Diet and Acne

Looking at the Research and Possible Links Between Diet and Acne

Diet and Acne

Article Summary

Studying the relationship between diet and any disease, including acne, is complex, time consuming, and expensive. For these reasons, the research done thus far on diet and acne has relied mainly on surveys, which scientists agree are less than ideal. However, from the admittedly imperfect data we have, a preponderance of evidence is pointing toward the possibility that a low-glycemic diet, zinc, omega-3 fats, and antioxidants may help combat acne. While you may have heard that dairy causes acne, the reality is that we simply do not know what impact, if any, dairy has on acne.

 


Science still does not know whether diet and acne are related, but evidence is starting to trickle in. Based on what we are seeing in clinical research, it seems prudent to eat a relatively low-glycemic diet rich in colorful fruits and vegetables and omega-3 fats and to perhaps supplement with 30mg of zinc gluconate per day. However, due to our modern diets and Western style of living, achieving sustainable relief of acne from changes in diet alone remains an elusive goal.

No matter what anti-acne diet you embark upon, while you may see a short-term reduction in acne while your body loses weight, symptoms are likely to return as your weight levels off. If your goal is to achieve completely clear skin, your time is likely much better spent  effectively treating your skin  than chasing any theoretical, yet unproven, diet.


Dairy and Acne

Summary

Due to the lack of concrete evidence on the subject of dairy and acne, and major design limitations in the studies researchers have performed thus far, scientists in the journal Clinics in Dermatology wrote after a review of the existing evidence:

Clinics in Dermatology

"Our conclusion, on the basis of existing evidence, is that the association between dietary dairy intake and the development of acne is slim."1

It makes common sense based on the hormones present in milk that dairy products could affect acne, but study results remain inconclusive, and evidence of an association between dairy and acne is sparse.1-13

Dairy and Acne

Hormones

IGF-1: Milk contains insulin-like growth factor (IGF-1).4IGF-1 is a hormone which helps the body build necessary tissues. Increased levels of IGF-1 result in increased skin oil production. Since over-production of skin oil is a contributor to acne, some scientists hypothesize that milk, and its IGF-1 component, could potentially lead to increased skin oil production and resulting breakouts.

IGF-1 also stimulates the body to produce cells. Acne is thought to sometimes begin with an over-production of skin cells inside the pore which causes the pore to become clogged. Thus, some scientists also hypothesize that milk may lead to over-production of skin cells within pores which cause the pores to become clogged and produce the beginning stages of acne lesions.

Androgens: Milk also contains male hormone (androgen) precursors.4-5These precursors require enzymes to convert them into actual male hormones in the body, and these enzymes are readily available in the pores of the skin.6Similar to IGF-1, male hormones have been implicated in increased skin oil production and increased skin cell production.7-8

Iodine in milk

At large doses,   iodine   can cause what are called acneiform (pronounced "ack-nee-form", the i is silent) eruptions.14 While unproven, some scientists postulate that the iodine content of milk, due largely to the sterilization of the teats of cows with an iodine solution prior to milking, may also contribute to acne vulgaris.3,15

Iodine on Periodic Table of Elements

Glycemic Index / Glycemic Load

Summary

At this time, we do not know if low-glycemic diets reduce acne symptoms based on the glycemic load of the foods eaten, or simply based on the accompanying weight loss of such diets.1

Low-Glycemic Foods
What does the glycemic index refer to? The glycemic index compares different foods, giving them a numerical ranking, based on how quickly they spike blood glucose levels (the time it takes for the blood sugar to rise when you eat that food).

What does glycemic load mean? The glycemic load takes the glycemic index one step further by calculating how much the blood sugar level rises when you eat a particular quantity of that food (the degree to which the blood sugar rises when you eat that food).

Hormones

Eating lots of high glycemic foods (i.e. sugar, white bread, white potatoes, white rice) which are prevalent in modern diets cause people to live with chronically elevated insulin levels. These chronically elevated insulin levels may lead to problems with:

IGF-1: Increased blood insulin levels lead to increases in insulin-like growth factor (IGF-1), a hormone in our bodies which promotes increased cell growth. Scientists hypothesize that this could lead to an overgrowth of cells inside pores and/or an increase in skin oil production, which could cause pores to become clogged, leading to acne.2-7Scientists also hypotesize that high IGF-1 levels could lead to increased sebum (skin oil) production which may lead to breakouts.

IGFBP-3: Chronically elevated insulin levels lower the amount of insulin-like growth factor binding-protein 3 (IGFBP-3) in the blood. IGFBP-3 regulates IGF-1 and keeps it in check by preventing IGF-1 from binding to its cellular receptor. So, lower amounts of IGFBP-3 means even higher IGF-1 levels. As we have discussed, scientists postulate that increased IGF-1 may lead to overgrowth of cells inside pores.2-4A second way that low levels of IGFBP-3 may potentially affect acne is through lowering the effectiveness of the natural retinoids in the skin. These retinoids prevent cell overgrowth. When IGFBP-3 is low, these retinoids can't do the work they are made to do.8-14

Androgens: Insulin acts as a "master" hormone. Increased insulin levels raise androgen (male hormone) levels. Increased androgen levels are well known for their effect on stimulating sebum production, which can lead to more severe acne symptoms.12-13

mTORC1 and Fox01 proteins: Could our Western, high glycemic diet be suppressing and/or over-activating cell proteins which in turn unbalance hormones and increase skin oil production, leading to acne? Scientists are discussing it.6,15-18


Caloric Intake

Summary

If in fact lower calories help with acne symptoms, this may be why almost any "acne diet" appears to work. When we remove foods from our diet and do not replace them with others, we are eating less calories, and thus losing weight. It is important that scientists flesh this out. Until then, we cannot say whether any acne diet is working based on the content of what is eating or simply the overall calories. An article in the Journal of the Academy of Nutrition and Dietetics puts it well:

Journal of the Academy of Nutrition and Dietetics

"These gaps in the literature should not intimidate but rather challenge dermatologists and registered dietitians to work collaboratively to design and conduct quality research."1

Caloric Intake and Acne
Can increased calories cause acne?

The argument for: Increased calories result in higher male hormone (androgen) levels. Higher androgen levels can lead to skin cell growth and increased skin oil (sebum) output. Skin cell overgrowth may clog pores, leading to acne formation, and increased skin oil may lead to worsening of acne symptoms.

Doctors have noted that in hard-hit parts of the world, starvation level calories result in dramatic reduction in skin oil production and a complete halting of acne symptoms.2-3This is obviously not a sustainable way to treat acne. However, even when exposed to a moderate calorie deficit the body becomes insulin sensitive. Insulin is a master hormone, and insulin sensitivity lowers levels of insulin (this is because your body needs less insulin to do the same job since it is more sensitive to the hormone). This results in a hormonal cascade which theoretically would help prevent pores from becoming clogged and help the skin produce less oil. After a period of lowered calories, however, when calories resume to a maintenance level, this could also theoretically lead to an acne symptom recurrence. Therefore, it is more important, and practical, to focus on the quality of calories (by cutting down on junk foods and increasing the proportion of colorful fruits and vegetable in our diet), rather than their quantity.

Increased body mass (BMI) was found to be correlated with acne in one study of young males.4In another study, no significant correlation was found in young men, but a significant correlation was found amongst young women.5

Obesity is correlated with other skin diseases such as psoriasis.5

The argument against: From three studies, obesity and body mass index do not appear correlated with acne.6-8


Chocolate

Summary

It is far too early to draw conclusions between chocolate and acne. While there may or may not be a correlation between chocolate and acne, singling out any food as an acne villain is likely to be a wild goose chase. The combined stress involved in nervously avoiding chocolate and other perceived "bad" foods may itself lead to stress-induced acne.

Chocolate and Acne
History of the debate

For decades in the early 20th Century, doctors and medical texts warned acne prone people to avoid chocolate. This advice was put to the test with two studies in 1969 and 1971.1-2Both studies showed no correlation with chocolate intake and acne. However, these studies were small, uncontrolled, short duration, subjective, included very short follow up, and employed inadequate statistical analysis. They also did not account for the sugar or dairy content of chocolate being ingested. Despite the severe design limitations inherent in these chocolate-specific studies, not only did the dermatology community dismiss the possible chocolate/acne correlation, but also sent out the message that diet and acne are not related. This massive overstating of flawed evidence is an historic and staggering error of the entire dermatology community. However, as time has moved on, modern scientists are putting diet, and along with it, chocolate, back under consideration.

Insulin

A 2003 study showed insulin levels raised after meals which included chocolate, especially chocolate mixed with milk (chocolate milk) in lean young adults.3While it is certainly too soon to draw conclusions, this could theoretically be the result of the active compounds in chocolate spiking insulin levels and/or the combination of the amino acids in chocolate mixed with carbohydrates and causing an insulin spike.If in fact elevated insulin increases skin cell production and/or sebum (skin oil) production, this could clogs pores and provide a breeding ground for acne bacteria. Therefore, chocolate could theoretically be part of this insulin cascade and resulting acne symptoms.

Protein signaling or something else entirely

Scientists have uncovered a small amount of evidence pointing toward chocolate perhaps increasing IL-10 protein production.4Might this, or something else entirely such as the unique effects of the monounsaturated and saturated fats in cocoa butter contribute to acne?5

Beneficial effects of chocolate

On the other hand, chocolate contains antioxidants, which could theoretically help with acne symptoms.

Dark chocolate may actually reduce blood pressure as well. Might reduced blood pressure in some way promote oxygen and nutrient distribution to the dermis, thus preventing acne in some marginal way?5
 

Fatty / Oily Foods

Summary

Fat is needed for our overall health and well-being. However, whether saturated, unsaturated, and/or hydrogenated fats affect acne remains unknown.

Fatty, Oily Foods and Acne
Evidence

Current evidence shows that the fat we eat is in fact used to make skin oil (sebum). In addition, at least one study has shown that fatty diets lead to higher fat content in sebum.1The evidence stops there. Whether more sebum leads toward increased or decreased acne symptoms is up for debate. Scientists are looking into the nature of sebum, particularly its saturated or unsaturated content, to see if they can find clues to acne development.


Omega-3

Summary

Most people living in modernized societies eat far more Omega-6 fats from foods such as grains, vegetable oils, nuts, and poultry than they do Omega-3 fats from foods such as fish and fish oils, grass fed meat, seeds such as flax seeds and chia seeds, and hemp.1This is in stark contrast to hunter/gatherer societies and to what our ancestors evolved to eat. Eating a more balanced ratio of Omega-3:Omega-6 fats can help modulate inflammation in the human body.2Since acne is an inflammatory disease, it makes sense that anything that can reduce inflammation would also help reduce acne.

Omega-3 Sources
Inflammation

Omega-3 fats, especially the omega-3 fatty acids from EPA and DHA commonly found in cold-water fish, work by reducing the production of inflammatory cytokines3-5and inflammatory leukotriene B4 molecules.6EPA and DHA also inhibits mTORC1, a protein which can signal skin oil glands to produce more oil.7-9

Stress

Omega-3s are known to improve mood and reduce stress and anxiety.10Since stress and acne are linked,11this is another way omega-3 fats could theoretically help reduce acne symptoms.

Anti-bacterial properties

EPA in particular is anti-bacterial12and along with other fatty acids can inhibit the growth of Propionibacterium acnes (P. acnes) as well as Staphylococcus aureus bacteria, both of which have been associated with acne.13

Hormones

Omega-3s also help keep IGF-1 (insulin-like growth factor) levels in check,5which theoretically could help keep the skin from overproducing skin cells, and skin oil thus preventing breakouts.

Studies

Korean researchers in one study demonstrated that taking 2000mg EPA + DHA alongside 400mg of gamma-linoleic acid, a type of omega-6 fatty acid, significantly reduced inflammation and acne.14More studies attempting to link Omega-3 intake and acne are needed.


Zinc

Summary

As far as supplementation goes, zinc stands alone with the most evidence pointing toward a beneficial effect on acne, however moderate that effect may be. Over-the-counter zinc supplements normally come in 30-50mg tablets. The National Institutes of Health put tolerable levels of zinc for adults (19 years and above) at 40mg a day.1Zinc gluconate may be a better choice than zinc sulfate due to its superior bioavailability. Since meat and poultry provide the majority of zinc in Western diets, vegetarians may want to take special care to ensure they are ingesting adequate amounts of zinc.

Journal of Drugs in Dermatology

A systematic review of medical literature in the Journal of Drugs in Dermatology concludes, "The preponderance of evidence suggests zinc has anti-bacterial and anti-inflammatory effects and that it may decrease sebum production."2

Six percent of our body's supply of zinc is in our skin,3and after years of study and quite a bit of evidence, it appears that zinc supplementation may help with acne symptoms.

Zinc Gluconate
The evidence

Multiple studies have been performed on people with acne who are administered oral zinc supplementation.4-7Overall results show a reduction in acne lesion count above that of placebo, albeit only moderately. The dosage of zinc in these studies is normally quite high,8and more studies are needed to see if the reduction in acne symptoms could be sustained at lower levels of zinc. However, since other studies show lower blood zinc levels in people with acne,9-10keeping zinc levels up to par is a compelling option. The Recommended Daily Allowance (RDA) of zinc in adults (19 years and above) is 11mg (which includes supplements and the food we consume).

How Zinc works

Zinc helps maintain skin integrity, reduces inflammation, promotes wound healing, helps kill and suppress acne bacteria, and may reduce skin oil production.11-15

Getting zinc naturally

A variety of foods contain zinc.  Oysters contain about 5X that of the Daily Value (DV) of zinc (which is the recommended daily intake of zinc through natural foods). Eating 2 ounces (about 4 oysters), twice a week, is a fun way to get 100mg of zinc per week.


Iodine

Summary

We do not have enough evidence to convict or acquit iodine in acne vulgaris formation at this point.

Iodine
High levels of iodine have been shown to illicit what are called acneiform eruptions. These eruptions are different from run-of-the-mill acne and are evidenced by a quick onset, wide distribution on the body, and pustule-only outbreaks. Whether smaller levels of iodine affect acne is unknown.

Journal of the American Academy of Dermatology

According to an overview of the latest evidence regarding diet and acne published in the Journal of the American Academy of Dermatology, "Iodine has been implicated as a cause of acne vulgaris, however, no literature to date supports iodine as a culprit in comedonal acne."1

The evidence

The evidence is sparse. It appears that consuming very high levels of iodine containing kelp and iodine containing drugs can cause acneiform eruptions.2-3However, in one study from 1961, people who ate a lot of seafood and fish, a food group which contains high levels of iodine, were shown to actually have lower levels of acne.4Other studies have shown no correlation between fish/seafood and acne.


Antioxidants

Summary

Eating a diet rich in colorful fruits and vegetables will help your overall health and may or may not help reduce the inflammation inherent in the acne process.

Antioxidant Foods
Acne is partly an inflammatory disease. The inflammatory process is what causes acne affected pores to become characteristically inflamed and red. Antioxidants in the body help resolve this inflammatory response.

The evidence

People with acne tend to have less antioxidants, such as vitamin A, vitamin E, and selenium, in their skin.1-3It makes common sense that bringing antioxidant levels up to par would help calm the inflammatory response. However, we do not have enough evidence at this point to definitively say whether or not antioxidants in food or supplements help with acne. Topical antioxidants on the other hand, have shown promise in reducing acne lesion count. Examples of topical antioxidants include green tea, resveratrol, and licochalcone.
 

The Gut

Acne rosacea AKA (Rosacea), a disease which presents somewhat similar symptoms to acne vulgaris (run-of-the-mill acne), tends to show a strong correlation with intestinal issues, including bacteria overgrowth.

Acne vulgaris is not the same disease as acne rosacea, and intestinal discomfort is not as common amongst acne vulgaris sufferers. However, this would be an interesting area of study. Would a high fiber diet help with acne? What about probiotics?

The Gut
There is limited evidence on the relationship between gut bacteria and acne vulgaris. Some studies have shown that consuming probiotics leads to an improvement in acne symptoms. The proposed theory for this effect is that probiotics help to maintain the balance of bacteria in the gut, which helps to decrease systemic inflammation, which in turn may reduce inflammation and oil production in the skin. However, further research is required to confirm a definite relationship between gut bacteria and acne, and whether taking probiotics would be beneficial.

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  "As a critical sociology major in college, I learned that it is important for an author to present his or her bias. Because we are human and it is impossible to be completely unbiased, the presentation of bias allows the reader to take the author's bias into account when absorbing content.

My bias: Throughout my adolescence and early adulthood, I read in various places that chocolate and sugar were bad for acne. I carefully avoided chocolate and sweets for years, which did not end up helping with my acne, but did harm social interactions. I finally gave up on eliminating so-called "bad" foods from my diet, and my acne did not change considerably. Years later, after I had already discovered The Acne.org Regimen and cleared up, I decided to attempt to clear my skin from the inside out by eating in a hunter/gatherer way, thus eliminating any potential "modern" dietary causes of acne. About 25 Acne.org members joined me in stopping The Acne.org Regimen and instead eating a caveman style diet, which consisted of only food which was available before modern civilization emerged about 10,000 years ago. This meant vegetables, fruit, tubers (potatoes, yams, sweet potatoes), nuts, seeds, and meat. I completely eliminated sugar, added salt, all grains, legumes (beans), and dairy. The diet seemed to work at first. My skin did not break out much for the first month or so. However, during this first month I was also losing weight from eating in such a clean way. About six weeks into the diet, as soon as my weight leveled off, the acne returned. Unfortunately, due to the rigors of eating in such a strict fashion, none of the 25 Acne.org members kept to the diet as strictly as I did, so I am left with only my anecdotal experience. My conclusion, drawn from personal experience, was that no matter how cleanly I ate, it was not enough to stay clear. I slowly returned to a Western style of eating, but still try to remain aware of my glycemic load and I also try to eat lots of colorful fruits and vegetables and take a 30mg zinc pill most days. My common sense tells me that eating sugar and high glycemic processed food can’t be a good thing for my overall health or the health of my skin."

The Experts at Acne.org

Our team of medical doctors, biology & chemistry PhDs, and acne experts work hand-in-hand with Dan (Acne.org founder) to provide the most complete information on all things acne. If you find any errors in this article, kindly use this Feedback Form and let us know.

References:

Dairy and Acne

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Glycemic index / Glycemic load
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  3. Brismar, K., Fernqvist-Forbes, E., Wahren, J. & Hall, K. Effect of insulin on the hepatic production of insulin-like growth factor-binding protein-1 (IGFBP-1), IGFBP-3, and IGF-I in insulin-dependent diabetes. J. Clin. Endocrinol. Metab. 79, 872–878 (1994).
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Caloric intake
  1. Burris, J., Rietkerk, W. & Woolf, K. Acne: the role of medical nutrition therapy. J. Acad. Nutr. Diet 113, 416–430 (2013).
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  3. Pochi, P. E., Downing, D. T. & Strauss, J. S. Sebaceous gland response in man to prolonged total caloric deprivation. J. Invest. Dermatol. 55, 303–309 (1970).
  4. Del Prete, M. et al. Insulin resistance and acne: a new risk factor for men? Endocrine 42, 555–560 (2012).
  5. Halvorsen, J. A., Vleugels, R. A., Bjertness, E. & Lien, L. A population-based study of acne and body mass index in adolescents. Arch. Dermatol. 148, 131–132 (2012).
  6. Lau, K. & Hoger, P. H. [Skin diseases associated with obesity in children]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 56, 539–542 (2013).
  7. Bourne, S. & Jacobs, A. Observations on acne, seborrhoea, and obesity. Br. Med. J. 1, 1268–1270 (1956).
  8. Ismail, N. H., Manaf, Z. A. & Azizan, N. Z. High glycemic load diet, milk and ice cream consumption are related to acne vulgaris in Malaysian young adults: a case control study. BMC Dermatol. 12, 13 (2012).
Chocolate
  1. Fulton, J. E., Jr., Plewig, G. & Kligman, A. M. Effect of chocolate on acne vulgaris. JAMA 210, 2071–2074 (1969).
  2. Anderson, P. C. Foods as the cause of acne. Am. Fam. Physician 3, 102–103 (1971).
  3. Brand-Miller, J., Holt, S. H., de Jong, V. & Petocz, P. Cocoa powder increases postprandial insulinemia in lean young adults. J. Nutr. 133, 3149–3152 (2003).
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Fatty / Oily foods
  1. Pappas, A., Anthonavage, M. & Gordon, J. S. Metabolic fate and selective utilization of major fatty acids in human sebaceous gland. J. Invest. Dermatol. 118, 164–171 (2002).
Omega-3
  1. Logan, A. C. Omega-3 fatty acids and acne. Arch. Dermatol. 139, 941–942; author reply 942–943 (2003).
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  3. Cordain, L. Implications for the role of diet in acne. Semin. Cutan. Med. Surg. 24, 84–91 (2005).
  4. Vowels, B. R., Yang, S. & Leyden, J. J. Induction of proinflammatory cytokines by a soluble factor of Propionibacterium acnes: implications for chronic inflammatory acne. Infect. Immun. 63, 3158–3165 (1995).
  5. Cordain, L. Implications for the role of diet in acne. Semin. Cutan. Med. Surg. 24, 84–91 (2005).
  6. Zouboulis, C. C. et al. A new concept for acne therapy: a pilot study with zileuton, an oral 5-lipoxygenase inhibitor. Arch. Dermatol. 139, 668–670 (2003).
  7. Melnik, B. Dietary intervention in acne: Attenuation of increased mTORC1 signaling promoted by Western diet. Dermatoendocrinol. 4, 20–32 (2012).
  8. Melnik, B. C. Linking diet to acne metabolomics, inflammation, and comedogenesis: an update. Clin. Cosmet. Investig  Dermatol  8, 371–388 (2015).
  9. Grossi, E. et al. The constellation of dietary factors in adolescent acne: a semantic connectivity map approach. J. Eur. Acad. Dermatol. Venereol. 30, 96–100 (2016).
  10. Freeman, M. P. et al. Omega-3 fatty acids: evidence basis for treatment and future research in psychiatry. J. Clin. Psychiatry 67, 1954–1967 (2006).
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  12. Desbois, A. P. in Marine Microbiology 351–367 (Wiley-VCH Verlag GmbH & Co. KGaA, 2013).
  13. Desbois, A. P. & Lawlor, K. C. Antibacterial activity of long-chain polyunsaturated fatty acids against Propionibacterium acnes and Staphylococcus aureus. Mar. Drugs. 11, 4544–4557 (2013).
  14. Jung, J. Y. et al. Effect of dietary supplementation with omega-3 fatty acid and gamma-linolenic acid on acne vulgaris: a randomised, double-blind, controlled trial. Acta Derm. Venereol. 94, 521–525 (2014).
Zinc
  1. Supplements, O. o. D. Zinc - Fact Sheet for Health Professionals, https://ods.od.nih.gov/factsheets/Zinc-HealthProfessional/.
  2. Brandt, S. The clinical effects of zinc as a topical or oral agent on the clinical response and pathophysiologic mechanisms of acne: a systematic review of the literature. J. Drugs Dermatol. 12, 542–545 (2013).
  3. King, J. C., Shames, D. M. & Woodhouse, L. R. Zinc homeostasis in humans. J. Nutr. 130, 1360S–1366S (2000).
  4. Dreno, B., Amblard, P., Agache, P., Sirot, S. & Litoux, P. Low doses of zinc gluconate for inflammatory acne. Acta Derm. Venereol. 69, 541–543 (1989).
  5. Dreno, B., Trossaert, M., Boiteau, H. L. & Litoux, P. Zinc salts effects on granulocyte zinc concentration and chemotaxis in acne patients. Acta Derm. Venereol. 72, 250–252 (1992).
  6. Dreno, B. et al. Multicenter randomized comparative double-blind controlled clinical trial of the safety and efficacy of zinc gluconate versus minocycline hydrochloride in the treatment of inflammatory acne vulgaris. Dermatology 203, 135–140 (2001).
  7. Meynadier, J. Efficacy and safety study of two zinc gluconate regimens in the treatment of inflammatory acne. Eur. J. Dermatol. 10, 269–273 (2000).
  8. Bowe, W. P., Joshi, S. S. & Shalita, A. R. Diet and acne. J. Am. Acad. Dermatol. 63, 124–141 (2010).
  9. Amer, M., Bahgat, M. R., Tosson, Z., Abdel Mowla, M. Y. & Amer, K. Serum zinc in acne vulgaris. Int. J. Dermatol. 21, 481–484 (1982).
  10. Michaelsson, G., Vahlquist, A. & Juhlin, L. Serum zinc and retinol-binding protein in acne. Br. J. Dermatol. 96, 283–286 (1977).
  11. Bae, Y. S., Hill, N. D., Bibi, Y., Dreiher, J. & Cohen, A. D. Innovative uses for zinc in dermatology. Dermatol. Clin. 28, 587–597 (2010).
  12. Jasson, F. et al. Different strains of Propionibacterium acnes modulate differently the cutaneous innate immunity. Exp. Dermatol. 22, 587–592 (2013).
  13. Poiraud, C. et al. Zinc gluconate is an agonist of peroxisome proliferator-activated receptor-alpha in the epidermis. Exp. Dermatol. 21, 347–351 (2012).
  14. Dreno, B. et al. Effect of zinc gluconate on propionibacterium acnes resistance to erythromycin in patients with inflammatory acne: in vitro and in vivo study. Eur. J. Dermatol. 15, 152–155 (2005).
  15. Isard, O. et al. Propionibacterium acnes activates the IGF-1/IGF-1R system in the epidermis and induces keratinocyte proliferation. J. Invest. Dermatol. 131, 59–66 (2011).
Iodine
  1. Danby, F. W. Acne and iodine: reply. J. Am. Acad. Dermatol. 56, 164–165 (2007).
  2. Harrell, B. L. & Rudolph, A. H. Letter: Kelp diet: A cause of acneiform eruption. Arch. Dermatol. 112, 560 (1976).
  3. Jackson, R. Nonbacterial pus-forming diseases of the skin. Can. Med. Assoc. J. 111, 801, 804–806 (1974).
  4. Hitch, J. M. & Greenburg, B. G. Adolescent acne and dietary iodine. Arch. Dermatol. 84, 898–911 (1961).
Antioxidants
  1. El-Akawi, Z., Abdel-Latif, N. & Abdul-Razzak, K. Does the plasma level of vitamins A and E affect acne condition? Clin. Exp. Dermatol. 31, 430–434 (2006).
  2. Michaelsson, G. Decreased concentration of selenium in whole blood and plasma in acne vulgaris. Acta Derm. Venereol. 70, 92 (1990).
  3. Ozuguz, P. et al. Evaluation of serum vitamins A and E and zinc levels according to the severity of acne vulgaris. Cutan. Ocul. Toxicol. 33, 99–102 (2014).
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