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Acne Explained – Beyond the Misinformation and Confusion

Just 10 years ago, when I was in training, we were taught that most dermatologic conditions, including acne, had no relationship to diet. And while a link between acne and stress was known, it was not highlighted as an important part of treatment. It is only recently that the influence of lifestyle factors on overall health has become a focus in the medical community, with more practitioners pointing out this important concept to their patients. A huge push forward has been characterization of the gut-skin-brain axis. This was the piece of the puzzle needed to be able to explain how mental health, nutrition, and the skin could be related.

Acne is one of my favorite conditions to treat, because it provides a starting point to discuss many factors that relate to both the skin and overall health. There is so much misinformation out there, it is easy to get overwhelmed, often resulting in overly complicated skincare regimens that actually harm the skin. And often while focusing too much on what we are applying to the skin, we are not paying enough attention to healthy lifestyle habits that would help not only our skin, but our health in general.

What causes acne?

Excess oil production. Excessive oil can come from overproduction or failure to remove oil from the skin. Oil production can be triggered by hormonal changes, like in puberty or from excessive cortisol, the stress hormone. Cortisol is elevated from mental or physical stress, lack of sleep and exercise, and excessive weight.

Pores clogged by oil and dead skin cells. Excessive oil and dead skin cells that do not exfoliate correctly clog pores, resulting in bumps in the skin called comedones.

Inflammation. Immune responses to certain bacteria on the skin lead to pimples.

Western diet. High glycemic load foods (white bread, baked goods, sugary foods and processed foods), dairy/whey, meat and high omega-6 fatty acid foods (processed foods, fast food, meat) increase oil production and reduce normal skin exfoliation, clogging pores. Foods rich in omega-6 (vegetable oils, processed foods) promote the inflammation leading to pimples.

Alterations of the microbiome. A diverse collection of microorganisms on the skin is necessary for clear skin. Exfoliating too aggressively, harsh products and use of antibiotics are common negative influences on our microbes. Diet comes into play here too. Eating inflammatory foods (sugar, high fat, red meat, trans fats and possibly gluten) releases inflammatory mediators from the gut which make their way to the skin and harm the good microbes.

What lifestyle measures could help my acne?

Diet changes. Consider avoiding dairy products, in particular skim milk and whey protein, and focusing on low glycemic index foods. Consider adding a probiotic and eating omega-3 rich foods (chia, hemp, flax, walnut and fish). Decrease meat consumption. Eat probiotic rich foods, such as sauerkraut or yogurt with live cultures, or take a probiotic supplement.

Get enough sleep and exercise. Meditate and strengthen personal relationships. It is all about minimizing that stress hormone, cortisol.

What medications are out there for acne?

Alpha and beta hydroxy acids (glycolic and salicylic acids respectively). These work to exfoliate and slough away dead skin cells so they do not clog pores, and can be found in a variety of over the counter products.

Niacinamide and antioxidants. These reduce inflammation and can be found in many over the counter products.

Antibiotics. Benzoyl peroxide is a common over the counter ingredient that acts as a topical antibiotic. There are also many prescription topical and oral antibiotics that have long been used to treat acne. These should really only be used for short periods of time, if at all, due to negative effects on the skin microbiome.

Retinoids. These work to normalize the turnover of our skin cells, so pores do not get clogged. They may also reduce oil production. Over the counter retinoids are retinol and adapalene. There are many prescription products, such as tretinoin and tazarotene. These must be used carefully to avoid over-exfoliation. Isotretretioin is an oral retinoid used for very severe acne.

Anti-Androgens. Generally, these work to reduce sebum production. A new prescription topical called clascoterone can be used in both men and women. Birth control pills, the oral medication spironolactone, are options for women.

So what is the bottom line?

A healthy lifestyle is the key to overall health and clear skin. Start with lifestyle changes and a simple skincare regimen (see below) that supports a healthy skin microbiome. See a dermatologist if these measures do not lead to clear skin.

Basic regimen if you are acne prone:

  1. Cleanse twice per day to remove oil and debris. Start by using a hydrating cleanser initially. Change to an alpha or beta hydroxy acid cleanser if further improvement needed.

  2. Use an antioxidant containing product daily.

  3. Use a retinol or adapalene containing product at bedtime twice a week,

  4. Keep the skin barrier hydrated with a moisturizing product daily.

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