il-1The question, “Is acne an autoimmune disease?” has always lingered in the back of my mind. An article in Swiss Medical Weekly recently looked into how an over-active immune response could be the culprit in chronic skin inflammation. Since we know that acne is largely an inflammatory disease, could this play a part? The authors state, “The skin is our largest organ, which is exposed to and protects the body from microbes, pathogens and several irritants. However, the skin can…be a site of excessive immune responses resulting in chronic inflammation, autoimmunity or autoinflammation.”

Our skin, like other organs of our body, is pretty amazing. It provides defense against a multitude of pathogens. However, in the case of acne, might it be overreacting to perceived pathogens and creating an unjustified inflammatory response in the form of excess oil and/or hyper-proliferation of skin cells? The key may be in researching inflammasomes that detect pathogens and the cytokines that these inflammasomes activate, specifically interleukin 1 (IL-1).

I have not come across much research on acne and autoimmunity, but if any of you come across some good hard science on this topic, please send it my way.

Also, have any of you gone on immune suppressing medications (i.e. Humira) and seen your acne symptoms change? I’d be curious to hear from you.

I noticed there is also a thread on the forum discussing this as well. Feel free to add your comments there as well.

References:

  • Contassot E, Beer HD, French LE. “Interleukin-1, inflammasomes, autoinflammation and the skin.” Swiss Medical Weekly. 2012; 142:w13590.

2.5% benzoyl peroxide Researchers at UCSF Medical School recently published a review article in the Journal of Dermatological Treatment which took a look at all available evidence on the dosing of benzoyl peroxide. They took a look at 8 studies in all. The authors concluded:

“There appears to be insufficient data…to document use of a higher concentration than 5% or even 2.5%.”

Regarding side effects, the authors note:

“There does appear a difference in the number of side effects according to the dose titration. The 2.5% formulations had a significant lower rate and lower severity of burning, erythema (redness) and peeling…”

They go on to further conclude:

“To increase compliance and thus the efficacy of the therapy, a lower titration of 2.5% should be preferred.”

Those of us who use benzoyl peroxide regularly have noticed this first hand. 2.5% works just as well or better than higher percentages because it does the same job as higher percentages without all the unnecessary irritation that can perpetuate acne cycle.

For best results, stick with 2.5%, and use it within The Regimen.

References:

  • Brandstetter AJ, Maibach HI. “Topical dose justification: benzoyl peroxide concentrations.” Journal of Dermatologic Treatment. 2013; 24(4): 275-7.

Screen Shot 2014-08-11 at 12.06.49 PMScientists recently took a look at 55,825 outpatient dermatologist visits from 1995-2009 and found that “In comparison to other dermatologic disorders, acne was over two times more likely to be associated with ADHD.” They controlled for age, sex, ADHD medications, and other mental disorders. A second look at 5240 patient visits showed similar results: “Our results…reveal a significantly high prevalence of ADHD in acne patients…”

These are retrospective studies, and even the authors themselves call their findings preliminary and say, “These findings need to be confirmed in clinical samples of acne patients.” However, if it turns out to be true, why might this be the case? Might both acne and ADHD be worsened by similar dietary factors? Perhaps it is the fidgeting of people with ADHD that causes increased irritation of the skin and thus acne.

Side note: Interestingly, eczema has also been associated with ADHD before.

References:

  • Gupta MA, Gupta AK and Vujcic B. “Increased frequency of Attention Deficit Hyperactivity Disorder(ADHD) in acne versus dermatologic controls: analysis of an epidemiological database from the US.” Journal of Dermatological Treatment. 2014; 25: 115-118.
  • Gupta MA, Gupta AK and Vujcic B. “Cormirbidity of acne with attention deficit hyperactivity disorder: Results from a nationally representative sample of 5240 patient visits for acne from 1995 to 2008.” Journal of the American Academy of Dermatology. 2012; 66(4): AB86.

Green Tea in Skincare

We use licochalcone, a Chinese licorice root extract, in Acne.org Moisturizer and Acne.org AHA+ (10% glycolic acid). This is what gives both products their characteristic yellow color. I chose licochalcone because it is powerfully calming to the skin and works especially well on irritated, acne-prone skin. It targets inflammation and has antioxidant properties and has proven its efficacy over the years that it has worked so well within the Acne.org line of products. However, it is extremely expensive ($6000 per kilogram), and some people don’t love the yellow color it imparts. Because it is such a specialized ingredient, we are also at the mercy of cyclical weather changes and potentially unreliable harvests in the few places where this particular species of licorice is grown.

For these reasons, I have kept my eye out for another comparable calming ingredient with research to back up its use on acne-prone skin. Green tea, or more particularly, the major polyphenol within green tea called EGCG, is one of the strong top contenders. I have been intrigued with green tea for several years now, but the more I look into it the more I’m liking what I’m seeing. Researchers performed two more studies within the last two years on EGCG and its effect on acne, both with promising results. The data is showing that EGCG not only produces anti-inflammatory effects, but may also help reduce skin oil (sebum) production.

Any change to Acne.org products takes lots of time to study, mock up, and ultimately implement, and I am still not 100% convinced that I can’t find anything even better than EGCG, but I’m intrigued to say the least.

References:

  • Im M, et al. “Epigallocatechin-3-gallate suppresses IGF-I-induced lipogenesis and cytokine expression in SZ95 sebocytes.” Journal of Investigative Dermatology. 2012; 132(12): 2700-8.
  • Yoon JY, et al. “Epigallocatechin-3-gallate improves acne in humans by modulating intracellular molecular targets and inhibiting P. acnes.” Journal of Investigative Dermatology. 2013; 133(2): 429-40.

…we still have no clue.

After scouring the research from the last several years regarding sebum (skin oil), acne bacteria, gene transcription, and a bunch of other super techie stuff, the answer to what causes acne is…um…we still have absolutely no idea. Most diseases are tricky things, and acne is no exception. Scientists are really only still scratching the surface when it comes to nailing down what actually happens that starts the acne ball rolling.

Let’s take acne bacteria for instance. Over the past few years, scientists have located more strains of P. Acnes, the bacteria present in human skin. We don’t know which strains might be harmful and which might actually be helpful. Furthermore, we don’t know which of the secretions of which of the bacteria strains cause problems and why. Additionally, we don’t know if it’s the secretions that cause a problem or if certain strains of bacteria interact with cells in some other way, such as interacting with cell RNA, toll-like receptors, or inflammation. And, um…if these bacteria do interact with skin cells in some way, we don’t know whether it’s dermal cells, oil cells, or immune/inflammatory cells.

The story is equally muddled when you look at the immune response of the skin, the inflammatory cascade, cell signaling, et cetera, et cetera.

Regardless, it’s not all bad news. Some directions of inquiry are starting to look more interesting than others. For instance, scientists are starting to frame acne as an inflammatory disease and are focusing in on how to mediate the body’s inflammatory response in the skin.

With time, we may be able to better specify what causes acne, which could theoretically lead to a cure. Rest assured that I’ll keep on top of the latest research. In the meantime, The Regimen should work well to keep acne under complete control, and in more severe cases, Accutane is an option as well.

The more I learn about antibiotic therapy for acne, the more wary and less enthused I become. Due to overuse and misuse over the past twenty years, antibiotic resistance has become widespread throughout the skin of the world population. This is evidenced by the increasing ineffectiveness of both oral and topical antibiotics in clinical studies. Antibiotics never worked very well for acne, and now they work even less well.

According to a “Global Alliance to Improve Outcomes in Acne” published in the Journal of the American Academy of Dermatology, antibiotics should be avoided as the sole treatment of acne. Researchers agree strongly that if antibiotic therapy is used, it should be combined with other therapies. When you look at the superior effectiveness of these other therapies the question arises as to why someone would want to include antibiotics at all. For example, when one takes into consideration the fact that benzoyl peroxide kills 99.9% of acne bacteria on its own and does not create resistant colonies of bacteria, one has to wonder why so many prescriptions for antibiotic acne therapy–over 11 million per year–are still written. According to an article published in the journal Expert Opinion on Pharmacotherapy, “…evidence demonstrates that [topical antibiotics] are no more effective against inflamed lesions than [benzoyl peroxide], and are less effective against non-inflamed lesions…To date, [benzoyl peroxide], as both mono- and combination therapy, is the most evidence-based approach.” Other acne treatments exist, and while they may not be as effective as benzoyl peroxide, they easily outpace antibiotics.

The misuse of antibiotics can also cause antibiotic resistance in other skin bacteria, especially the bacteria known to lead to impetigo and folliculitis. If all of this weren’t enough, when we look at how gene mutations work in bacteria, we see that genes which allow for resistance to antibiotics are easily transferred from acne bacteria to other bacteria in the skin, thus further promoting unwanted antibiotic resistance in other skin bacteria.

If your doctor has you on antibiotic therapy for acne and nothing else, it may be time to have a talk with her/him. The authors of the expert opinion review also note that topical antibiotics should be used for no longer than 3 months and oral antibiotics for no longer than 6 months. So, if you have been on antibiotic therapy for a long time, it may also be time for an appointment with your dermatologist. Since poor compliance with antibiotic regimens are one of the main causes of antibiotic resistance, just make sure you do not stop antibiotic therapy on your own without consulting with your physician first.

The last few days I have spent going through all clinical studies/trials regarding acne and Omega-3 fats, iodine, antioxidants, chocolate, calorie intake, fatty/oily food, digestion, and zinc. Adding to this what I have learned regarding dairy and glycemic load, I’m sorry to say that nothing stands out for me as a smoking gun when it comes to diet and acne. We simply don’t have enough research yet, and nothing feels super compelling to me at this point. However, at least researchers are looking into how diet may affect acne, so hopefully by the next time I review the literature, the evidence available to the scientific community will start taking shape. In the meantime, based on digesting everything the research community has to offer regarding diet and acne, here is what I am personally going to do as far as diet goes:

1.  Keep taking fish oil and eating wild delicious sushi :)  I take 4 fish oil pills per day to make up for my Western-style diet, which like almost everyone living in modern society, is overly rich in Omega-6 fats from vegetable oils, grains, etc. There is enough evidence to persuade me of the overall health benefits of Omega-3s and I feel good taking fish oil regardless of whether or not it may be helping with my skin. Also, when I go out to eat, I specifically ask whether the fish or sushi on the menu is wild. Farm raised seafood is far inferior in Omega-3s and other nutrition than wild seafood.

2.  Keep taking a zinc supplement. Having dived deeper into the role of zinc, I am still convinced that it is likely an important nutrient when it comes to combating inflammation and keeping bacteria in check. I’ll keep taking my 30mg per day.

3.  Not worry about iodine, chocolate, fatty/oily food. I’ll keep eating seaweed salad and seafood (contain iodine).  There exists no evidence showing that the amounts of iodine consumed in these foods is in any way detrimental for acne. Based on the available evidence, I’ll also continue eating a little dark chocolate every day without worrying about how my skin will react. I will also keep eating the occasional naughty greasy meal without fear.

4.  Try to be generally healthy. Antioxidants are important calming agents in the body, and eating antioxidant-rich colorful fruits and vegetables is fun and tasty anyway. When it comes to glycemic load, whether or not scientists know if it will help with acne yet, I’ll try to keep my meals balanced with carbs, fat, and protein to keep my energy and mood level and avoid crashes.

A full update to the diet and acne page of acne.org is on its way with much more information on each of the above mentioned topics. In the meantime, when you look at the evidence at hand, eating healthy and in moderation will suffice as a general wrap up for what we know regarding diet and acne at this point. Not exactly a Eureka moment.

If you eat a high glycemic diet with foods like white bread, sugary soda, white potatoes, and white rice, you will experience insulin spikes. This we know. What we don’t know (sorry Josh) is whether this sort of diet will directly affect acne.

Scientists hypothesize that a high glycemic diet and its resulting insulin reaction will result in higher levels of hormones (IGF-1 and androgens) which may contribute to clogged pores and increased skin oil production.

When it comes to high glycemic diets in particular, scientists also postulate that eating this way may lower the amount of beneficial proteins (IGFBP-3) and natural retinoids, which help keep skin cell growth in check and pores from becoming clogged.

However, as is becoming customary in my research on diet and acne, we do not have enough research to make any strong correlations. The only 2 studies which have been done on glycemic load and acne have been performed by the same group of Australian researchers, led by Robin Smith, and while acne lesion counts appear to reduce on low glycemic diets, results are inconclusive. What stands out most sharply is the lingering question of whether glycemic load leads to decreased acne symptoms or whether it is the weight loss that tends to go hand in hand with this sort of diet that causes the reduction in acne. To answer this question, we need data on whether a reduction in acne symptoms is sustained after weight loss has leveled off. Until then, I’m happy that the scientific community is at least starting to investigate.

Thanks for voting for what you guys wanted me to concentrate my acne research on. The last I looked at the poll results diet and acne was winning. Now I see that scars have a few more votes. Well, scars will be next. But first, let’s delve into diet and acne. In fact, let’s get deep and dirty and nitty gritty with it shall we? Yes? Great, then we shall :) I’ve read every published trial and review of literature since 2008 regarding diet and acne there is good news and bad news.

Good news: Scientists are all over it! No longer is diet and acne relegated to a back seat. According to the Journal of the American Academy of Dermatology (2010), “…it is evident that dermatologists can no longer dismiss the association between diet and acne…In light of the last decade of research investigating the relationship between diet and acne, it is no longer dermatologic dogma to state that any association between diet and acne is mere myth.” In other words, researchers are conducting studies and we’re getting interesting data.

Bad news: The data is still spotty and almost all of the recent studies come with serious “design limitations” as they call them. An example of a design limitation is researchers relying on subjects’ personal recollection of their diet habits instead of actually watching what they eat. Another example of a design limitation is trusting subjects to define for themselves whether they have “acne” instead of employing a professional to count lesions across a study cohort. In other words, we can’t trust the data that’s coming out yet. We need more trials, and better trials, before we make conclusions.

Um, a little more bad news: Because pharmaceutical companies do not make money from educating the public on diet, funding for diet and acne studies is sparse. But hey, even without the pharmaceutical companies, we’re seeing a resurgence of interest in the topic of diet and acne.

My gut feeling on the subject: Regardless of whether some hunter/gatherer tribes do not have acne, it is literally impossible for us to go back to a hunter/gatherer way of living, and for real concrete answers to acne, we’ll have to include diet as only one piece of a much larger puzzle. As much as I would love for it to happen, I don’t think we’re going to find a magic bullet. I don’t think we’ll find a super bad food or food group which we’re all eating which is causing acne. I also don’t think educating people to “eat right” and “low glycemic” will clear people up to the degree any of us want.

I’ll keep updating the blog with specifics regarding some diet and acne subtopics like dairy, glycemic load, iodine, etc. for the next few updates. Hopefully with all of us wading deep into the muck of the latest research we can pool our minds and get food working for us as much as possible.

I’m diving headfirst into acne trials and medical journal articles, starting with Accutane. What do you want me to research after that?

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