sunlight and characteristics of Vietnamese people's rather dark skin, a sense of care and early treatment in acne vulgaris disease is not high, leading to an increase in postinflammatory hyperpigmentation and concave scars Severity of acne vulgaris disease: In our study, classified according to the GAGS scale, moderate (42.8%) and mild (41.2%) acne vulgaris disease accounted for the majority, severe severity less common (16%) This rate is similar to the study of Tchiu Bich Xuan, Nguyen Thi Tra Mi, and Trinh Tien Thanh but heavier than the study of Adityan et al., Goulden et al., Poli et al., partly reflecting the lack of interest in early treatment of acne vulgaris disease in Vietnam compared to other countries in the world Patients often tend to only go to the hospital for examination and treatment when their condition is already severe, this should be noted in order to better propagate and educate the treatment consciousness This difference can also be explained by the fact that the place we surveyed is a specialized hospital, 4.2 Serum vitamin D and IL-17 levels of moderate and severe acne vulgaris patients before and after treatment with Isotretinoin in combination with vitamin D The patient group and the healthy group in our study had no difference in sex, age group and mean age of acne vulgaris Serum vitamin D concentration before treatment: We measured serum Vit D levels in 70 patients with moderate and severe acne vulgaris, the results were 17.3 ± 4.8 (ng/ml) lower than this concentration in 70 healthy subjects for control was 20.2 ± 6.4 (ng/ml), the difference was statistically significant with p = 0.003 Our results are similar to the study of author Mostafa Y et al in 2015: the average concentration of Vit D in 43 patients with nodular cystic acne was 11.2 ± 5.9 (ng/ml) significantly lower than the control group of 46 healthy people was 19.7 ± 8.1 (ng/ml) with p