Lifestyle & Dietary Changes for Acne
As we head into the school season, many teenagers face the anxiety and emotional distress of acne-prone skin.
Our skin is a complex, self-renewing organ that is our primary barrier against external threats.
The most common but challenging and complex skin disorder is acne. Acne affects 85% of teenagers, 42.5% of men, and 50.9% of women between the ages of 20-30.
Acne is not a trivial disease or just a cosmetic condition. It is an inflammatory skin condition with a complicated origin that carries with it a significant psychological and physical burden. It is a lifestyle disorder superimposed on a genetic susceptibility.
Acne involves the sebaceous glands associated with hair follicles. These two combined create what is termed the pilosebaceous unit.
In acne, excess oil production clogs the pilosebaceous unit. This results in abnormal keratinization and expansion of the duct. This in turn allows for proliferation of the bacteria Cutibacterium acnes, an immune inflammatory response, and skin microbiome imbalance. C. acnes also stimulates the production of fat, more keratin, disturbs other microorganisms, and produces inflammatory cytokines, resulting in a vicious cycle.
Acne is linked to excess hormone production including androgens, growth hormone, insulin-like growth factor 1 (IGF-1), insulin, and cortisol. Cortisol increases oil production. Higher levels of insulin increase IGF-1 and androgens. Growth hormone and IGF-1 cause a rise in androgens and is associated with puberty.
Puberty often causes an elevation in oil production, leading to an increased incidence of acne during teenage years and young adulthood. The enzyme (5-alpha reductase) that converts testosterone to dihydrotestosterone (DHT) is found in the skin hair follicles. DHT is the preferred hormone for androgen activity. A higher density of the DHT receptor is found in the skin of individuals with acne. Sex hormone binding globulin (SHBG) is a protein that transports androgens in the body. Lower levels are seen in acne. Lower levels of SHBG results in an increase in free circulating testosterone. In short, acne is a dermatological manifestation of excess testosterone.
The skin microbiome can be affected by facial products, genetics, hormones, and diet. When the facial skin microbiome is disturbed (dysbiosis) this can lead to further inflammation and sensitivity of the skin.
The gut-skin axis is a bidirectional connection linking the gut microbiome with skin homeostasis. Cutaneous manifestations, such as acne, are often seen with GI disorders. Individuals with acne have been found to have a decrease in the diversity of their gut microbiome with lower abundance of healthier bacteria (Firmicutes) and increased levels of more harmful bacteria (Bacteroides). The gut microbiome likely regulates the skin through the control of systemic immunity and production of metabolites (SCFAs).
Thus, dysbiosis of the skin microbiome, as well as the gut, can increase the risk of acne.
Other triggers for acne include
· Endocrine disorders
· Medications (corticosteroids, lithium, testosterone)
· Stress
Stress increases the production of cortisol and androgens
· Poor sleep
Decreased, or poor quality, sleep results in higher levels of cortisol
· Cigarette smoking
Possibly due to lower levels of vitamin E and higher levels of oxidized skin oil
· Facial products with high oil content
· Family history of acne
Higher risk when both parents had acne in adolescence
There are a variety of genes that have been associated with acne. The majority of these are involved in regulation of the immune response or androgen metabolism.
Does diet matter?
The strongest evidence is found between consumption of a high glycemic index diet and acne.
Glycemic index is the measurement of the rise in blood glucose after consumption of a particular food. Simply put, foods that raise your blood sugar rapidly, increase your chance of having acne.
This includes pasta, white rice, sugar sweetened beverages, fast food, non-whole grain cereals, white bread, non-whole grain bagels, sugar, potatoes, and processed foods.
A low glycemic index diet has been found to decrease IGF-1 production in adults with moderate acne.
In studies conducted in nations with a prevailing Western diet (characterized by processed foods high in simple sugars and saturated fats), dairy is also linked with an increased incidence of acne. Androgens and hormonal mediators (including IGF-1) are found in dairy products and can survive processing.
The Western diet stimulates fat production and inflammation in the pilosebaceous unit by an inflammatory molecule termed mTORC1. This results in increased skin fatty acids and oil.
There is also data to suggest that diets high in animal protein increase the incidence of acne. This is thought to be due to a higher concentration of branched-chain amino acids (BCAAs) found in animal protein. BCAAs cause an increase in IGF-1.
The 28th European Academy of Dermatology and Venereology Congress identified the following foods that trigger acne:
· Refined grains and sweets
· Dairy products
· Fast food
· Chocolate (possibly due to the included sugar and milk, not necessarily the cocoa)
· Whey protein
Goals for treatment:
· Support key endocrine response (decrease excess androgens)
· Eliminate persistent C. acnes
· Optimize immune function
· Eliminate chronic inflammation
· Address metabolic imbalances (insulin resistance, etc.)
· Address gut dysbiosis
What foods can help?
· A diet rich in fiber, polyphenols, and antioxidants
These compounds are prebiotics for the microbiome and have direct anti-inflammatory effects
· Low glycemic index complex carbohydrates
Whole grains, legumes, fruits, and vegetables
· Foods low in saturated fats and simple sugars
· A diet lower in animal protein
· To support the immune system and decrease inflammation
Foods containing zinc
pumpkin seeds, cashews, quinoa, lentils, turkey
Foods containing vitamin A
Leafy green vegetables, tomatoes, orange and yellow vegetables, fruits
Foods containing vitamin E
Avocados, mangos, kiwi, seeds & nuts
Curcumin (turmeric)
Foods containing omega 3 fatty acids
Fatty fish, flaxseed, chia seeds, walnuts
Dietary supplementation to consider with your healthcare provider
Zinc, vitamin D, selenium, chromium, omega-3 fatty acids.
Other supplements that are currently being studied include green tea, chaste tree, milk thistle, golden seal, calendula, echinacea, probiotics, Oregon grape, and licorice + white peony root (in women). Both golden seal and Oregon grape contain berberine. Berberine is a polyphenol that also increases SHBG and lowers blood sugar levels.
The best evidence for supplemental topical application is for tea tree oil. Be cautious, however, due to an increased number of products with adulterated tea tree oil. Combining tea tree oil with diluted licorice creates a gentler cleanser. Harsh cleansers often result in rebound oil production.
Potential biochemical targets
· mTORC1
Calorie restriction, polyphenols, and exercise decrease mTORC1
Specific polyphenols include berberine, resveratrol, and curcumin
· Insulin
Gymnema sylvestre and green tea with a meal can potentially slow down sugar absorption
Cinnamon, as well as lemon and/or lime juice, can have similar benefits
· IGF-1
· Androgens
· 5-alpha reductase
· SHBG
· Skin and gut microbiome
There is some evidence that blue light therapy can help treat or prevent acne breakouts. Blue light therapy likely destroys P. acnes and has an anti-inflammatory effect on the outer layer of the skin.
“Rebalancing the natural microbiome of the skin by restoring the natural skin barrier, limiting the proliferation of C. acnes on the skin by using topical antibacterial which do not cause resistance, and regulating quantity and quality of sebum will be the main acne treatment challenges in the future.” (Azzouni F, Zeitouni, N, Mohler J. J Drugs Dermatol. 2013; 12(2): 30-35.)
Other small lifestyle changes that can add up to make a large difference
· Wash your phone
· Wash your face after exercise
· Do not touch your face/acne
· Wash your workout gear
· Always remove makeup
· Stay hydrated
