Dietary supplementation with gamma-linolenic, linoleic and oleic acids decreases PPAR-gamma expression and helps the tetracycline derivative to reduce NOD2 expression in patients with acne vulgaris

elipe Bochnia Cerci: Participation in the design and planing of the study; collection, analysis, and interpretation of ata; writing; critical review of the manuscript; approval of he final version. Stanislav Tolkachjov: Writing; critical review of the anuscript; approval of the final version. Betina Werner: Writing; critical review of the manuscript; pproval of the final version. 6. Yeom SD, Lee SH, Ko HS, Chung KS, Shin J, Choi GS, et al. Effectiveness of dermoscopy in Mohs micrographic surgery (MMS) for nonmelanoma skin cancer (NMSC). Int J Dermatol. 2017;56:136--9. 7. Reiter O, Mimouni I, Dusza S, Halpern AC, Leshem YA, Marghoob AA. Dermoscopic features of basal cell carcinoma and its subtypes: a systematic review. J Am Acad Dermatol. 2019;85:653--64. 8. Suppa M, Micantonio T, Di Stefani A, Soyer HP, Chimenti S, Fargnoli MC, et al. Dermoscopic variability of basal cell carcinoma according to clinical type and anatomic location. J Eur Acad Dermatol Venereol. 2015;29:1732--41. 9. Cerci FB, Kubo EM, Werner B, Tolkachjov SN. Surgical margins required for basal cell carcinomas treated with Mohs micrographic surgery according to tumor features. J Am Acad Dermatol. 2020;83:493--500. 10. Conforti C, Giuffrida R, Zalaudek I, Guarneri F, Cannavò SP, Pizzichetta MA, et al. Dermoscopic findings in the presurgical evaluation of basal cell carcinoma. A prospective study. Dermatol Surg. 2021;47:37--41.

The means obtained before and after treatment were compared between groups and lesions. Quantitative variables were described by mean and standard deviation, comparing those with a symmetrical distribution by analysis of variance (ANOVA), followed by Tukey's posthoc; intergroup evaluation was carried out with the Kruskal-Wallis test for non-parametric data; and intragroup evaluation with Wilcoxon test. Descriptive statistics were used, with standard deviation, minimum, maximum , and median values, with a significance level of 5% (p < 0.05) using the statistical package IBM SPSS version 20.
Of the 45 subjects, 36 (80%) completed the study: 11 from Group 1; 13 from Group 2; and 12 from Group 3. There was no statistical difference between the groups (p = 0.626). The ratio of subjects with papulopustular and cystic acne was similar for Groups 1, 2 and 3, and there were no differ-ences regarding phototypes (p = 0.548) and time of disease evolution (p = 0.959; Table 1).
A significant decrease was observed in the number of comedones and cysts throughout the study (p < 0.001), with no difference between the groups and no alterations in comedones and cysts. The pustules decreased significantly (p < 0.001), with no effect of time, difference between the groups (p = 0.049; Table 2). However, the papules and total AV lesions varied between the study groups (p = 0.049 and p = 0.011; group*Visit interaction; Table 2). There was a decrease in comedones and pustules in all groups and visits when compared to D0, except between D60 and D90 (p = 0.966). For the cysts, there was a decrease, except from D30 on (Table 3).
On immunohistochemistry, there was no difference between the groups and analyzed histopathological sites on D0. On D90, there was a NOD2 difference in the IE between the Groups (Group 1 with higher values than Groups 2 and 3). The median of NOD2 in the IE was two in the three groups, with a maximum value in Group 1 surpassing the others, indicating a somewhat higher distribution of values in Group 1. In the intragroup comparisons, there was a decrease in PPARG in SG in Group 2 (p = 0.016) and a significant increase in NOD2 in HF in Group 1 (p = 0.011; Table 4).
The reduction of inflammatory lesions in the Groups with LM undergoing treatment (Groups 1 and 3) was predicted, as it is one of the tetracyclines of choice in the management of inflammatory AV, with high skin penetration. 3,4 Costa et al., in 2007, pointed out a clinical non-response with the use of GLA/LA/OA supplementation, compared to placebo, in AV, but a possible improvement in the SG size, seen in pre-and post-treatment biopsies. 5 The present study, however, indicated a possible usefulness of GLA/LA/OA for comedones and cysts, confirming Rustin's remote assumptions. 6 NODs are activated by bacterial muramyl peptidoglycans, combined or not with TLRs. Thus, the result observed in NOD2 may have come from the control of microorganism-       mediated inflammation, as the overexpression of NOD2 reduces clonal proliferation. 7,8 PPARG acts on sebocyte modulation. Its GLA/LA/OAinduced SG reduction may be the cause of the increase in lauric, myristic, and palmitic acids under equal therapy, suggesting the same role in NOD2-lowering effects in the IE. 9 GLA/LA/OA were used In Groups 2 and 3. Therefore, we suggest that their administration causes PPARG reduction in sebocytes in Group 2 and NOD2 in the IE of both Groups 2 and 3, reinforcing the hypothesis of beneficial supplementation with GLA/LA/OA for comedonal and cystic AV. 5---7 Therefore, FAs with great bactericidal potential could reduce the concentrations of Cutibacterium acnes and, thus, the expression of bacterium-activated receptors. Interestingly, isolated LM increased NOD2 labeling in HF, requiring further elucidative studies. As PPARG and NOD2 are inversely related to papules in Group 3, perhaps they can be recruited in the early stages of the dermatosis.
Therefore, it is concluded that daily administration of LM and/or GLA/LA/OA interferes with the pro-inflammatory markers in AV, and supplementation with GLA/LA/OA could be an adjuvant in the treatment of AV.

Authors' contributions
Clarissa Prati: Statistical analysis; approval of the final version of the manuscript; design and planning of the study; drafting and editing of the manuscript; collection, analysis, and interpretation of data; critical review of the literature.
Emily Ferreira Salles Pilar: Approval of the final version of the manuscript; collection, analysis, and interpretation of data; effective participation in research orientation.
Andre Cartel: Approval of the final version of the manuscript; collection, analysis, and interpretation of.
João Bayma Galvão Pitoni: Approval of the final version of the manuscript; collection, analysis, and interpretation of data.
Cidia Vasconcellos: Approval of the final version of the manuscript; effective participation in research orientation; critical review of the manuscript.
Adilson da Costa: Approval of the final version of the manuscript; design and planning of the study; drafting and editing of the manuscript; effective participation in research orientation; critical review of the manuscript.