An integrative approach to acne

Acne affects between 79 to 95 percent of adolescents and 40 to 54 percent of adults in Western societies. Yet anthropological studies have found that acne is virtually non-existent in hunter-gatherer cultures.1 This suggests that genetic factors are not the primary driver of acne – and that environmental factors like diet and lifestyle play a major role.

Conventional treatments of acne include oral antibiotics, Accutane, and oral contraceptives, all of which produce unwanted side effects, don’t address the root cause of disease, and in many cases, just make the problem worse! In this article, I’ll discuss the underlying causes of acne, and how to treat them to get rid of acne for good.

The top underlying causes of acne

From my extensive reading of the literature and experience, there are seven major underlying causes of acne. These include:

  • Sugar and high glycemic index foods
  • Dairy consumption
  • Low stomach acid, SIBO and gut dysbiosis
  • Food intolerances and intestinal permeability
  • Nutrient deficiencies
  • Stress and HPA-dysregulation
  • Insulin resistance and hormone imbalance

In the next sections, I want to discuss the evidence behind each of these root causes. Afterward, I’ll provide some practical action steps to get you started on your acne healing journey.

1) Sugar and high glycemic index foods

Diets high in sugar and simple carbohydrates lead to increased production of insulin. Insulin signals through a transcription factor called SREBP-1, which increases the production of oily sebum in the sebaceous glands of the skin. This lipid-rich environment allows for the growth of the bacterium Propionibacterium acnes.2 P. acnes is a normal colonist of human skin, but its overgrowth is thought to be involved in the development of acne lesions.

In 2007, an Australian research group recruited 43 young adult males with moderate acne for a randomized controlled trial.3 The experimental group ate a low-glycemic load diet for 12 weeks, while the control group continued to eat a high-glycemic load diet. Glycemic load takes into account both the speed of carbohydrate absorption and the total amount of carbohydrate in foods. After 12 weeks, total acne lesions had significantly decreased in the low glycemic-load group compared to the control group. The experimental diet also resulted in weight loss, improved insulin sensitivity, and altered the fatty acid composition of the sebum.4

2) Dairy consumption

It is well-established that acne is driven by insulin-like growth factor 1 (IGF-1), which converges on the same insulin signaling pathway I mentioned above. IGF-1 stimulates keratinocyte proliferation, production of sebum, and the synthesis of androgens in ovaries and testes. IGF-1 is produced by our bodies throughout life, especially during puberty, but is also found in high levels in milk and dairy.

Several studies have found positive associations between milk consumption and severity of acne.5 Interestingly, no studies have linked fermented dairy consumption to acne. This may be because certain beneficial microbes found in fermented dairy (Lactobacilli) utilize IGF-1 during the fermentation process, resulting in a 4-fold lower level of IGF-1 in fermented milk compared to conventional milk.6

3) Low stomach acid and SIBO

In the 1930s, the dermatologists Stokes and Pillsbury hypothesized that inadequate stomach acid could allow the migration of bacteria from the colon towards the distal small intestine and that this could be a prime cause of skin conditions.7 They reported that as many as 40 percent of individuals with acne have hypochlorhydria, or low stomach acid production. This not only prevents the proper absorption of nutrients, but is also a major risk factor for small intestinal bacterial overgrowth (SIBO).

While few studies to date have assessed the prevalence of SIBO in acne patients, abdominal bloating is highly associated with acne.8 Another older study on 30 acne patients reported that 47 percent had low gut motility and 40 percent had a clinical complaint of constipation.9 Clinically, many practitioners report high levels of SIBO in their acne patients.

4) Food intolerances and intestinal permeability

Several studies suggest that patients with acne have increased intestinal permeability. One older study showed that of 57 acne patients, 66% had blood samples with enhanced reactivity to bacterial strains isolated from stool, while none of the control patients without active skin disease had any reactivity.10 Another study of 40 patients with deep inflammatory acne found an increased reactivity to E. coli lipopolysaccharide (LPS). Those with the most severe acne had elevated micro-clot formation, indicating high levels of LPS in the blood.11

Intestinal permeability and the influx of endotoxins from the gut into the bloodstream can cause systemic inflammation, which can also increase local inflammation in the skin. Small intestinal permeability is closely associated with food hypersensitivities, and eliminating inflammatory foods may help to resolve permeability.12

The gut-skin axis is just beginning to take the research stage, and studies on the gut microbiota in acne patients to date are extremely limited. A 1955 study found that Bacteroides spp. were more commonly isolated from acne patients, but this study used outdated culture techniques and only tested a handful of microbes. A more recent study published in Russia found that 54 percent of acne patients have significant gut dysbiosis.13 More studies using modern sequencing technologies are needed to better understand the role of the gut microbiota in acne.

5) Nutrient deficiencies

While rarely the sole driver of acne, nutrient deficiencies can also contribute to the pathogenesis of acne. The following are the most common nutrient deficiencies in acne.

Zinc: One study of 94 acne patients and 56 controls found that acne patients had significantly lower plasma levels of zinc.14 Another study using a supplement containing zinc methionine and antioxidants reported that 38 of 48 acne patients had over 80 percent improvement in their acne.15 Other studies have reported similar benefits of zinc, showing that it may even be as effective as antibiotics.16 Zinc tends to reduce free fatty acids in the sebum, and inhibits the lipases in several bacteria, including P. acnes.17 Zinc is also important for gut barrier function and may reduce the influx of inflammatory molecules into the bloodstream.18

Vitamin A: At least two studies have found that acne patients have low blood levels of Vitamin A and retinol-binding protein, its transport protein.14,19 Vitamin A works along with zinc to modulate the skin response to microbes, inhibit sebum production, reduce androgen formation.20 One preliminary report suggests that high dose vitamin A is highly effective for the treatment of severe inflammatory acne.21 High doses of Vitamin A should always be taken along with Vitamin D and Vitamin K2, which work synergistically with Vitamin A and also prevent symptoms of toxicity.

Omega-3 fats: The ratio of omega-6 to omega-3 fatty acids in Western diets is often estimated to be between 15:1 and 20:1, compared to a ratio of 2:1 in hunter-gatherer diets. Omega-6 fatty acids are precursors to pro-inflammatory eicosanoids and have been implicated in the development of inflammatory acne.22 In contrast, omega-3 fatty acids are anti-inflammatory and may help reduce IGF-1 levels and prevent the hyperkeratinization of sebaceous follicles that is characteristic of acne. One small observational study found that supplementation of 3 grams of fish oil for 12 weeks resulted in improvement for 8 of 13 patients with inflammatory acne.23 Another RCT found that supplementation of 2 grams of EPA and DHA daily for 10 weeks resulted in significant histological and subjective improvement in 45 patients with mild to moderate acne.

Selenium: Acne patients have also been shown to have low levels of blood selenium24 and lower levels of glutathione peroxidase, an antioxidant enzyme that depends on selenium.25 An open-label trial of selenium and Vitamin E supplementation for 6-12 weeks resulted in clinical improvements in acne symptoms, especially in those with low baseline glutathione peroxidase activity.25

6) Stress and HPA-dysregulation

The role of stress in acne flares is often under-appreciated, despite being hypothesized since the 1930s. Dermatologists Stokes and Pillsbury suggested that stress-induced changes to the gut flora could increase the likelihood of intestinal permeability and set the stage for systemic and local skin inflammation.26  More recent studies have suggested that acne tends to worsen under conditions of mental stress, such as during exam week for high school or college students.27,28

Mechanistic studies have shown that activation of the hypothalamic-pituitary-adrenal (HPA) axis during mental stress induces secretion of hormones that cause sebaceous hyper-proliferation and aggravate acne. A research group in Japan performed a study where they evaluated the abundance of P. acnes and the level of sebum production on the skin and related it to right prefrontal cortex (PFC) activity during a mental stress task:29

 “…subjects with higher sebum levels and higher P. acnes populations in the facial skin have right dominant PFC activity during a mental stress task, [suggesting] that such subjects are sensitive to mental stress associated with hyperactivity of the stress response system […]”

Furthermore, studies have shown that psychological stress impairs normal gut motility, encourages bacterial overgrowth, and increases gut permeability.30

7) Insulin resistance and hormone imbalance

Lastly, acne may also occur as part of various syndromes associated with insulin resistance and excess androgens. For instance, 70 percent of women with polycystic ovary syndrome (PCOS) experience acne. PCOS is characterized by insulin resistance, irregular menstrual cycles, and excess production of androgens. Androgens are typically thought of as the “male” hormones and include testosterone, dihydrotestosterone (DHT), and dehydroepiandrosterone (DHEA).

Insulin resistance and hyperandrogenism are also prevalent among males with acne. One small study assessed 22 male subjects with resistant acne and found significantly decreased insulin sensitivity compared to control subjects.31 A 1986 study found that free testosterone was significantly elevated in both male and female acne sufferers compared to controls.32

How to treat the underlying causes of acne

So, there you have it, the seven most common root causes of acne! Below, I’ve provided some practical action steps to heal acne from the inside out:

  • Reduce simple carbohydrates and sugar: adopt a whole foods diet that avoids any processed and refined carbohydrates, grains, and simple sugars. For severe acne, you may also want to limit starchy vegetables like potatoes, sweet potatoes, and high-sugar fruits.
  • Cut out dairy for at least 30 days: for many people, simply cutting dairy out of their diet can make an enormous difference. After 30 days, try reintroducing fermented dairy first, and see how your body and skin respond.
  • Test and treat SIBO and correct low stomach acid: many patients with skin conditions have what I call “silent” SIBO, where they don’t have any gut symptoms, yet addressing SIBO will often resolve their skin symptoms. SIBO can be identified by lactulose breath testing.
  • Identify other food intolerances and heal the gut: try an elimination diet or consider stool testing or food intolerance testing to identify what might be contributing to intestinal permeability. Support a healthy gut microbiome by eating plenty of fermentable fiber, fermented foods, and supplementing with high-quality probiotics:

Oral probiotics: Several strains of Lactobacillus and Bifidobacterium probiotics and fermented dairy products have shown promise for improving symptoms of acne in clinical trials. Saccharomyces cervisiae, a beneficial yeast, may also help in some individuals.33

  • Correct nutrient deficiencies: eat a nutrient-dense diet, and specifically focus on increasing consumption of zinc, omega-3 fats, vitamin A, and selenium. Below, I’ve provided the top dietary sources of each nutrient along with my recommended supplemental forms:

Zinc: The best dietary sources of zinc are organ meats, red meat, and seafood such as scallops, shellfish, and oysters. Plant foods like nuts and seeds also contain zinc, but this zinc is often bound to phytate, which inhibits absorption. The best supplemental forms of zinc are zinc methionine and zinc picolinate.

Omega-3s: Omega-3 fats are abundant in cold-water fatty fish like salmon, sardines, mackerel, black cod, and anchovies. You can also supplement with fish oil or krill oil. Krill oil also contains astaxanthin, an antioxidant beneficial for skin health.

Vitamin A: The best dietary source of Vitamin A is liver. Vitamin A can also be obtained from cold water fatty fish, or from supplementing with fish or krill oil. Vitamin D and K2 should also be taken to prevent Vitamin A toxicity.

Selenium: The richest source of dietary selenium is Brazil nuts, with just two Brazil nuts per day meeting the recommended adequate intake. Other sources include organ meats, seafood, muscle meats, and fish. Plant foods can contain selenium, but content will depend greatly on soil concentrations. If supplementing, try 100-200 mcg of the selenomethionine form.

  • Manage stress and support HPA balance: try yoga, meditation, mindfulness, or another stress management technique to help prevent stress-induced flares. Some patients with severe HPA dysregulation may benefit from testing and targeted supplementation with adaptogens to restore HPA balance.
  • Restore insulin sensitivity and support hormone balance: removing processed foods from the diet and engaging in regular resistance exercise training will help improve insulin sensitivity. Botanical supplements that may also help include:

Berberine: a natural compound isolated from a variety of herbs that has been shown to relieve insulin resistance. Berberine also has antimicrobial against P. acnes and Staphylococcus spp., decreases lipogenesis of sebaceous glands, and has an antiproliferative effect on keratinocytes.34

EGCG: a major polyphenol in green tea that modulates lipogenesis and may reduce inflammation and P. acnes overgrowth. An RCT found reduced acne lesions in females and a trend for reduced fasting blood sugar after supplementation with EGCG.35

  • Promote a healthy skin microbiome: While acne is primarily driven by the internal state of the body, the skin environment does play a role in acne. In 1912, topical Lactobacillus bulgaricus application was shown to be helpful in acne and seborrhea.36 Several other probiotic lactic acid bacteria have been shown to have antimicrobial activity against P. acnes in vitro.37,38 Try opening up a good quality probiotic capsule, mixing the contents with coconut oil, and applying it directly to the affected skin overnight.

That’s all for now! I hope you found this article helpful. If you did, be sure to sign up for my weekly newsletter. In a few weeks, I’ll be releasing an exclusive gut-skin axis guide for my subscribers.

Need some guidance on your acne-healing journey? Book a free consultation and find out how I can help.

 

Sources:

  1. Cordain, L. et al. Acne vulgaris: a disease of Western civilization. Arch Dermatol 138, 1584–1590 (2002).
  2. Melnik, B. C. & Schmitz, G. Role of insulin, insulin-like growth factor-1, hyperglycaemic food and milk consumption in the pathogenesis of acne vulgaris. Exp. Dermatol. 18, 833–841 (2009).
  3. Smith, R. N., Mann, N. J., Braue, A., Mäkeläinen, H. & Varigos, G. A. A low-glycemic-load diet improves symptoms in acne vulgaris patients: a randomized controlled trial. Am. J. Clin. Nutr. 86, 107–115 (2007).
  4. Smith, R. N., Braue, A., Varigos, G. A. & Mann, N. J. The effect of a low glycemic load diet on acne vulgaris and the fatty acid composition of skin surface triglycerides. J. Dermatol. Sci. 50, 41–52 (2008).
  5. Adebamowo, C. A. et al. High school dietary dairy intake and teenage acne. J. Am. Acad. Dermatol. 52, 207–214 (2005).
  6. Kang, S. S. et al. Diet and exercise orthogonally alter the gut microbiome and reveal independent associations with anxiety and cognition. Mol Neurodegener 9, 36 (2014).
  7. THE EFFECT ON THE SKIN OF EMOTIONAL AND NERVOUS STATES: III. THEORETICAL AND PRACTICAL CONSIDERATION OF A GASTRO-INTESTINAL MECHANISM | JAMA Dermatology | JAMA Network. Available at: https://jamanetwork.com/journals/jamadermatology/article-abstract/505747. (Accessed: 11th May 2018)
  8. Zhang, Q. et al. Accelerated dysbiosis of gut microbiota during aggravation of DSS-induced colitis by a butyrate-producing bacterium. Sci Rep 6, (2016).
  9. Ketron, L. W. & King, J. H. GASTRO-INTESTINAL FINDINGS IN ACNE VULGARIS: ESPECIALLY FLUOROSCOPIC. JAMA LXVII, 671–675 (1916).
  10. The Journal of Cutaneous Diseases Including Syphilis … (1916).
  11. Juhlin, L. & Michaëlsson, G. Fibrin microclot formation in patients with acne. Acta Derm. Venereol. 63, 538–540 (1983).
  12. Ventura, M. T. et al. Intestinal permeability in patients with adverse reactions to food. Digestive and Liver Disease 38, 732–736 (2006).
  13. Volkova, L. A., Khalif, I. L. & Kabanova, I. N. [Impact of the impaired intestinal microflora on the course of acne vulgaris]. Klin Med (Mosk) 79, 39–41 (2001).
  14. Ozuguz, P. et al. Evaluation of serum vitamins A and E and zinc levels according to the severity of acne vulgaris. Cutaneous and Ocular Toxicology 33, 99–102 (2014).
  15. Sardana, K. & Garg, V. K. An observational study of methionine-bound zinc with antioxidants for mild to moderate acne vulgaris. Dermatologic Therapy 23, 411–418 (2010).
  16. Michaëlsson, G., Juhlin, L. & Vahlquist, A. Effects of Oral Zinc and Vitamin A in Acne. Arch Dermatol 113, 31–36 (1977).
  17. Rebello, T., Atherton, D. J. & Holden, C. The effect of oral zinc administration on sebum free fatty acids in acne vulgaris. Acta Derm. Venereol. 66, 305–310 (1986).
  18. Mahmood, A. et al. Zinc carnosine, a health food supplement that stabilises small bowel integrity and stimulates gut repair processes. Gut 56, 168–175 (2007).
  19. Michaëlsson, G., Vahlquist, A. & Juhlin, L. Serum zinc and retinol-binding protein in acne. British Journal of Dermatology 96, 283–286 (1977).
  20. Agak, G. W. et al. Propionibacterium acnes Induces an IL-17 Response in Acne Vulgaris that Is Regulated by Vitamin A and Vitamin D. Journal of Investigative Dermatology 134, 366–373 (2014).
  21. Kligman, A. M. et al. Oral Vitamin A in Acne Vulgaris Preliminary Report. International Journal of Dermatology 20, 278–285 (1981).
  22. Zouboulis, C. C. Is Acne vulgaris a Genuine Inflammatory Disease? DRM 203, 277–279 (2001).
  23. Khayef, G., Young, J., Burns-Whitmore, B. & Spalding, T. Effects of fish oil supplementation on inflammatory acne. Lipids in Health and Disease 11, 165 (2012).
  24. Michaëlson, G. Decreased concentration of selenium in whole blood and plasma in acne vulgaris. Acta Dermato-Venereologica 70, (1990).
  25. Michaëlsson, G. & Edqvist, L. E. Erythrocyte glutathione peroxidase activity in acne vulgaris and the effect of selenium and vitamin E treatment. Acta Derm Venereol 64, 9–14 (1984).
  26. Bowe, W. P. & Logan, A. C. Acne vulgaris, probiotics and the gut-brain-skin axis – back to the future? Gut Pathog 3, 1 (2011).
  27. Chiu, A., Chon, S. Y. & Kimball, A. B. The response of skin disease to stress: changes in the severity of acne vulgaris as affected by examination stress. Arch Dermatol 139, 897–900 (2003).
  28. Yosipovitch, G. et al. Study of psychological stress, sebum production and acne vulgaris in adolescents. Acta Derm. Venereol. 87, 135–139 (2007).
  29. Tanida, M., Katsuyama, M. & Sakatani, K. Relation between mental stress-induced prefrontal cortex activity and skin conditions: a near-infrared spectroscopy study. Brain Res. 1184, 210–216 (2007).
  30. Wang, S.-X. & Wu, W.-C. Effects of psychological stress on small intestinal motility and bacteria and mucosa in mice. World J. Gastroenterol. 11, 2016–2021 (2005).
  31. Insulin resistance and acne: a new risk factor for men? | SpringerLink. Available at: https://link.springer.com/article/10.1007/s12020-012-9647-6. (Accessed: 12th May 2018)
  32. Lawrence, D., Shaw, M. & Katz, M. Elevated free testosterone concentration in men and women with acne vulgaris. Clinical and Experimental Dermatology 11, 263–273 (1986).
  33. Bowe, W., Patel, N. B. & Logan, A. C. Acne vulgaris, probiotics and the gut-brain-skin axis: from anecdote to translational medicine. Benef Microbes 5, 185–199 (2014).
  34. Clark, A. & Mach, N. Exercise-induced stress behavior, gut-microbiota-brain axis and diet: a systematic review for athletes. Journal of the International Society of Sports Nutrition 13, 43 (2016).
  35. Does supplementation with green tea extract improve acne in post-adolescent women? A randomized, double-blind, and placebo-controlled clinical trial – ScienceDirect. Available at: https://www.sciencedirect.com/science/article/pii/S0965229916300280?via%3Dihub. (Accessed: 12th May 2018)
  36. Peyri, J. Topical bacteriotherapy of the skin. J Cutaneous Dis 30, 688–89 (1912).
  37. Al-Ghazzewi, F. H. & Tester, R. F. Effect of konjac glucomannan hydrolysates and probiotics on the growth of the skin bacterium Propionibacterium acnes in vitro. Int J Cosmet Sci 32, 139–142 (2010).
  38. Antimicrobial activity of enterocins from Enterococcus faecalis SL-5 against Propionibacterium acnes, the causative agent in acne vulgaris, and its… – PubMed – NCBI. Available at: https://www.ncbi.nlm.nih.gov/pubmed/19229497?dopt=Abstract. (Accessed: 12th May 2018)

An integrative approach to acne

Acne affects between 79 to 95 percent of adolescents and 40 to 54 percent of adults in Western societies. Yet anthropological studies have found that acne is virtually non-existent in hunter-gatherer cultures.1 This suggests that genetic factors are not the primary driver of acne – and that environmental factors like diet and lifestyle play a major role.

Conventional treatments of acne include oral antibiotics, Accutane, and oral contraceptives, all of which produce unwanted side effects, don’t address the root cause of disease, and in many cases, just make the problem worse! In this article, I’ll discuss the underlying causes of acne, and how to treat them to get rid of acne for good.

The top underlying causes of acne

From my extensive reading of the literature and experience, there are seven major underlying causes of acne. These include:

  • Sugar and high glycemic index foods
  • Dairy consumption
  • Low stomach acid, SIBO and gut dysbiosis
  • Food intolerances and intestinal permeability
  • Nutrient deficiencies
  • Stress and HPA-dysregulation
  • Insulin resistance and hormone imbalance

In the next sections, I want to discuss the evidence behind each of these root causes. Afterward, I’ll provide some practical action steps to get you started on your acne healing journey.

1) Sugar and high glycemic index foods

Diets high in sugar and simple carbohydrates lead to increased production of insulin. Insulin signals through a transcription factor called SREBP-1, which increases the production of oily sebum in the sebaceous glands of the skin. This lipid-rich environment allows for the growth of the bacterium Propionibacterium acnes.2 P. acnes is a normal colonist of human skin, but its overgrowth is thought to be involved in the development of acne lesions.

In 2007, an Australian research group recruited 43 young adult males with moderate acne for a randomized controlled trial.3 The experimental group ate a low-glycemic load diet for 12 weeks, while the control group continued to eat a high-glycemic load diet. Glycemic load takes into account both the speed of carbohydrate absorption and the total amount of carbohydrate in foods. After 12 weeks, total acne lesions had significantly decreased in the low glycemic-load group compared to the control group. The experimental diet also resulted in weight loss, improved insulin sensitivity, and altered the fatty acid composition of the sebum.4

2) Dairy consumption

It is well-established that acne is driven by insulin-like growth factor 1 (IGF-1), which converges on the same insulin signaling pathway I mentioned above. IGF-1 stimulates keratinocyte proliferation, production of sebum, and the synthesis of androgens in ovaries and testes. IGF-1 is produced by our bodies throughout life, especially during puberty, but is also found in high levels in milk and dairy.

Several studies have found positive associations between milk consumption and severity of acne.5 Interestingly, no studies have linked fermented dairy consumption to acne. This may be because certain beneficial microbes found in fermented dairy (Lactobacilli) utilize IGF-1 during the fermentation process, resulting in a 4-fold lower level of IGF-1 in fermented milk compared to conventional milk.6

3) Low stomach acid and SIBO

In the 1930s, the dermatologists Stokes and Pillsbury hypothesized that inadequate stomach acid could allow the migration of bacteria from the colon towards the distal small intestine and that this could be a prime cause of skin conditions.7 They reported that as many as 40 percent of individuals with acne have hypochlorhydria, or low stomach acid production. This not only prevents the proper absorption of nutrients, but is also a major risk factor for small intestinal bacterial overgrowth (SIBO).

While few studies to date have assessed the prevalence of SIBO in acne patients, abdominal bloating is highly associated with acne.8 Another older study on 30 acne patients reported that 47 percent had low gut motility and 40 percent had a clinical complaint of constipation.9 Clinically, many practitioners report high levels of SIBO in their acne patients.

4) Food intolerances and intestinal permeability

Several studies suggest that patients with acne have increased intestinal permeability. One older study showed that of 57 acne patients, 66% had blood samples with enhanced reactivity to bacterial strains isolated from stool, while none of the control patients without active skin disease had any reactivity.10 Another study of 40 patients with deep inflammatory acne found an increased reactivity to E. coli lipopolysaccharide (LPS). Those with the most severe acne had elevated micro-clot formation, indicating high levels of LPS in the blood.11

Intestinal permeability and the influx of endotoxins from the gut into the bloodstream can cause systemic inflammation, which can also increase local inflammation in the skin. Small intestinal permeability is closely associated with food hypersensitivities, and eliminating inflammatory foods may help to resolve permeability.12

The gut-skin axis is just beginning to take the research stage, and studies on the gut microbiota in acne patients to date are extremely limited. A 1955 study found that Bacteroides spp. were more commonly isolated from acne patients, but this study used outdated culture techniques and only tested a handful of microbes. A more recent study published in Russia found that 54 percent of acne patients have significant gut dysbiosis.13 More studies using modern sequencing technologies are needed to better understand the role of the gut microbiota in acne.

5) Nutrient deficiencies

While rarely the sole driver of acne, nutrient deficiencies can also contribute to the pathogenesis of acne. The following are the most common nutrient deficiencies in acne.

Zinc: One study of 94 acne patients and 56 controls found that acne patients had significantly lower plasma levels of zinc.14 Another study using a supplement containing zinc methionine and antioxidants reported that 38 of 48 acne patients had over 80 percent improvement in their acne.15 Other studies have reported similar benefits of zinc, showing that it may even be as effective as antibiotics.16 Zinc tends to reduce free fatty acids in the sebum, and inhibits the lipases in several bacteria, including P. acnes.17 Zinc is also important for gut barrier function and may reduce the influx of inflammatory molecules into the bloodstream.18

Vitamin A: At least two studies have found that acne patients have low blood levels of Vitamin A and retinol-binding protein, its transport protein.14,19 Vitamin A works along with zinc to modulate the skin response to microbes, inhibit sebum production, reduce androgen formation.20 One preliminary report suggests that high dose vitamin A is highly effective for the treatment of severe inflammatory acne.21 High doses of Vitamin A should always be taken along with Vitamin D and Vitamin K2, which work synergistically with Vitamin A and also prevent symptoms of toxicity.

Omega-3 fats: The ratio of omega-6 to omega-3 fatty acids in Western diets is often estimated to be between 15:1 and 20:1, compared to a ratio of 2:1 in hunter-gatherer diets. Omega-6 fatty acids are precursors to pro-inflammatory eicosanoids and have been implicated in the development of inflammatory acne.22 In contrast, omega-3 fatty acids are anti-inflammatory and may help reduce IGF-1 levels and prevent the hyperkeratinization of sebaceous follicles that is characteristic of acne. One small observational study found that supplementation of 3 grams of fish oil for 12 weeks resulted in improvement for 8 of 13 patients with inflammatory acne.23 Another RCT found that supplementation of 2 grams of EPA and DHA daily for 10 weeks resulted in significant histological and subjective improvement in 45 patients with mild to moderate acne.

Selenium: Acne patients have also been shown to have low levels of blood selenium24 and lower levels of glutathione peroxidase, an antioxidant enzyme that depends on selenium.25 An open-label trial of selenium and Vitamin E supplementation for 6-12 weeks resulted in clinical improvements in acne symptoms, especially in those with low baseline glutathione peroxidase activity.25

6) Stress and HPA-dysregulation

The role of stress in acne flares is often under-appreciated, despite being hypothesized since the 1930s. Dermatologists Stokes and Pillsbury suggested that stress-induced changes to the gut flora could increase the likelihood of intestinal permeability and set the stage for systemic and local skin inflammation.26  More recent studies have suggested that acne tends to worsen under conditions of mental stress, such as during exam week for high school or college students.27,28

Mechanistic studies have shown that activation of the hypothalamic-pituitary-adrenal (HPA) axis during mental stress induces secretion of hormones that cause sebaceous hyper-proliferation and aggravate acne. A research group in Japan performed a study where they evaluated the abundance of P. acnes and the level of sebum production on the skin and related it to right prefrontal cortex (PFC) activity during a mental stress task:29

 “…subjects with higher sebum levels and higher P. acnes populations in the facial skin have right dominant PFC activity during a mental stress task, [suggesting] that such subjects are sensitive to mental stress associated with hyperactivity of the stress response system […]”

Furthermore, studies have shown that psychological stress impairs normal gut motility, encourages bacterial overgrowth, and increases gut permeability.30

7) Insulin resistance and hormone imbalance

Lastly, acne may also occur as part of various syndromes associated with insulin resistance and excess androgens. For instance, 70 percent of women with polycystic ovary syndrome (PCOS) experience acne. PCOS is characterized by insulin resistance, irregular menstrual cycles, and excess production of androgens. Androgens are typically thought of as the “male” hormones and include testosterone, dihydrotestosterone (DHT), and dehydroepiandrosterone (DHEA).

Insulin resistance and hyperandrogenism are also prevalent among males with acne. One small study assessed 22 male subjects with resistant acne and found significantly decreased insulin sensitivity compared to control subjects.31 A 1986 study found that free testosterone was significantly elevated in both male and female acne sufferers compared to controls.32

How to treat the underlying causes of acne

So, there you have it, the seven most common root causes of acne! Below, I’ve provided some practical action steps to heal acne from the inside out:

  • Reduce simple carbohydrates and sugar: adopt a whole foods diet that avoids any processed and refined carbohydrates, grains, and simple sugars. For severe acne, you may also want to limit starchy vegetables like potatoes, sweet potatoes, and high-sugar fruits.
  • Cut out dairy for at least 30 days: for many people, simply cutting dairy out of their diet can make an enormous difference. After 30 days, try reintroducing fermented dairy first, and see how your body and skin respond.
  • Test and treat SIBO and correct low stomach acid: many patients with skin conditions have what I call “silent” SIBO, where they don’t have any gut symptoms, yet addressing SIBO will often resolve their skin symptoms. SIBO can be identified by lactulose breath testing.
  • Identify other food intolerances and heal the gut: try an elimination diet or consider stool testing or food intolerance testing to identify what might be contributing to intestinal permeability. Support a healthy gut microbiome by eating plenty of fermentable fiber, fermented foods, and supplementing with high-quality probiotics:

Oral probiotics: Several strains of Lactobacillus and Bifidobacterium probiotics and fermented dairy products have shown promise for improving symptoms of acne in clinical trials. Saccharomyces cervisiae, a beneficial yeast, may also help in some individuals.33

  • Correct nutrient deficiencies: eat a nutrient-dense diet, and specifically focus on increasing consumption of zinc, omega-3 fats, vitamin A, and selenium. Below, I’ve provided the top dietary sources of each nutrient along with my recommended supplemental forms:

Zinc: The best dietary sources of zinc are organ meats, red meat, and seafood such as scallops, shellfish, and oysters. Plant foods like nuts and seeds also contain zinc, but this zinc is often bound to phytate, which inhibits absorption. The best supplemental forms of zinc are zinc methionine and zinc picolinate.

Omega-3s: Omega-3 fats are abundant in cold-water fatty fish like salmon, sardines, mackerel, black cod, and anchovies. You can also supplement with fish oil or krill oil. Krill oil also contains astaxanthin, an antioxidant beneficial for skin health.

Vitamin A: The best dietary source of Vitamin A is liver. Vitamin A can also be obtained from cold water fatty fish, or from supplementing with fish or krill oil. Vitamin D and K2 should also be taken to prevent Vitamin A toxicity.

Selenium: The richest source of dietary selenium is Brazil nuts, with just two Brazil nuts per day meeting the recommended adequate intake. Other sources include organ meats, seafood, muscle meats, and fish. Plant foods can contain selenium, but content will depend greatly on soil concentrations. If supplementing, try 100-200 mcg of the selenomethionine form.

  • Manage stress and support HPA balance: try yoga, meditation, mindfulness, or another stress management technique to help prevent stress-induced flares. Some patients with severe HPA dysregulation may benefit from testing and targeted supplementation with adaptogens to restore HPA balance.
  • Restore insulin sensitivity and support hormone balance: removing processed foods from the diet and engaging in regular resistance exercise training will help improve insulin sensitivity. Botanical supplements that may also help include:

Berberine: a natural compound isolated from a variety of herbs that has been shown to relieve insulin resistance. Berberine also has antimicrobial against P. acnes and Staphylococcus spp., decreases lipogenesis of sebaceous glands, and has an antiproliferative effect on keratinocytes.34

EGCG: a major polyphenol in green tea that modulates lipogenesis and may reduce inflammation and P. acnes overgrowth. An RCT found reduced acne lesions in females and a trend for reduced fasting blood sugar after supplementation with EGCG.35

  • Promote a healthy skin microbiome: While acne is primarily driven by the internal state of the body, the skin environment does play a role in acne. In 1912, topical Lactobacillus bulgaricus application was shown to be helpful in acne and seborrhea.36 Several other probiotic lactic acid bacteria have been shown to have antimicrobial activity against P. acnes in vitro.37,38 Try opening up a good quality probiotic capsule, mixing the contents with coconut oil, and applying it directly to the affected skin overnight.

That’s all for now! I hope you found this article helpful. If you did, be sure to sign up for my weekly newsletter. In a few weeks, I’ll be releasing an exclusive gut-skin axis guide for my subscribers.

Need some guidance on your acne-healing journey? Book a free consultation and find out how I can help.

 

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