It’s probably most common to associate acne with moody teenagers, but acne breakouts can affect anyone at any age. Certain factors such as stress, hormones and diet are all known to influence skin health and whilst the odd spot here or there may not be such a big thing, serious acne flare-ups can be painful, distressing and may lead to depression in more severe cases. Pharmaceutical interventions include both topical applications and use of antibiotics, both of which come with potential side effects. By understanding how factors (diet and environment) affect the initiation and progression of acne, it is possible to take steps to manage and reduce the severity of acne flare-ups.
The function of the sebaceous glands (the tiny glands attached to hair follicles found near the surface of the skin) is to lubricate the hair and skin to stop them drying, through the production of an oily substance called sebum. With acne, these glands produce too much sebum, and when the excess sebum mixes with dead skin cells it can form a plug in the follicle. If the plugged follicle is close to the surface of the skin, it bulges outwards, creating a whitehead, and if open to the skin, creates a blackhead. When sebum mixes with bacteria and dead skin cells, these clog the pores and cause inflammation, leading to the hallmark of acne – papules and pustules:
- Papules are a form of acne that appear as small bumps on the face with no visible pores (unlike blackheads), and they are not white like whiteheads, but closed, red and surrounded by skin inflammation.
- Pustules are considered to be a moderate form of acne that presents itself as medium-sized bumps on the face. These bumps have a noticeably white or yellow dot in the centre and are surrounded by inflammation.
There are 4 primary factors, which interact to produce acne ‘lesions’:
- Excess sebum production by the sebaceous gland
- Colonisation of the follicle by bacteria (especially propionibacteriumacnes or p acnes, which is the key bacterium linked to acne (p acnes feeds on sebum!!)
- Alterations in the process of keratinisation (keratin is the key structural protein that makes up the outer layer of skin)
8 key factors to consider to reduce acne flare-ups
A number of factors – including diet, hormones, insulin, digestion, liver function, sebum production, cell turnover and nutrient deficiencies – can affect these 4 primary factors and can affect acne flare-ups. By making a few relatively simple changes it is possible to improve skin health and reduce or minimise flare-ups.
1. The role of hormones
Whilst some adults develop acne, the majority of cases occur in teenagers at a time when the hormones oestrogen and testosterone are wreaking havoc in the body! Sex hormone-binding globulin (SHBG) is a protein made by the liver, that functions to bind to hormones making them essentially ‘inactive’. If SHBG levels are low, circulating levels of oestrogen and testosterone increase. As testosterone increases sebum production, any dietary factors that reduce SHBG levels increase levels of testosterone and exacerbate acne. SHBG levels are specifically decreased by high levels of insulin (produced in response to carbohydrate consumption) and insulin-like growth factor 1 (IGF-1), a hormone that promotes tissue growth and prevents cell death. Overproduction of IGF-1 plays a direct role in promoting acne by inducing hyperkeratosis (over production of keratin) and epidermal hyperplasia (thickening of the skin), leading to blockage of the follicle. High carbohydrate diets and/or diets high in refined grains and simple carbohydrate (sugar = glucose) will also lower SHBG, by increasing fat synthesis in the liver, which in turn shuts off the gene involved in SHBG production. Habitually consuming foods high in carbohydrate, or food combinations that elicit a high insulin response may be directly responsible for decreasing SHBG. Addressing the type and amount of carbohydrate in the diet is therefore highly important for acne sufferers.
2. Carbohydrate and insulin production
When we eat carbohydrate it is broken down in the body to produce the energy molecule glucose. In response to an increase in blood glucose levels after a carbohydrate-containing meal, the pancreas releases the hormone insulin which acts like a key in a lock, opening ‘doors’ within cell membranes allowing glucose to enter where it can be utilised for fuel. Sugars, starches and fibre are all carbohydrates and are defined as simple or complex based on the number of sugars in their chemical structure. Foods with only one or two sugars, such as fructose (the sugar in fruits) and sucrose (table sugar), are simple carbohydrates. Carbohydrates with many sugar molecules joined together are known as complex carbohydrates and include vegetables, legumes and whole grains. Fibre, unlike simple and complex carbohydrate, isn’t digested (so no calories!) but plays an essential role in regulating good gut health, in part by acting as prebiotics that feed friendly bacteria and starve the ‘bad’ bacteria. Complex carbohydrates take longer to digest and have less impact on blood sugar levels. The impact that a type of carbohydrate has on blood sugar levels is called its glycaemic index (GI). Foods with a high GI are rapidly absorbed, leading to higher blood sugar levels and corresponding elevated levels of insulin. Insulin and IGF-1 have been shown to augment sebum production, stimulate testosterone synthesis, and bioavailability, all of which play a role in the pathogenesis of acne.
3. Fatty acids and inflammation
A major cause of inflammation is due to the imbalance in levels of omega-6 and omega-3 fatty acids in our diet. An out-of-balance diet that is high in omega-6 fatty acids disrupts the balance of pro- and anti-inflammatory agents in the body, promoting chronic inflammation and elevating the risk of health problems – including acne. Omega-6 fats are found predominantly in common vegetable oils (corn oil, sunflower oil), processed foods, ready meals and junk foods. As intensive farming methods and grain-based feed raises omega-6 levels in livestock, consuming meat and meat products from these animals can also increase intake of omega-6.
- Reducing omega-6 is possible by eating grass-fed meat and dairy and swapping to olive oil, butter from grass-fed animals, or coconut oil for cooking/drizzling. In addition to reducing omega-6, increase omega-3 by consuming 2 portions of oily fish (sardines, mackerel, salmon) weekly.
- Supplement with Pharmepa RESTORE pure EPA. A 2008 case study of 5 individuals with inflammatory acne study found that 1g EPA taken for 2 months significantly improved acne flare-ups, with notably less flawed skin in all participants.
- Have a teaspoon (or two) of organic coconut oil per day. Lauric acid makes up about 50% of the fatty acid content of coconut oil and has specific antimicrobial activity acid against P. acnes, the bacterium that promotes inflammatory acne.
4. Micronutrient deficiencies
Processed food including fast food, frozen meals, cereals, most bread, and many snack foods are altered so much during processing that many of the essential nutrients required for a range of physiological functions are lost. Antioxidants reduce inflammation and vitamins & minerals act as cofactors for many processes required for optimising skin health. A balanced intake of nutrients is possible by avoiding processed refined foods and focusing on a diet that includes lots of vegetables, quality protein (lean meat, plenty of oily fish), legumes (such as lentils, quinoa, chickpeas) and good fats (such as olive oil & coconut oil), nuts and seeds, with a few portions of low GI fruits.
- Eat plentiful amounts of raw fruits and vegetables, especially dark green leafy vegetables and orange, yellow, and red coloured fruits and vegetables. Try to eat some raw fruits or vegetables with every meal, as they contain living enzymes, vitamins and minerals, natural antibiotic substances and other nutrients that are naturally destroyed during the cooking process.
- Topping up levels of essential nutrients with Super B-Complex will help manage/support both inflammatory and detoxification pathways needed to reduce acne flare-ups.
As milk is meant to increase the growth of calves, it naturally contains growth hormones with a direct link between milk consumption (skimmed especially) and acne. Milk from intensively farmed cows has been shown to contain the highest levels of IGF-1. Interestingly, fermented milk products (like kefir) have much lower levels of IGF-1 because the beneficial bacteria (Lactobacilli in particular) utilise IGF-I during the fermentation process. If excluding dairy from the diet is difficult, try drinking organic milk from grass-fed cows, or raw milk (unpasteurised) if possible.
- There is some evidence that raw milk may be beneficial for acne sufferers due to its content of lactoferrin, an enzyme that inhibits the growth of p. acnes and decreases skin inflammation through antibacterial and anti-inflammatory activities. In addition to the lactoferrin content, raw milk also contains a number of cysteine-rich proteins (lactalbumin) that provide the building blocks required to make the potent anti-inflammatory and detoxifying enzyme glutathione, which is essential for optimal liver health and acts to neutralise potential inflammatory products that may exacerbate acne.
6. Liver function
The liver plays a vital role in the elimination of toxins generated on a daily basis as waste products of metabolism (the numerous chemical reactions involved in maintaining body processes) and environmental exposure (i.e. smoking, pollution). Acne is often related to a ‘sluggish liver’ and it is therefore imperative that you maintain good liver function. If liver health is poor, your body cannot handle toxins efficiently and this will increase toxic products (free radicals) that can exacerbate inflammation. Limit fructose (found in fruit and fruit juice) and avoid sucrose, as diets high in these two sugars can cause the liver to become fatty and inflamed. Drink plenty of water, get enough soluble fibre (which can bind and eliminate toxins and ‘excess’ hormones) and eat cruciferous vegetables.
- Fish and fish oil (especially high EPA oils) can help prevent the build-up of fat in the liver, improve the action of insulin and reduce inflammation throughout the body.
- Green tea and green tea extract (as a supplement) is anti-inflammatory and may keep fatty deposits from building up in the liver. Drink about 3 cups of green tea daily and try to drink at least 4 pints of water a day.
- Glutathione is the major detox enzyme produced by cells using glutathione ‘precursors’ which are the amino-acids glutamate, glycine and cysteine, the latter being the limiting factor for how much glutathione your cells are able to produce. Cysteine-rich foods include raw milk (as above!) soybeans, beef, lamb, chicken, oats, pork, fish and eggs.
7. Gut function and flora
The intestine is naturally permeable to very small molecules to allow the absorption of vital nutrients. At the same time, the cell barrier wall is designed to prevent large or harmful molecules from gaining entry to the bloodstream. If the healthy intestinal barrier becomes inflamed or irritated, it can become permeable to harmful substances, a condition known as ‘leaky gut’. The bacteria or ‘gut flora’ that live in our guts play multiple roles, including regulating immune and inflammatory function and producing a number of beneficial nutrients. Certain foods, such as grains, contain anti-nutrients that may increase intestinal permeability and cause leaky gut and associated symptoms. Gliadin, for example, is the primary protein found in wheat gluten and is capable of increasing the production of the intestinal protein zonulin, which in turn opens up gaps in the normally tight junctures between intestinal cells. The gut flora play a direct role in keeping the gut lining healthy and any disturbances in the normal ‘healthy’ gut flora can lead to leaky gut syndrome. Long-term antibiotic use (often prescribed for acne), psychological distress (depression and anxiety) alone or in combination with a high fat diet, processed ‘comfort’ foods lacking in important fibre, cause alterations to the normal gut flora.
The cells that make up our immune system are able to recognise and destroy invading pathogens (including the ‘bad’ bacteria in the gut) via specialised receptors embedded within their cell membranes known as Toll like receptors (TLR). These receptors are not only activated by specific bacteria but also by saturated fats, which has the additional effect of increasing insulin resistance (the inability of insulin to allow glucose into the cells – normally associated with diabetes) resulting in higher insulin levels which, as previously stated, is linked to lower SHBG levels and higher levels of testosterone thereby indirectly exacerbating acne flare-ups! Gut inflammation can also arise as a consequence of leaky gut where undigested food particles or toxic products directly derived from pathogenic bacteria (a process known as endotoxaemia) stimulate inflammatory processes. Substance P which is a type of protein produced in response to high inflammation and endotoxaemia can cause excessive sebum production, one of the hallmarks of acne, through a direct stimulatory effect on the sebaceous glands.
Inappropriate TLR activation may also promote the excessive inflammation that is directly linked to inflammatory skin diseases such as acne, psoriasis and atopic dermatitis. There are a number of topical creams available for the treatment of mild-moderate acne and the active ingredient retinoic acid acts not only to ‘normalise’ skin cell turnover and reduce inflammation but also limits the availability of TLR, thereby reducing the impact that bacteria have on inducing an inflammatory response.
In addition, inadequate production of stomach acid (hypochlorhydria), commonly seen in acne sufferers can lead to nutrient deficiencies and can cause alterations in the normal gut flora. As the stomach plays a vital role in the digestion process by stimulating the pancreas to produce digestive enzymes and bile, ensuring we produce sufficient stomach acid is a prerequisite for digestion and absorption of nutrients.
- Drinking water with a slice of lemon, a squeeze of lemon juice or a teaspoon of apple cider vinegar are well known ways to naturally increase stomach acid production.
- Eliminating grains (and sugars) from the diet, while introducing traditionally fermented foods, can help restore healthy gut function.
- Whilst naturally fermented foods such as kimchi, tempeh, and sauerkraut are all examples of “friendly-flora” foods that can help to maintain a healthy gut flora, the addition of a good quality probiotic culture to the diet may be a wise step to help put a stop to this inflammatory ‘cycle’.
- Good sources of insoluble fibre include whole-grain (gluten-free) breads, cereals and pasta, nuts, dark green leafy vegetables, broccoli, cabbage and other gas-producing vegetables – these will help feed your good bacteria and help reduce testosterone.
Chronic long-term stress increases inflammation and suppresses immune function and can be a key trigger for acne flare-ups! When under stress, the adrenal glands produce adrenaline, cortisol and testosterone and those who have a stress filled life are more likely to suffer from adrenal burnout (with an increased availability of testosterone). Take actions to reduce stress by adopting deep breathing techniques, take regular exercise (not intensive if you have adrenal fatigue) and find time for mindful meditation.
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