American Journal of Internal Medicine

Submit a Manuscript

Publishing with us to make your research visible to the widest possible audience.

Propose a Special Issue

Building a community of authors and readers to discuss the latest research and develop new ideas.

Association Between Obesity and Sarcoidosis: A Systematic Review and Meta-analysis

Background: Sarcoidosis is a systemic inflammatory disease characterized by epithelioid granuloma formation in various organs. The etiology of sarcoidosis is unknown. Several studies report an increased risk of sarcoidosis in obese patients. The purpose of this study is to conduct a systematic review to assess the risk of sarcoidosis in obese or overweight patients, and to provide a population-based estimate of the risk of sarcoidosis in obese and overweight individuals. Methods: Using the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA) guidelines, we conducted a comprehensive search of studies (Randomized control trial (RCT), cohort or case-control) studies that estimated the risk of sarcoidosis with body mass index (BMI) between 2009-2019 using keywords and MESH terms related to obesity and sarcoidosis. The search was conducted in MEDLINE, EBSCO, and CINAHL. Three independent investigators reviewed each article and assessed for bias. Data was extracted from each study that met inclusion criteria. Quantitative analysis was performed using Review Manager 5.3 software. Results: An initial search yielded 77 potential articles; 73 articles did not meet inclusion criteria and 4 were included in the final analysis. The pooled risk estimate for the incidence of sarcoidosis in obese and overweight individuals was 1.68 [95% confidence interval 1.5-1.87] with a significant statistical heterogeneity, I2 of 92%. Conclusion: From our systematic review, obese and overweight individuals have a 68% (RR 1.68, 95% CI 1.50 to 1.87) increased risk of developing sarcoidosis in comparison with normal or underweight individuals. More studies are needed to further evaluate the role of obesity in the etiopathogenesis of sarcoidosis.

Sarcoidosis, Obesity, Pulmonary

David Wainaina Wambui, Ogugua Ndili Obi, Gregory Dale Kearney. (2020). Association Between Obesity and Sarcoidosis: A Systematic Review and Meta-analysis. American Journal of Internal Medicine, 8(5), 237-245.

Copyright © 2020 Authors retain the copyright of this article.
This article is an open access article distributed under the Creative Commons Attribution License ( which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

1. Y. C. Chooi, C. Ding, and F. Magkos, "The epidemiology of obesity," (in eng), Metabolism, vol. 92, pp. 6-10, Mar 2019, doi: 10.1016/j.metabol.2018.09.005.
2. A. Afshin et al., "Health Effects of Overweight and Obesity in 195 Countries over 25 Years," (in eng), N Engl J Med, vol. 377, no. 1, pp. 13-27, 07 2017, doi: 10.1056/NEJMoa1614362.
3. K. M. Flegal, D. Kruszon-Moran, M. D. Carroll, C. D. Fryar, and C. L. Ogden, "Trends in Obesity Among Adults in the United States, 2005 to 2014," (in eng), JAMA, vol. 315, no. 21, pp. 2284-91, Jun 2016, doi: 10.1001/jama.2016.6458.
4. D. P. Symmons et al., "Blood transfusion, smoking, and obesity as risk factors for the development of rheumatoid arthritis: results from a primary care-based incident case-control study in Norfolk, England," (in eng), Arthritis Rheum, vol. 40, no. 11, pp. 1955-61, Nov 1997, doi: 10.1002/art.1780401106.
5. M. C. Harpsøe et al., "Body mass index and risk of autoimmune diseases: a study within the Danish National Birth Cohort," (in eng), Int J Epidemiol, vol. 43, no. 3, pp. 843-55, Jun 2014, doi: 10.1093/ije/dyu045.
6. M. Versini, P. Y. Jeandel, E. Rosenthal, and Y. Shoenfeld, "Obesity in autoimmune diseases: not a passive bystander," (in eng), Autoimmun Rev, vol. 13, no. 9, pp. 981-1000, Sep 2014, doi: 10.1016/j.autrev.2014.07.001.
7. A. Stavropoulos-Kalinoglou, G. S. Metsios, Y. Koutedakis, and G. D. Kitas, "Obesity in rheumatoid arthritis," (in eng), Rheumatology (Oxford), vol. 50, no. 3, pp. 450-62, Mar 2011, doi: 10.1093/rheumatology/keq266.
8. L. H. Duntas and B. Biondi, "The interconnections between obesity, thyroid function, and autoimmunity: the multifold role of leptin," (in eng), Thyroid, vol. 23, no. 6, pp. 646-53, Jun 2013, doi: 10.1089/thy.2011.0499.
9. W. Sterry, B. E. Strober, A. Menter, and I. P. Council, "Obesity in psoriasis: the metabolic, clinical and therapeutic implications. Report of an interdisciplinary conference and review," (in eng), Br J Dermatol, vol. 157, no. 4, pp. 649-55, Oct 2007, doi: 10.1111/j.1365-2133.2007.08068.x.
10. A. K. Hedström, T. Olsson, and L. Alfredsson, "High body mass index before age 20 is associated with increased risk for multiple sclerosis in both men and women," (in eng), Mult Scler, vol. 18, no. 9, pp. 1334-6, Sep 2012, doi: 10.1177/1352458512436596.
11. "World Health Organization," Obesity: Preventing and Managing the Global Epidemic., vol. Geneva, Switzerland: World Health Organization, 2000.
12. C. M. Hales, M. D. Carroll, C. D. Fryar, and C. L. Ogden, "Prevalence of Obesity Among Adults and Youth: United States, 2015–2016. NCHS data brief, No 288. 2017," ed.
13. "Prevalence of Self-Reported Obesity Among U. S. Adults by State and Territory, BRFSS, 2018." (accessed October 26, 2019, 2019).
14. "Statement on sarcoidosis. Joint Statement of the American Thoracic Society (ATS), the European Respiratory Society (ERS) and the World Association of Sarcoidosis and Other Granulomatous Disorders (WASOG) adopted by the ATS Board of Directors and by the ERS Executive Committee, February 1999," (in eng), Am J Respir Crit Care Med, vol. 160, no. 2, pp. 736-55, Aug 1999, doi: 10.1164/ajrccm.160.2. ats4-99.
15. M. C. Iannuzzi, B. A. Rybicki, and A. S. Teirstein, "Sarcoidosis," N Engl J Med, vol. 357, no. 21, pp. 2153-65, Nov 22 2007, doi: 10.1056/NEJMra071714.
16. R. P. Baughman et al., "Clinical characteristics of patients in a case control study of sarcoidosis," Am J Respir Crit Care Med, vol. 164, no. 10 Pt 1, pp. 1885-9, Nov 15 2001, doi: 10.1164/ajrccm.164.10.2104046.
17. Y. C. Cozier, "Assessing the worldwide epidemiology of sarcoidosis: challenges and future directions," (in eng), Eur Respir J, vol. 48, no. 6, pp. 1545-1548, 12 2016, doi: 10.1183/13993003.01819-2016.
18. L. E. Siltzbach et al., "Course and prognosis of sarcoidosis around the world," (in eng), Am J Med, vol. 57, no. 6, pp. 847-52, Dec 1974.
19. B. A. Rybicki, M. Major, J. Popovich, Jr., M. J. Maliarik, and M. C. Iannuzzi, "Racial differences in sarcoidosis incidence: a 5-year study in a health maintenance organization," Am J Epidemiol, vol. 145, no. 3, pp. 234-41, Feb 1 1997.
20. R. P. Baughman et al., "Sarcoidosis in America. Analysis Based on Health Care Use," (in eng), Ann Am Thorac Soc, vol. 13, no. 8, pp. 1244-52, 08 2016, doi: 10.1513/AnnalsATS.201511-760OC.
21. P. Brito-Zerón, B. Kostov, R. P. Baughman, and M. Ramos-Casals, "Geoepidemiology of Sarcoidosis," in Sarcoidosis, A Clinician's Guide, R. P. Baughman and D. Valeyre Eds., no. Section 1). USA: Elsevier, 2019, ch. 1.
22. J. Barnard et al., "Job and industry classifications associated with sarcoidosis in A Case-Control Etiologic Study of Sarcoidosis (ACCESS)," J Occup Environ Med, vol. 47, no. 3, pp. 226-34, Mar 2005.
23. L. S. Newman et al., "A case control etiologic study of sarcoidosis: environmental and occupational risk factors," Am J Respir Crit Care Med, vol. 170, no. 12, pp. 1324-30, Dec 15 2004, doi: 10.1164/rccm.200402-249OC.
24. E. S. Chen and D. R. Moller, "Etiology of sarcoidosis," (in eng), Clin Chest Med, vol. 29, no. 3, pp. 365-77, vii, Sep 2008, doi: 10.1016/j.ccm.2008.03.011.
25. S. Saidha, E. S. Sotirchos, and C. Eckstein, "Etiology of sarcoidosis: does infection play a role?," (in eng), Yale J Biol Med, vol. 85, no. 1, pp. 133-41, Mar 2012.
26. D. R. Moller et al., "Genetic, Immunologic, and Environmental Basis of Sarcoidosis," Ann Am Thorac Soc, vol. 14, no. Supplement_6, pp. S429-S436, Dec 2017, doi: 10.1513/AnnalsATS.201707-565OT.
27. J. P. Cremers et al., "Body composition profiling in a Dutch sarcoidosis population," (in eng), Sarcoidosis Vasc Diffuse Lung Dis, vol. 30, no. 4, pp. 289-99, Dec 2013.
28. Y. C. Cozier, P. F. Coogan, P. Govender, J. S. Berman, J. R. Palmer, and L. Rosenberg, "Obesity and weight gain in relation to incidence of sarcoidosis in US black women: data from the Black Women's Health Study," (in eng), Chest, vol. 147, no. 4, pp. 1086-1093, Apr 2015, doi: 10.1378/chest.14-1099.
29. Y. C. Cozier, P. Govender, and J. S. Berman, "Obesity and sarcoidosis: consequence or contributor?," (in eng), Curr Opin Pulm Med, vol. 24, no. 5, pp. 487-494, 09 2018, doi: 10.1097/MCP.0000000000000503.
30. P. Ungprasert, C. S. Crowson, and E. L. Matteson, "Smoking, obesity and risk of sarcoidosis: A population-based nested case-control study," (in eng), Respir Med, vol. 120, pp. 87-90, 11 2016, doi: 10.1016/j.rmed.2016.10.003.
31. O. Dumas, K. M. Boggs, Y. C. Cozier, M. J. Stampfer, and C. A. Camargo, "Prospective study of body mass index and risk of sarcoidosis in US women," (in eng), Eur Respir J, vol. 50, no. 4, 10 2017, doi: 10.1183/13993003.01397-2017.
32. J. Olsen et al., "The Danish National Birth Cohort--its background, structure and aim," (in eng), Scand J Public Health, vol. 29, no. 4, pp. 300-7, Dec 2001.
33. Y. C. Cozier, J. S. Berman, J. R. Palmer, D. A. Boggs, D. M. Serlin, and L. Rosenberg, "Sarcoidosis in black women in the United States: data from the Black Women's Health Study," (in eng), Chest, vol. 139, no. 1, pp. 144-50, Jan 2011, doi: 10.1378/chest.10-0413.
34. O. Dumas, L. Abramovitz, A. S. Wiley, Y. C. Cozier, and C. A. Camargo, "Epidemiology of Sarcoidosis in a Prospective Cohort Study of U. S. Women," (in eng), Ann Am Thorac Soc, vol. 13, no. 1, pp. 67-71, Jan 2016, doi: 10.1513/AnnalsATS.201508-568BC.
35. T. Izumi, "Symposium: Population differences in clinical features and prognosis of sarcoidosis throughout the world. International survey report.," Sarcoidosis, vol. 9, pp. S105-S110, 1992.
36. U. Costabel, T. E. Wessendorf, and F. Bonella, "[Epidemiology and Clinical Presentation of Sarcoidosis]," Klin Monbl Augenheilkd, vol. 234, no. 6, pp. 790-795, Jun 2017, doi: 10.1055/s-0042-105569. Epidemiologie und klinisches Erscheinungsbild der Sarkoidose.
37. M. A. Judson, A. D. Boan, and D. T. Lackland, "The clinical course of sarcoidosis: presentation, diagnosis, and treatment in a large white and black cohort in the United States," (in eng), Sarcoidosis Vasc Diffuse Lung Dis, vol. 29, no. 2, pp. 119-27, Oct 2012.
38. B. A. Rybicki et al., "Familial aggregation of sarcoidosis. A case-control etiologic study of sarcoidosis (ACCESS)," Am J Respir Crit Care Med, vol. 164, no. 11, pp. 2085-91, Dec 1 2001, doi: 10.1164/ajrccm.164.11.2106001.
39. T. Morimoto et al., "Epidemiology of sarcoidosis in Japan," (in eng), Eur Respir J, vol. 31, no. 2, pp. 372-9, Feb 2008, doi: 10.1183/09031936.00075307.
40. B. Jayakrishnan et al., "Clinical features of Sarcoidosis in Oman: A report from the Middle East region," Sarcoidosis Vasc Diffuse Lung Dis, vol. 33, no. 3, pp. 201-208, Oct 7 2016.
41. G. A. Bray et al., "The Science of Obesity Management: An Endocrine Society Scientific Statement," (in eng), Endocr Rev, vol. 39, no. 2, pp. 79-132, 04 2018, doi: 10.1210/er.2017-00253.
42. M. D. Jensen et al., "2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society," (in eng), J Am Coll Cardiol, vol. 63, no. 25 Pt B, pp. 2985-3023, Jul 2014, doi: 10.1016/j.jacc.2013.11.004.
43. A. Mohan, J. Grace, B. R. Wang, and N. Lugogo, "The Effects of Obesity in Asthma," (in eng), Curr Allergy Asthma Rep, vol. 19, no. 10, p. 49, Sep 2019, doi: 10.1007/s11882-019-0877-z.
44. G. Klepaker et al., "Influence of Obesity on Work Ability, Respiratory Symptoms, and Lung Function in Adults with Asthma," (in eng), Respiration, pp. 1-9, Aug 2019, doi: 10.1159/000502154.
45. B. S. Gvozdenovic et al., "Effect of obesity on patient-reported outcomes in sarcoidosis," (in eng), Int J Tuberc Lung Dis, vol. 17, no. 4, pp. 559-64, Apr 2013, doi: 10.5588/ijtld.12.0665.
46. M. Fleischer, A. Hinz, E. Brähler, H. Wirtz, and A. Bosse-Henck, "Factors associated with fatigue in sarcoidosis," (in eng), Respir Care, vol. 59, no. 7, pp. 1086-94, Jul 2014, doi: 10.4187/respcare.02080.
47. A. Baydur, "Sarcoidosis and obesity: twin problems for the patient," (in eng), Int J Tuberc Lung Dis, vol. 17, no. 4, p. 431, Apr 2013, doi: 10.5588/ijtld.13.0119.
48. K. Mizuta, A. Matoba, S. Shibata, E. Masaki, and C. W. Emala, "Obesity-induced asthma: Role of free fatty acid receptors," (in eng), Jpn Dent Sci Rev, vol. 55, no. 1, pp. 103-107, Nov 2019, doi: 10.1016/j.jdsr.2019.07.002.
49. P. F. Coogan, J. R. Palmer, G. T. O'Connor, and L. Rosenberg, "Body mass index and asthma incidence in the Black Women's Health Study," (in eng), J Allergy Clin Immunol, vol. 123, no. 1, pp. 89-95, Jan 2009, doi: 10.1016/j.jaci.2008.09.040.
50. S. Xu, F. D. Gilliland, and D. V. Conti, "Elucidation of causal direction between asthma and obesity: a bi-directional Mendelian randomization study," (in eng), Int J Epidemiol, vol. 48, no. 3, pp. 899-907, Jun 2019, doi: 10.1093/ije/dyz070.
51. J. Costa-Font and J. Gil, "Obesity and the incidence of chronic diseases in Spain: a seemingly unrelated probit approach," (in eng), Econ Hum Biol, vol. 3, no. 2, pp. 188-214, Jul 2005, doi: 10.1016/j.ehb.2005.05.004.
52. E. Dal Grande, T. Gill, L. Wyatt, C. R. Chittleborough, P. J. Phillips, and A. W. Taylor, "Population attributable risk (PAR) of overweight and obesity on chronic diseases: South Australian representative, cross-sectional data, 2004-2006," (in eng), Obes Res Clin Pract, vol. 3, no. 3, pp. I-IV, Aug 2009, doi: 10.1016/j.orcp.2009.03.004.
53. M. Granata, E. Skarmoutsou, C. Trovato, G. A. Rossi, M. C. Mazzarino, and F. D'Amico, "Obesity, Type 1 Diabetes, and Psoriasis: An Autoimmune Triple Flip," (in eng), Pathobiology, vol. 84, no. 2, pp. 71-79, 2017, doi: 10.1159/000447777.
54. K. Van Raemdonck, S. Umar, Z. Szekanecz, R. K. Zomorrodi, and S. Shahrara, "Impact of obesity on autoimmune arthritis and its cardiovascular complications," (in eng), Autoimmun Rev, vol. 17, no. 8, pp. 821-835, Aug 2018, doi: 10.1016/j.autrev.2018.02.007.
55. E. Gremese, B. Tolusso, M. R. Gigante, and G. Ferraccioli, "Obesity as a risk and severity factor in rheumatic diseases (autoimmune chronic inflammatory diseases)," (in eng), Front Immunol, vol. 5, p. 576, 2014, doi: 10.3389/fimmu.2014.00576.
56. G. J. Gibson et al., "British Thoracic Society Sarcoidosis study: effects of long term corticosteroid treatment," (in eng), Thorax, vol. 51, no. 3, pp. 238-47, Mar 1996, doi: 10.1136/thx.51.3.238.
57. R. P. Baughman, H. Nunes, N. J. Sweiss, and E. E. Lower, "Established and experimental medical therapy of pulmonary sarcoidosis," (in eng), Eur Respir J, vol. 41, no. 6, pp. 1424-38, Jun 2013, doi: 10.1183/09031936.00060612.
58. S. H. Beegle, K. Barba, R. Gobunsuy, and M. A. Judson, "Current and emerging pharmacological treatments for sarcoidosis: a review," (in eng), Drug Des Devel Ther, vol. 7, pp. 325-38, 2013, doi: 10.2147/DDDT. S31064.
59. A. C. Schutt, W. M. Bullington, and M. A. Judson, "Pharmacotherapy for pulmonary sarcoidosis: a Delphi consensus study," (in eng), Respir Med, vol. 104, no. 5, pp. 717-23, May 2010, doi: 10.1016/j.rmed.2009.12.009.
60. M. A. Judson, "Corticosteroids in Sarcoidosis," (in eng), Rheum Dis Clin North Am, vol. 42, no. 1, pp. 119-35, ix, Feb 2016, doi: 10.1016/j.rdc.2015.08.012.
61. N. A. Khan et al., "Toxicity risk from glucocorticoids in sarcoidosis patients," (in eng), Respir Med, vol. 132, pp. 9-14, Nov 2017, doi: 10.1016/j.rmed.2017.09.003.
62. D. Huscher et al., "Dose-related patterns of glucocorticoid-induced side effects," (in eng), Ann Rheum Dis, vol. 68, no. 7, pp. 1119-24, Jul 2009, doi: 10.1136/ard.2008.092163.
63. R. P. Baughman et al., "Use of fluticasone in acute symptomatic pulmonary sarcoidosis," (in eng), Sarcoidosis Vasc Diffuse Lung Dis, vol. 19, no. 3, pp. 198-204, Oct 2002.
64. M. A. Judson, H. Chaudhry, A. Louis, K. Lee, and R. Yucel, "The effect of corticosteroids on quality of life in a sarcoidosis clinic: the results of a propensity analysis," (in eng), Respir Med, vol. 109, no. 4, pp. 526-31, Apr 2015, doi: 10.1016/j.rmed.2015.01.019.
65. A. N. Aggarwal, K. K. Sahu, and D. Gupta, "Fatigue and health-related quality of life in patients with pulmonary sarcoidosis treated by oral Corticosteroids," (in eng), Sarcoidosis Vasc Diffuse Lung Dis, vol. 33, no. 2, pp. 124-9, Aug 2016.
66. M. Savas et al., "Systematic Evaluation of Corticosteroid Use in Obese and Non-obese Individuals: A Multi-cohort Study," (in eng), Int J Med Sci, vol. 14, no. 7, pp. 615-621, 2017, doi: 10.7150/ijms.19213.
67. C. E. Broos, M. van Nimwegen, H. C. Hoogsteden, R. W. Hendriks, M. Kool, and B. van den Blink, "Granuloma formation in pulmonary sarcoidosis," (in eng), Front Immunol, vol. 4, p. 437, Dec 2013, doi: 10.3389/fimmu.2013.00437.
68. A. K. Gerke and G. Hunninghake, "The immunology of sarcoidosis," (in eng), Clin Chest Med, vol. 29, no. 3, pp. 379-90, vii, Sep 2008, doi: 10.1016/j.ccm.2008.03.014.
69. P. Sakthivel and D. Bruder, "Mechanism of granuloma formation in sarcoidosis," Curr Opin Hematol, vol. 24, no. 1, pp. 59-65, Jan 2017, doi: 10.1097/MOH.0000000000000301.
70. C. Taflin et al., "FoxP3+ regulatory T cells suppress early stages of granuloma formation but have little impact on sarcoidosis lesions," (in eng), Am J Pathol, vol. 174, no. 2, pp. 497-508, Feb 2009, doi: 10.2353/ajpath.2009.080580.
71. M. Miyara et al., "The immune paradox of sarcoidosis and regulatory T cells," (in eng), J Exp Med, vol. 203, no. 2, pp. 359-70, Feb 2006, doi: 10.1084/jem.20050648.
72. G. Rappl et al., "Regulatory T cells with reduced repressor capacities are extensively amplified in pulmonary sarcoid lesions and sustain granuloma formation," (in eng), Clin Immunol, vol. 140, no. 1, pp. 71-83, Jul 2011, doi: 10.1016/j.clim.2011.03.015.
73. K. A. Oswald-Richter et al., "Reversal of global CD4+ subset dysfunction is associated with spontaneous clinical resolution of pulmonary sarcoidosis," (in eng), J Immunol, vol. 190, no. 11, pp. 5446-53, Jun 2013, doi: 10.4049/jimmunol.1202891.
74. H. Cao, "Adipocytokines in obesity and metabolic disease," (in eng), J Endocrinol, vol. 220, no. 2, pp. T47-59, Feb 2014, doi: 10.1530/JOE-13-0339.
75. A. Stofkova, "Leptin and adiponectin: from energy and metabolic dysbalance to inflammation and autoimmunity," (in eng), Endocr Regul, vol. 43, no. 4, pp. 157-68, Oct 2009.
76. M. Ahmed and S. L. Gaffen, "IL-17 in obesity and adipogenesis," (in eng), Cytokine Growth Factor Rev, vol. 21, no. 6, pp. 449-53, Dec 2010, doi: 10.1016/j.cytogfr.2010.10.005.
77. S. Nishimura et al., "Adipose Natural Regulatory B Cells Negatively Control Adipose Tissue Inflammation," (in eng), Cell Metab, vol. 18, no. 5, pp. 759-766, Nov 2013, doi: 10.1016/j.cmet.2013.09.017.
78. M. Rakhshandehroo, E. Kalkhoven, and M. Boes, "Invariant natural killer T cells in adipose tissue: novel regulators of immune-mediated metabolic disease," (in eng), Cell Mol Life Sci, vol. 70, no. 24, pp. 4711-27, Dec 2013, doi: 10.1007/s00018-013-1414-1.
79. T. D. Kanneganti and V. D. Dixit, "Immunological complications of obesity," (in eng), Nat Immunol, vol. 13, no. 8, pp. 707-12, Jul 2012, doi: 10.1038/ni.2343.
80. H. S. Schipper, B. Prakken, E. Kalkhoven, and M. Boes, "Adipose tissue-resident immune cells: key players in immunometabolism," (in eng), Trends Endocrinol Metab, vol. 23, no. 8, pp. 407-15, Aug 2012, doi: 10.1016/j.tem.2012.05.011.
81. E. V. Arkema and Y. C. Cozier, "Epidemiology of sarcoidosis: current findings and future directions," (in eng), Ther Adv Chronic Dis, vol. 9, no. 11, pp. 227-240, Nov 2018, doi: 10.1177/2040622318790197.
82. P. Ungprasert, D. A. Wetter, C. S. Crowson, and E. L. Matteson, "Epidemiology of cutaneous sarcoidosis, 1976-2013: a population-based study from Olmsted County, Minnesota," (in eng), J Eur Acad Dermatol Venereol, vol. 30, no. 10, pp. 1799-1804, Oct 2016, doi: 10.1111/jdv.13760.