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Indian J Dermatol. 2013 Jul-Aug; 58(4): 326.
doi: 10.4103/0019-5154.113947
PMCID: PMC3726896
PMID: 23919019

The Evaluation of the Impact of Age, Skin Tags, Metabolic Syndrome, Body Mass Index, and Smoking on Homocysteine, Endothelin-1, High-sensitive C-reactive Protein, and on the Heart

Omar Soliman El Safoury, Marwa Ezzat, Mahmoud F Abdelhamid,1 Nadia Shoukry,1 and Ehssan Badawy2
Author information Article notes Copyright and License information Disclaimer

Abstract

Background:

Skin tags (STs) are small, pedunculated skin-colored or brown papules that occur around any site where skin folds occur. The literature is short of comprehensive and controlled clinical studies aimed to evaluate the atherogenic risk factors in patients with STs.

Aim of Work:

The aim of this study is to evaluate the impact of age, STs, metabolic syndrome (METs), body mass index (BMI), and smoking on homocysteine (Hcy), endothelin-1 (ET-1), high-sensitive C-reactive protein (Hs-CRP), and on cardiovascular diseases.

Materials and Methods:

This study included 30 cardiac patients with STs, 30 non-cardiac patients with STs, and 30 healthy controls with neither heart disease nor STs. History of smoking, measurement of height, weight, BMI, waist circumference (WC), blood pressure, STs number, color, acanthosis nigricans, estimation of serum level of fasting glucose, triglycerides (TGs), cholesterol, high-dense lipoproteins (HDL), Hcy, ET-1, Hs-CRP, and the presence of the METs were elicited in the three groups.

Results:

Regarding the Hcy, ET-1, and Hs-CRP, the cardiac-STs group showed the highest levels and the control group showed the least (P < 0.001). The percents of patients with METs were 56.7% in the cardiac-STs, 40% in the non-cardiac-STs, and 0% in the control group (P < 0.001). Mean BMI exceeded the limit of obesity in the cardiac-STs group (30.9 ± 3.9) and the non-cardiac-STs group (32.6 ± 6) and was normal in the control group (24.7 ± 2.8). Hyperpigmented STs were present in 66.7% of the cardiac-STs group. Multivariate regression analysis for the independent effectors on Hcy level were the presence of STs (P < 0.001), METs (P = 0.001), and BMI (P = 0.024). Regarding ET-1, the effectors were the presence of STs and METs (P = 0.032). For Hs-CRP, effectors were the presence of STs (P < 0.001) and smoking (P = 0.040). Multivariate logistic regression of the predictors of cardiac disease showed that the independent predictors of the occurrence of cardiac disease were BMI (P < 0.001), STs (P = 0.002), and METs (P = 0.037).

Conclusion:

STs may act as a physical sign of underlying raised cardiac atherogenic factors. This may indicates an ongoing risk on coronary circulation which may indicate further corrective action, hopefully early enough. The association of ST with obesity and METs represents a Bermuda Triangle that act against the heart.

Keywords: Blood pressure, cardiac risk factors, cholesterol, endothelin-1, high-sensitive C-reactive protein, high-dense lipoproteins, homocysteine, metabolic syndrome, obesity, skin tags, smoking, triglycerides, waist circumference

Introduction

What was known?

Skin tags (STs) are associated with obesity, metabolic syndrome (METs), insulin resistance, and hyperlipidemia.

Skin tags (STs), soft fibromas, fibroepithelial polyps, or acrochordons are all alternative terms to describe a common benign skin condition, which consists of a projecting bit of skin often, in areas of skin friction.[1] They have been reported with an incidence of 46% in the general population.[2] The association between STs and metabolic syndrome (METs) has been investigated.[3] However, the literature is short of comprehensive and controlled clinical studies evaluating the atherogenic risk factors in patients with STs.[4]

Homocysteine (Hcy) is a sulfur-containing amino acid. The plasma total Hcy levels are influenced by genetic, physiological (age and sex), lifestyle factors, and various pathological conditions.[5] The normal concentration of plasma Hcy ranges between 5 and 15 μmol/l. Elevation of plasma Hcy from 15 to 30 μmol/l, 30 to 100 μmol/l, and > 100 μmol/l are termed mild/moderate, intermediate, and severe hyperhomocysteinemia, respectively.[6] Prospective data in high-risk patients have suggested that mild or moderate hyperhomocysteinemia could be a risk factor for recurrent cardiovascular events and overall mortality.[7]

Endothelin-1 (ET-1) is a potent vasoconstrictor peptide secreted mainly by endothelial cells. It is also produced by other cells associated with cardiovascular homeostasis such as smooth muscle cells, cardiomyocytes, and macrophages.[8] Deficiency of the endothelium-derived nitric oxide (NO) is well documented in coronary endothelial dysfunction and in human atherosclerotic arteries. ET-1 can decrease NO bioavailability by decreasing its production via inhibition of endothelial NO synthase activity or by increasing its degradation via formation of oxygen radicals.[9]

High-sensitive C-reactive protein (Hs-CRP) belongs to the pentraxin family of proteins. A direct comparison of Hs-CRP and low-dense lipoprotein (LDL) cholesterol showed that Hs-CRP was a stronger predictor for cardiovascular events and death compared to LDL cholesterol.[10] In a recent study,[11] Hs-CRP levels were significantly elevated in individuals with multiple risk factors of cardiovascular disease in comparison to individuals with no risk factors. It was suggested that Hs-CRP levels of < 1, 1-3, and > 3 mg/l be used to represent lower, moderate, and higher vascular risk and cardiovascular complications, respectively.[12]

METs comprises obesity, raised fasting blood glucose, hypertension, and hyperlipidemia.[13] It is associated with increased cardiovascular morbidity and mortality, stroke, and type II diabetes. In METs, endothelial dysfunction of the coronary, the peripheral, or the cerebral vasculature is an early pathogenic vascular event and appears to be a marker of uncontrolled atherosclerotic risk that adds to the burden of the genetic predisposition to cardiovascular disease.[14]

The aim of this study is to evaluate the impact of age, STs, METs, body mass index (BMI), and smoking on cardiovascular atherogenic factors and on cardiovascular diseases.

Materials and Methods

Study design and population

This cross-sectional investigative study was approved by the Dermatology Research Ethical Committee and the Ethics Committee of National Research Center. Written informed consents were retrieved from all participants. This study included three groups: 30 non-cardiac participants with STs (non-cardiac-STs), 30 cardiac participants with STs (cardiac-STs), recruited from the Dermatology and Cardiology Clinics in a University Hospital and the National Research Center, and a the third control group of 30 healthy participants with neither STs nor cardiac disease. The cardiac patients were diagnosed with ischemic heart disease. Exclusion criteria included pregnant females, children below 12 years of age, and patients with drugs or diseases that could affect the outcome of the study as valvular, conductive defects, and terminal end stage heart failure. This study was conducted between January 2011 and June 2011.

Methods

Plasma Hcy was assayed according to the method of Melnky et al. (2000).[15] The quantitative determination of ET-1 protein by enzyme immunoassay in human serum was performed according to the method described by Takakuwa et al. (1994).[16] The quantitative determination of Hs-CRP protein by enzyme immunoassay in human serum was performed according to the method of Borque et al. (2001).[17] METs was calculated according to the criteria of the American Heart Association/Updated NCEP (Scott and Grundy, 2004).[18]

Statistical methods

Data were statistically described in terms of range, mean ± standard deviation, frequencies (number of cases), and percentages when appropriate. Comparison of numerical variables between the study groups was done using one way analysis of variance test with post-hoc multiple two-group comparisons. For comparing categorical data, Chi-square (χ2) test was performed. Exact test was used instead when the expected frequency was < 5. P < 0.05 were considered statistically significant. All statistical calculations were done using Statistical Package for the Social Science (SPSS; SPSS Inc., Chicago, IL, USA) Version 15 for Microsoft Windows.

Results

The basic characteristics of the three studied groups are represented in Table 1 and the statistical difference between the three groups is as follows: Regarding gender, the three groups were sex matched (P = 0.490). Regarding age, the multivariate regression analysis showed that the effect of age on ET-1, Hc-CRP, and the occurrence of heart diseases was non-significant, though significant only on Hcy [Tables ​[Tables22 and ​and33].

Table 1

Baseline characteristics of the study groups

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Table 2

Multivariate regression analysis for the effectors on homocysteine, endothelin-1 and high-sensitive C-reactive protein levels

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Table 3

Multivariate logistic regression of the predictors of cardiac disease

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Regarding serum Hcy, there was a statistically significant difference between cardiac-STs and non-cardiac-STs groups (P < 0.001), between cardiac-STs group and control (P < 0.001), and between non-cardiac-STs group and control (P < 0.001) [Table 1].

Serum ET-1 showed a statistically significant difference between cardiac-STs and non-cardiac-STs groups (P < 0.001), between cardiac-STs group and control (P < 0.001), and between non-cardiac-STs group and control (P < 0.001) [Table 1].

Regarding serum Hs-CRP, there was a statistically significant difference between cardiac-STs and non-cardiac-STs groups (P < 0.001), between cardiac-STs group and the control (P < 0.001), and between non-cardiac-STs group and the control (P < 0.001) [Table 1].

METs demonstrated no statistical difference between cardiac-STs and non-cardiac-STs groups (P = 0.196). Nevertheless, there was a statistically significant difference between the cardiac-STs group and the control (P < 0.001) as well as between the non-cardiac-STs group and the control (P < 0.001) [Table 1].

Regarding fasting blood glucose (FBS), there was no statistically significant difference between cardiac-STs and non-cardiac-STs groups (P = 0.999), whereas there was a statistically significant difference between cardiac-STs group and control (P = 0.010) as well as between non-cardiac-STs group and control (P = 0.013) [Table 1].

As regards triglycerides (TGs), there was no statistically significant difference between non-cardiac-STs and cardiac-STs groups (P = 0.999), whereas there was a statistically significant difference between cardiac-STs group and control (P < 0.001) and between non-cardiac-STs group and control (P = 0.002) [Table 1 and Figure 1].

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Lipid profile in cases and control

Regarding serum cholesterol, there was no statistically significant difference between non-cardiac-STs and cardiac-STs groups (P = 0.230), whereas there was a statistically significant difference between cardiac-STs group and control (P = 0.008) and between non-cardiac-STs group and control (P < 0.001) [Table 1 and Figure 1].

Regarding serum high-dense lipoproteins (HDL), there was no statistically significant difference between cardiac-STs and non-cardiac-STs groups (P = 0.137) and between non-cardiac-STs group and control (P = 0.999), whereas there was a statistically significant difference between cardiac-STs group and control (P = 0.025) [Table 1 and Figure 1].

BMI exhibited a statistically significant difference between cardiac-STs and non-cardiac-STs groups (P = 0.386), whereas there was a statistically significant difference between cardiac-STs group and control (P < 0.001) and between non-cardiac-STs group and control (P < 0.001) [Table 1].

Regarding systolic blood pressure (SBP), there was statistically significant difference between SBP between cardiac-STs and non-cardiac-STs groups (P = 0.001) and between cardiac-STs group and control (P < 0.001). There was no statistically significant difference between non-cardiac-STs group and control (P = 0.750) [Table 1].

Regarding diastolic blood pressure (DBP), there was statistically significant difference between DBP between cardiac-STs and non-cardiac-STs groups (P < 0.001) and between cardiac-STs group and control (P < 0.001). There was no statistically significant difference between non-cardiac-STs group and control (P = 0.065) [Table 1].

Regarding waist circumference (WC), there was statistically significant difference between cardiac-STs and non-cardiac-STs groups (P = 0.024) and between cardiac-STs patients and control (P < 0.001). There was no statistically significant difference between non-cardiac-STs group and control (P = 0.529) [Table 1].

Smoking showed no statistical difference between cardiac-STs and non-cardiac-STs groups (P = 0.1) and between non-cardiac-STs group and control (P = 0.145). There was statistical difference between cardiac-STs group and control patients (P = 0.001) [Table 1].

Regarding the STs color, in the non-cardiac-STs group, the number of the hyperpigmented STs was 8 (26.7%), mixed color STs (hyperpigmented and flesh) was 15 (50%), and the flesh color STs was 7 (23.3%). In the cardiac-STs group, the number of hyperpigmented STs was 20 (66.7%), the number of mixed color STs was 9 (30%), and flesh color STs was 1 (3.3%) (P < 0.004) [Table 4].

Table 4

Comparison between skin tags (STs) color in the cardiac and the non-cardiac groups

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The independent effectors on Hcy level are the presence of STs (P < 0.001), METs (P = 0.001), BMI (P = 0.024), and age (P = 0.027) [Table 2].

The independent effectors on ET-1 level are the presence of ST (P = 0.004) and METs (P = 0.032) [Table 2].

The independent effectors on Hs-CRP level are the presence of STs (P < 0.001) and smoking (P = 0.040) [Table 2].

The independent predictors of the occurrence of cardiac disease are BMI (P < 0.001), presence of STs (P = 0.002), and METs (P = 0.037) [Table 3].

Discussion

To the best of our knowledge, this is the first study to be conducted on three groups, cardiac patients with STs, non-cardiac with STs, and control. This study is considered a De novo study regarding the estimation of the serum level Hcy and ET-1 in patients with STs and in measuring Hcy, ET-1, and Hs-CRP level in cardiac patients with STs. In (1976), Wilcken and Wilcken[19] were the first to record the relation between coronary artery disease and the high level of Hcy. It has been demonstrated that in the presence of traditional risk factors, Hcy may have a permissive role in endothelial damage. The endothelial damage of coronary artery is mediated by increasing oxidative stress.[19] Nurk et al. (2002) classified the increase in plasma Hcy level (hyperhomocysteinemia) as mild/moderate 5-15 μmol/l, intermediate 30-100 μmol/l, and severe >100 μmol/l.[6] In this study, the cardiac-STs group showed intermediate hyperhomocysteinemia (32.4 ± 4.3 μmol/l), Whereas the non-cardiac-ST group showed mild∕moderate level (13.4 ± 4.6 μmol/l) and in the control group (9.2 ± 3.2 μmol/l) showed normal Hcy levels.

It has been demonstrated that the circulating ET-1 is increased in patients with atherosclerosis and in the coronary circulation of patients with early atherosclerosis and coronary endothelial dysfunction.[20] In this study, the serum level of ET-1 showed the highest level in the cardiac-STs group (5.9 ± 1.5 pg/ml). This was highly significant in comparison to the other groups. There was also a statistically significant difference between non-cardiac-STs group (3.4 ± 1.7 pg/ml) and the control group (2.4 ± 0.56 pg/ml).

Pearson et al. (2003) suggested that Hs-CRP levels of < 1, 1-3, and >3 mg/l are used to represent lower, moderate, and higher vascular risk and cardiovascular complications.[12] In this study, both the cardiac-STs group and the non-cardiac-STs group showed high-risk level (9.1 ± 1.9 and 6.6 ± 2.9 mg/d, respectively). The controls group showed lower intermediate risk level for cardiovascular disease (1.8 ± 0.9 mg/l). This study is an agreement with Sari et al., (2010) who evaluated 113 patients with STs and 31 healthy subjects for Hs-CRP. They found a significant difference between the two groups (P < 0.001).[21]

In other studies,[1,22] STs number correlated with age until menopause/andropause, when their number starts to decline. In this study, ST was independent effecter on Hcy, ET-1, and Hs-CRP levels [Table 2]. This may indicates an ongoing risk on coronary circulation which may indicate further corrective action, hopefully early enough.

In this study, participants were screened for METs, and there was a significant difference in its prevalence among cardiac-STs, 17/30 (56.7%), non-cardiac-STs, 12/30 (40%), and control, 0/30 (0%) (P < 0.001). This is an agreement with El Safoury et al., (2011) who measured the association of the METs in patients with STs and found a significant association, 26/40 (65%) compared to the control group 2/40 (5%) (P < 0.001)[23] and in agreement with Shaheen et al., (2011) who found that 71% of patient with STs fulfilled the criteria of METs.[24]

As regards the TGs, there was higher statistical significant difference in serum TGs and cholesterol levels in cardiac-ST, non-cardiac-ST groups than in the control groups (P = 0.004). This is an agreement with the results of Crook (2000),[25] Erdogan et al. (2005),[26] and El Safoury et al. (2011).[23] Although HDL level was low in the cardiac-STs group, moderate in the non-cardiac-ST group and high in the control, yet HDL level was statistically different only in the cardiac group-STs relative to controls. This is in agreement with Sari et al., (2010)[21] who found a significant difference in HDL level between STs cases, 50.0 mg/dl ± 12.3 and control, 61.8 mg/dl ± 14.5. However, this study showed no significant difference between cardiac-ST group and non-cardiac-ST group (P = 0.137), which is an agreement with Crook (2000).

In this study, there was a statistically significant difference in SBP and DBP among cardiac-STs, non-cardiac-STs groups, and control (P < 0.001). This is in an agreement with Sari et al., (2010)[21] who found a significant difference in BP between the STs group and control (P < 0.023).

BMI exceeded the threshold for obesity in the cardiac-STs (30.9 ± 3.9) and the non-cardiac-STs (32.6 ± 6) groups and was normal in the control group (24.7 ± 2.8). A higher statistical significant difference in BMI was found in the cardiac-STs and non-cardiac-STs groups than in the control group (P < 0.001). This is an agreement with Sari et al., (2010)[21] who found that mean BMI was (29.9 ± 5.3) in the STs group and (21.5 ± 3.5) in the control group (P < 0.001), with El Safoury et al.,[23] who found that BMI mean was 35.2 ± 7.05 in the STs group and 28.03 ± 4.29 in the control group (P < 0.001), with Shaheen et al.,[24] who found that the number and extent of STs increased with the increase in obesity, with the results of Puneet and Deepak.,[27] who reported an association between STs, impaired glucose tolerance, and obesity, and finally with the results of Garcia-Hidalgo et al.,[28] who studied 156 obese patients and found that percentage of those with STs increased with severity of obesity.

In a recent study,[1] mixed color STs (flesh and dark) were tightly associated with obesity. In this study, dark color STs was present in 20/30 cardiac patients (66.7%). To our knowledge, this is the first study that recognized a certain pattern of STs color in cardiac patients and this may again alert the physicians to identify and take an early action for those patients.

Conclusion

This study suggests four points that raises STs as a physical sign of underling cardiac risk factors.

  1. There is no significant difference between the non-cardiac-STs and the cardiac-STs groups, though significantly higher than control, as regards cholesterol, TGs, FBS, METs, and BMI.
  2. ST was independent effecter on the three risky factors: Hcy, ET-1, and Hs-CRP.
  3. 66.7% of cardiac patients are associated with dark color ST.
  4. The multivariate logistic regression of the predictors of cardiac disease showed that STs, BMI, and METs represent a harmful triangle (Bermuda Triangle) working against the heart.

Recommendations

To adopt STs as a physical sign of underling high cardiac atherogenic factors and as a risk factor for cardiovascular disease, especially if associated with obesity and METs.

What is new?

1. Homocysteine (Hcy), endothelin-1 (ET-1), and high-sensitive C-reactive protein levels are statistically significantly higher in patients of STs than in control (highest in cardiac, less in non-cardiac, and least in control).

2. 66.7% of cardiac patients are associated with dark color STs

3. Patients with STs whether cardiac or non-cardiac have no significant difference in serum level of cholesterol, triglycerides (TGs), fasting blood glucose (FBS) and also with no significant difference in incidence of metabolic syndrome (METs) and obesity (though statistically higher than in control).

Footnotes

Source of Support: Nil

Conflict of Interest: Nil.

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