What Causes Acne? An Overview

I’ve been promising a series on acne and rosacea for almost two years, but I’ve had trouble working up enthusiasm for it. The problem is that Pubmed has 12,966 papers on acne and 2,587 papers on rosacea, most of those papers are of poor quality, and it is painful to sift through the dross in search of gold.

Fortunately, Seppo Puusa, who blogs at the Acne Einstein, has offered to help. Seppo’s a very smart guy and I thought a conversation between us about acne and rosacea might be an interesting way to do the series.  Seppo has just written a book called Clear for Life: Science-Based Natural Acne Treatment Program, which looks like a terrific guide to overcoming acne. In this first post in our acne and rosacea series, Seppo gives us his overview of acne. Here’s Seppo!

Does it ever feel like acne is just maddeningly confusing? That it just comes and goes without making any sense? It’s almost as if acne is not one disease but a combination of many diseases. For example one person gets acne from eating gluten, while another claims she can eat whatever she wants but breaks out every time she uses certain skin care products. A third person puts the blame on stress. Another person said zinc supplements helped her to get clear.

Is there a way to make sense of this, to reconcile all these seemingly separate causes? I believe there is. And in this post I’ll do my best to give you a framework for understanding acne. Something that ties all these seemingly separate causes together and helps you to make sense of your acne.

Deconstructing acne

In Tim Ferris’s latest book The Four Hour Chef he explains how to use deconstruction to learn a new skill. Basically you boil the skill down to its bare essentials. In acne these are inflammation and hormones (insulin to be more specific).

Let me start by explaining the pimple formation process. Looking at what happens in your skin is important because, surprisingly, understanding this helps you to understand how diet, gut issues, stress and other things can cause acne. Acne is more than skin-deep, but it still happens at the skin.

In acne, skin cells produce too much keratin, a protein that’s the key structural component of your skin, hair and nails. In the skin it holds skin cells together. Normally as skin cells die they separate and are pushed out of the hair/skin follicle (I’ll just call this a “skin pore” from now on). But the excess keratin makes it harder for the dead cells to separate so they are shed in larger lumps. [1]

These lumps of dead skin cells can block the skin pore, and this block prevents sebum from flowing out. One study showed that acne-prone skin produces about 3 times more sebum than normal skin [2], though other studies have found somewhat smaller differences [3, 4]. Now this torrent of sebum flows into the blocked pore and has nowhere to go. So the skin pore expands, like what happens when you blow into a balloon. Oxygen content drops in the blocked pore, and this helps the bacterium P. Acnes to thrive in the blocked pore [5]. The rest you probably know: the immune system responds and causes inflammation in the area.

This process has two breakpoints — points at which we can intervene to prevent or lessen acne. These are:

  • Excess keratin production
  • Excess sebum production

Counter either, or both, of these and your chances of getting acne go down dramatically. And here is where inflammation and hormones comes into play. Because research shows that inflammation in the skin and hormonal factors are the key drivers in both excessive keratin and sebum production.

Inflammation

Many people think of acne as bacterial disease, but more than anything it’s an inflammatory problem. Many researchers now believe that inflammation in the skin is the trigger that kicks off the whole process. Studies have shown that inflammation is present in the very earliest stages of a pimple, even before P. Acnes bacteria colonizes the skin pore [6, 7]. Cell culture studies also show that inflammatory cytokines increase both sebum and keratin production [1,8]. Finally, several studies have shown that antioxidants, whether topical and supplemental, can be as effective as benzoyl peroxide or antibiotics in treating acne [5,9]; this is consistent with the inflammatory view because oxidative stress can trigger inflammation.

Hormones

Acne has been conclusively linked to elevated levels of androgens, insulin, and insulin like growth factor 1 (IGF-1). These hormones stimulate sebum production and there’s some research to suggest they also affect keratin production. [1]

The relationship between acne and hormones is quite complicated. Androgens, or male sex hormones, are arguably the primary hormones affecting the skin. It has been shown that acne does not occur in people with inactive androgen receptors in the skin [10].

However, acne patients do not necessarily have higher levels of androgen hormones than people with clear skin. A portion of acne patients seem to have higher levels of some androgen hormones, but this is far from universal. Rather, acne-prone skin seems to be excessively sensitive to androgen hormones.

Insulin and IGF-1 are key hormones in acne. That’s because while androgens mediate lot of the effects on the skin, insulin and IGF-1 are the hormones you have the most control over. I like to call insulin a booster hormone in acne. And where there’s insulin, there’s also IGF-1. That’s why I group these two hormones together. [11]

Insulin and IGF-1 can stimulate sebum production on their own, but they also stimulate the release of androgen hormones from the liver and can increase the skin’s sensitivity to androgen hormones. That’s why studies show low GI diets can help with acne, and why milk can be so bad for the skin. [1, 11]

How sebum production drives antioxidant demand

The skin is the most exposed of all the organs. It’s frequently exposed to UV radiation, ozone from air pollution, bacteria, dust and other ‘inflammatory insults’. So the skin needs constant protection, and that protection comes in the form of antioxidants. In the skin the antioxidants are primarily in sebum. [12]

Research shows a tight correlation between sebum production and vitamin E secretion by the skin [13]. More specifically vitamin E secretion correlates with squalene secretion. Squalene is a fatty acid and a part of sebum. It really looks like the body uses vitamin E to protect squalene in the skin. When squalene oxidizes it turns into squalene peroxide, a highly inflammatory and comedogenic fatty acid. Animal studies show that applying squalene peroxide on the skin causes acne, and the severity of acne is linked to the degree of oxidation of squalene [5].

So the more sebum your skin produces the more antioxidants it requires. There’s good evidence to show that the antioxidant system in acne patients just can’t cope up with this increased demand. For example comparing skin and blood levels of several antioxidants shows significantly lower levels in acne patients than in people with healthy skin. [5, 9]

This is the factor that, I believe, ties together all those seemingly disparate factors that can trigger or relieve acne:

  • Gut problems increase systemic inflammation and deplete antioxidant reserves leading to more acne.
  • Stress triggers the release of neurotransmitters (such as substance P) that can increase inflammation in the skin leading to more acne [1].
  • Diet can induce or relieve inflammation leading to more or less acne. Diet also affects insulin levels.
  • Supplementing with zinc or other nutrients can provide antioxidants which lessen acne [14].
  • Candida and other pathogens in the skin cause local inflammation which can induce acne.

Conclusion

Acne is a very complicated condition and I don’t for one second pretend that this simple framework perfectly explains every case. Individual differences exist, and things get much more complicated when we get down into details. But I do believe it’s a good big picture overview of what causes acne and hopefully clears some confusion surrounding it.

Most importantly, this framework is broadly actionable. It gives you a systematic way to approach acne. Anything you can do to lower insulin and inflammation (both systemic and local in the skin) can help in acne.

Just remember, where there’s insulin there’s oily skin, and where there’s inflammation there’s acne.

References

  1. Ichiro Kurokawa, et al. New developments in our understanding of acne pathogenesis and treatment. Experimental Dermatology. Volume 18, Issue 10, pages 821–832, October 2009. http://onlinelibrary.wiley.com/doi/10.1111/j.1600-0625.2009.00890.x/full
  2. Harris HH, et al. Sustainable rates of sebum secretion in acne patients and matched normal control subjects. J Am Acad Dermatol. 1983 Feb;8(2):200-3. http://www.ncbi.nlm.nih.gov/pubmed/6219137
  3. S-W. Youn, et al. Does facial sebum excretion really affect the development of acne? British Journal of Dermatology. Volume 153, Issue 5, pages 919–924, November 2005. http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2133.2005.06794.x/full
  4. Apostolos Pappas, et al. Sebum analysis of individuals with and without acne. Dermatoendocrinol. 2009 May-Jun; 1(3): 157–161. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2835908/
  5. Whitney P Bowe, Alan C Logan. Clinical implications of lipid peroxidation in acne vulgaris: old wine in new bottles. Lipids in Health and Disease 2010, 9:141. http://www.lipidworld.com/content/9/1/141
  6. Eady E, et al. Is Acne an Infection of Blocked Pilosebaceous Follicles?: Implications for Antimicrobial Treatment. American Journal of Clinical Dermatology. July/August 2000 – Volume 1 – Issue 4 – pp 201-209. http://adisonline.com/dermatology/Abstract/2000/01040/Is_Acne_an_Infection_of_Blocked_Pilosebaceous.1.aspx
  7. Anthony HT Jeremy, et al. Inflammatory Events Are Involved in Acne Lesion Initiation. Journal of Investigative Dermatology (2003) 121, 20–27; doi:10.1046/j.1523-1747.2003.12321.x. http://www.nature.com/jid/journal/v121/n1/full/5601829a.html
  8. Monica Ottaviani, et al. Lipid Mediators in Acne. Mediators Inflamm. 2010; 2010: 858176. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2943135/
  9. Bowe WP, et al. Acne vulgaris: the role of oxidative stress and the potential therapeutic value of local and systemic antioxidants. J Drugs Dermatol. 2012 Jun;11(6):742-6. http://www.ncbi.nlm.nih.gov/pubmed/22648222
  10. J Imperato-McGinley, et al. The androgen control of sebum production. Studies of subjects with dihydrotestosterone deficiency and complete androgen insensitivity. The Journal of Clinical Endocrinology & Metabolism February 1, 1993 vol. 76 no. 2 524-528. http://jcem.endojournals.org/content/76/2/524.short
  11. Melnik BC, Schmitz G. Role of insulin, insulin-like growth factor-1, hyperglycaemic food and milk consumption in the pathogenesis of acne vulgaris. Exp Dermatol. 2009 Oct;18(10):833-41. Epub 2009 Aug 25. http://onlinelibrary.wiley.com/doi/10.1111/j.1600-0625.2009.00924.x/full
  12. Jens J. Thiele, Swarna Ekanayake-Mudiyanselage. Vitamin E in human skin: Organ-specific physiology and considerations for its use in dermatology. Molecular Aspects of Medicine. Volume 28, Issues 5–6, October–December 2007, Pages 646–667. http://www.sciencedirect.com/science/article/pii/S009829970700057X
  13. Mauro Picardo, et al. Sebaceous gland lipids. Dermatoendocrinol. 2009 Mar-Apr; 1(2): 68–71. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2835893/
  14. 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 2001, Vol. 203, No. 2 http://content.karger.com/ProdukteDB/produkte.asp?Aktion=ShowAbstractBuch&ArtikelNr=51728&ProduktNr=227730

Leave a comment ?

192 Comments.

  1. Dietary sources of Squalene? Olive oil.
    http://www.ncbi.nlm.nih.gov/pubmed/10668494

    good thing or bad for acne? squalene is a cholesterol precursor and inhibits HMG-coA redctase like cholesterol does.

    • George, I’m not sure dietary intake of squalene has any bearing on acne. I don’t know the reason acne prone skin produces more squalene. I presume the effect is partially genetic and partially down to hormones. Whether dietary intake of squalene has any effect on it, I don’t know. I’m not aware of any research on this, though I have to say I haven’t looked into this issue specifically.

      • It’s possible that squalene in the diet relieves some stress on the skin and it can use nutrients that would be used to make squalene for other functions. A quick google search turns up many anecdotes of successful olive oil treatment for acne, with one horror story.

  2. Thank you Paul. LOL, I haven’t read the article yet (busy), but I just have to tell you that I have been coming to your website for two years waiting for this post.

  3. Thank you Paul and Seppo! This is the most useful article on acne I’ve read in years! Acne is one of my few remaining nagging health concerns. I’ve found I can minimize it to almost zero by avoiding chocolate, and most fruits and nuts, but that’s hardly my ideal solution!

    This post gives me a great framework for further investigation and experimentation. Thanks!

    • Charlie, don’t forget external skin care. There are real differences between acne-prone and ‘healthy’ skin, and those differences can make acne-prone skin very, very sensitive. So that even very minor dietary ‘slips’ can harm the skin, slips that may have no bearing on your overall health.

      Topical treatments can, to a degree, mitigate those differences. Sometimes people who are in natural health and perfect health either ignore or forget this. There’s a tendency to think that acne is all internal and that once you nail down the perfect diet and lifestyle acne goes away. Sometimes this is the case, sometimes it’s not.

      I’m not saying this is the case with you. It’s just something to keep in mind.

      Having to avoid chocolate, most fruits and nuts is quite an unusual combination. For chocolate and nuts allergy or sensitivity reaction is a plausible cause. For fruits, maybe fructose malabsorption or FODMAP issue. Does any of these sound possible to you?

      • I do have a history of gut issues, and fructose malabsorption is what I figured was causing my fruit issues. Low fructose fruits such as cranberries and limes don’t trigger my acne. Interestingly, high fructose vegetables such as carrots, beets, and onions don’t trigger acne either.

        I had assumed it was some sort of sensitivity reaction for the nuts and chocolate as well.

        • I also have some FODMAP issues. A few days after I eat raw onions, leeks or strawberries my scalp starts breaking out. And a few days later the pimples start subsiding. It’s so predictable it’s almost ridiculous 😆

      • Hi Seppo,

        Do you have any experience using Manuka honey topically? Many people have reported great results. I have been using it for a few weeks and it seems to be helping, especially with healing and fading scars. Apparently the UMF rating is important. It’s spendy. Available on Amazon.

        • I’ve read the same anecdotes. Honey does have some anti-bacterial and anti-inflammatory properties. Whether Manuka honey is really better than ‘normal’ honey and how much of it is marketing hype, I can’t really say. Personally I wouldn’t spend a lot of money on Manuka honey.

          I prefer to use products that are formulated to penetrate the skin barrier and have PROVEN ingredients (like vitamin C derivates, B3 or zinc).

          Remember that in reading anecdotes and user stories you only get one side of the story. Those who got no results are far less likely to report in than those who got results. So you are reading from a biased sample.

    • I’ve been waiting to hear something from PHD about acne too! Nuts and vegetable oils are the worst for me and I have to avoid them completely. Luckily since they make my skin feel so grungy I don’t really ever feel like eating them.

    • You should check if the chocolate (that gives you acne) contains milk.

      And then try to find a milk-free dark-chocolate and try again if it gives you acne.

  4. Thanks for the article! I’ve never struggled with acne (only the occasional pimple) but have had really bad keratosis pilaris (KP) for years. I was surprised to learn that excess keratin is part of the issue with acne. If excess keratin + excess sebum = acne, what is KP? Just excess keratin? Thanks

    • Not having looked into KP, I can’t say for sure. But I have the impression that KP is a far more serious case of hyperkeratosis than acne is.

      In your case I would look into antioxidant creams. Try to find something with vitamin B3, C and E (or a combination of those). I haven’t looked into KP research, but there’s quite good evidence to say that topical B3 is effective in acne. In a few well-controlled studies it’s been shown to be more effective than benzoyl peroxide or antibiotic creams. There’s also good research on vitamin C derivate, Sodium Ascorbyl Phosphate (SAP), which has also done well in studies against BP.

      Again, these findings come from research pertaining to acne. But I do remember that some studies mentioned inflammation being a factor also in other hyperkeratosis-related skin problems. iHerb.com has a big collection of antioxidant creams that don’t break the bank. Perhaps they are worth a try?

      • Moderate KP is fabulously responsive to even mild alpha hydroxy acids (AHAs) like low conc lactic acid and glycolic acid. Or a combination of manual exfoliation (*gentle* use of those green scrubby pads is really effective) and moisturizing.

        For more stubborn cases, salicylic acid (beta hydroxy acid/BHA) or even retinoids work brilliantly.

        Because it’s an exfoliant, L-AA (vitamin C) at a low enough pH will work reasonably well on KP.

        My KP initially responded well to dietary improvements but, as we all know, regression to the mean is a bitch. Once a week or once every other week manual exfoliation plus an application of a chemical exfoliant (usually GA for me) works brilliantly.

        • Thanks for your your input Katherine. I’ve had some success with skin products in the past (I think it was KP Duty), but I couldn’t justify the cost for something that only covered up the issue instead of getting to the root of it. That said, chemical exfoliation does seem to improve skin texture quite well, in my experience. I’m glad you’ve had good success with it! I will look more into your suggestions… if it’s something I only need to do once a week or so, that sounds very doable.

    • I think keratosis pilaris is related to vitamin A deficiency. I had a mild case all my life and it completely cleared when I started eating ruminant liver on a regular basis.

      • Yes, vitamin A has been linked to hyperkeratosis. It’s also mentioned in some papers about acne.

      • Thanks for your comment Seppo! I have not tried B3, C, or E applied topically so I will give that a shot. You say that B3 has been shown to be more effective than antibiotics… are you saying it has an anti-bacterial effect on the skin? I have applied Vitamin A in liquid form to my skin (which didn’t seem to have any effect).

        Interestingly, I’ve had some improvement since doing a garlic “cleanse” (on day 9 now), so there definitely seems to be a bacterial component to the condition, since garlic is very anti-mircrobial. The redness has been reduced, although the bumps are still present. I’ve also noticed improvement when I was last on antibiotics (but unfortunately got secondary infections.)

        • Evan, you are making the classic mistake of jumping into conclusion without sufficient evidence to back it up. I would not assume that the reason ‘garlic cleanse’ helps your skin is because of the anti-bacterial effect of garlic. While it’s true that garlic has anti-bacterial effect in a test tube having the same effect in living humans is a totally different matter.

          I presume that this cleanse includes dietary restrictions? If so, it’s far more likely that caloric or dietary restrictions are what helps your skin. Restricting calories is known to be anti-inflammatory and reduce insulin levels.

          Sorry if I sound patronizing. It’s just that the harm of people jumping to wrong conclusions is evident every day in acne forums where confusion just piles on.

          B3 has several beneficial effects on the skin. If I remember correctly, it can reduce bacteria, but more importantly it can reduce inflammation and have also been shown to assist in repairing the skin barrier function.

          The thing with applying vitamins (or any other medicine) to the skin is that it needs to penetrate the skin barrier before it has any effect. The skin is very good in keeping water-based substances out. That’s why the products need to be formulated for skin penetration. Liquid vitamin A as such would probable penetrate very poorly.

          • Hi Seppo, yes my experience is anecdotal. However, I did not change my diet during the cleanse, which I’m now done with. I’ve eaten the same for months (mostly rice, rice products, fish, vegetables, fruits, butter, coconut oil, olive oil). And before that, nearly the same but w/ the addition of red meat. The only thing I did differently during the cleanse was to take 2-3 (crushed) cloves of raw garlic in a little water, 2-3 times a day after meals. If it’s not for the antibacterial properties of garlic that improved my skin, then I don’t know what it would be.

            I’ve been experimenting for years trying to get this condition under control. Diet has had virtually no effect, which is why I’ve been taking a more serious look at gut dysbiosis. Studies have shown that SIBO can lead to fat malabsorption, which may be a cause for KP.

            I don’t want to jump to conclusions, but I strongly believe (from my experiences and others that I’ve read) that there is a bacterial component to KP. And hopefully, science will be able to show that one day and offer hope those who suffer from this condition.

          • OK, perhaps I’m wrong about this. It’s just that detox and cleanse are such red flags to me. Usually what comes after those words is pure quackery and tortured logic. Glad to hear this was not the case with you 🙂

            Nothing wrong with anecdotal data, as long as we keep in mind the limitations. There’s no scientific evidence to show that FODMAPs cause acne, but anecdotally I know that’s the case for me. It happens with such ridiculous regularity that it’s kinda hard to deny it – even if the observation is anecdotal.

          • Yes, I hear you on the quackery surrounding cleanses. “Cleanse” probably wasn’t quite the right term to use… it was more of a course of natural antibiotics, which has been recommended to me by several people. I’ve tried cleanses and even a long-term water fast, and cannot vouch for their effectiveness. Of course, that’s just my experience 😕

      • Glad you were able to take care of your KP. Yes, I think Vitamin A does help… I don’t feel well with red meat, however, so I’ve stopped eating it.

        • Evan, try to replace (for a week or two at least) butter with Gee (clarified butter) – see if it does a change.

          As well, check to see if there are other sources of dairy in your diet. If so, remove them for a week or two.

          • Hi Tony, thanks for your input. Yes I’ve heard that dairy can affect KP. In my experience though, I noticed no difference when I was dairy free for about two years. If anything the butter I eat seems to help with it some (guessing from the Vit. A and Vit. K content).

        • Try Budwig diet and/or oil pulling. Could help with KP

  5. Hi Paul
    Please could you explain why omega 3 rich fish oils can cause acne in a small group of people. I seem to get acne breakouts even if I consume too much fish without supplementing fish oil. If I don’t eat a lot of fish or supplement fish oil my skin seems to remain under control. However, I worry that I’m then skewing my PUFA intakes towards omega 6 by avoiding fish and that this may have other negative health effects. If you have any advice for me on this it would be much appreciated.
    Thanks
    Josh

      • Hi Paul
        Thanks for replying. I read the other post but I am a little confused. I seem to get acne even from eating too much fish – like if I eat fish on consecutive days. So I don’t think I am getting a lot of DHA in my diet. In fact, I wonder sometimes if I should get some more DHA even if it does cause a little acne.

        I am trying to eat liver regularly, about 100g two or three times a week. I do this because I have mild keratosis pilaris and it seems to help. According to your previous post on angiogenesis vitamin A can also cause a problem but I don’t seem to get acne from the liver. I also struggle a bit with dandruff.

        What would you suggest I do? Should I cut out the liver and any fish?

        Sorry about the multiple questions.

        Regards
        Josh

  6. What Causes Acne? An Overview | Low Carb RSS - pingback on February 28, 2013 at 1:20 am
  7. Funny this post came up today. For the last 4 weeks I’ve been on holiday. During that time there were moments where I ate foods I avoid like the plague: commercial icecream, cake, cocktails, beer, a little bread, local Chinese, unfermented cream, etc.

    To my surprise I’ve had hardly ANY acne at all in those 4 weeks! I can’t explain it! 😕

    During this time I was going to the beach and getting plenty of Vitamin D and clean salt water than I have the last 4 months.

    Maybe they helped me out. But I’m dumbfounded that I could eat all of those things and my skin hardly broke out at all! …It just doesn’t add up when I think that diet has so much influence on my skin. 😆

    My skin seems a real mystery sometimes!

    John H.

    • I’ve noticed that people with acne often give way too much credit to diet. Diet can help, but it’s just one piece of the puzzle.

      Stories like yours are quite common in acne forums 🙂 Perhaps it’s lack of stress and more rest and sunshine that helps the skin. Something could also be said about leaving your normal environment with its countless psychological triggers.

      • There was still some stress during the holidays I must say. I think the VitD factor from the Sun was a big factor however… I remember about a year ago I went on a holiday to Thailand for four months and I hadn’t seen much Sun for quite some time before that. Once again, my acne cleared up incredibly for 2-3 weeks even while eating street food obviously cooked with cheap cooking oil. It did come back after that though.

        I’m now back in a place where there isnt much sunshine, so I’ve started taking 4,000U of D3. Might even increase a little over time.

        It is interesting stuff!

        • I looked into vitamin D when I was doing research on my book. There’s some evidence to show that it can mitigate insulin resistance, but the evidence wasn’t that convincing. It’s possible there are other ways it can help acne that we just don’t know yet.

          Anyway, stories like these just show that our understanding of acne is still limited.

          • Hi John and Seppo

            Vitamin D seems to affect insulin sensitivity by being anti-inflammatory (inflammation >> IR).

            It might be vitamin D’s anti-inflammatory effect (increases Treg cell function) that partly explains why acne is less prevalent/severe during summer. But that could also be because of antibacterial effects from D or from the sun

          • Steven, possibly. Though I’m not convinced this comes down to vitamin D. It may. But perhaps this can also be explained with change in environment. Changes in humidity and ambient temperature will all affect the skin. I live in Thailand and I’ve noticed that my skin actually feels much oilier here than when I’m in a cooler place. But perhaps a short-term change from cool to hot and humid can have a positive effect on the skin.

          • Could have something to do with the antibacterial properties of UV rays

          • Matt, I’m sure that’s possible. But without further research it’s impossible to say anything definitive.

        • John,

          It might be worth trying one of the really high quality sun lamps to see what happens.

  8. Hi Paul

    What a coincidence. I’m in the middle of researching acne and seem to be reading pretty much the same stuff you’ve read

    Looking forward to any further posts and I’ll be sure to check out your site Seppo

    • Hope you like the site. Though keep in mind that it’s aimed at people with limited scientific understanding, so I’ve tried to keep the articles quite simple. Most of them have references for digging deeper. Also, my book has an extensive reference list – perhaps you can use it as a shortcut.

  9. After years of suffering and self-experimenting I figured out the that the major triggers for me are gluten, processed food and pollution.

    What I am incredibly curious about though is something reported by many women (myself included) is just before that time of the month, a inflamed cystic pimple presents itself on the chin/jaw area. Hormones can explain the timing but why the chin/jaw? No idea. It is a “dry” area on the face but seems to be a problem spot for women past puberty.

    • As far as I know, the location of acne comes down to distribution of oil glands in the skin, which is probably genetic. Though I can imagine being wrong about this as this questions isn’t really studied.

    • Hi Lily,

      You might inspect your mouth at the corresponding spot on the other side of the cheek/skin to see if you have inflamed gums or tooth decay or if food gets caught in teeth. I suspect that inflammation in the oral cavity may propagate to the skin.

      • Chin/jawline acne is quintessentially hormonal, and so probably doesn’t have to do with her particular gums. Acne on the cheeks is more associated with gut inflammation. I’m speaking from a chinese medicine/observational standpoint, and I see this pattern often in clinic.

        I’m also curious why “hormonal acne” targets the chin. For my own part, too much coffee (especially late in my cycle) is a very reliable trigger of cystic acne on the chin. I’ve always attributed it vaguely to the effect of coffee on my adrenals, but if the only hormonal mediator is insulin I’m not quite sure why this would happen. But let me assure you it does!

        In my own experience zinc and improvements in diet made a huge difference in reducing acne.

        • I also get a pimple on my chin when my period starts.

          I also tend to get pimples when I’m stressed, but stress also triggers me to eat more sugar so I don’t know if it is the sugar or the stress.

    • I don’t know, if it is purely the genetic distribution of oil glands then acne breakouts shouldn’t shift. I know I’m not the only one who had breakouts mainly on the T-zone as a teenager then it shifted to the cheeks and now in my early 30s to the chin/jaw.

      The jaw area is not by any measure oily. T-zone is much oilier but I never breakout there. I just suspect (and this pure speculation on my part) that it is more than imbalance in sebum production. This is perhaps an out-there theory but perhaps certain skin areas are sensitive to different hormones?

      In any case, a good diet (like PHD, I LOVE it btw) prevents even that monthly cystic acne.

      • It’s possible that different parts of facial skin react differently to hormones. I know that research has compared facial skin to forearm skin and found big differences. I’m not aware of any research that would have compared skin from different areas of the face, but I think it’s one possibility here. The problem is lack of reliable data, so the best we can do is make educated guesses.

    • Google this book called Heal Your Face, and you’ll see a map of the face that shows which area of the face relates to which organs. I didn’t buy the book, but I did think the face as a telltale of health issues was interesting.

  10. Seppo, what do you think about mild acne, if that’s the right term, where it’s mostly only some reddened areas without bumps or pimples? Is the the same phenomenon, or something different?

    • I can’t really say Bill. Reddening of the skin can many many things, anything from sunburn to food allergy to some chronic skin disease. But I would guess that many of those issues are tied to inflammation.

  11. I’m looking forward to reading more of these posts, thanks Seppo and Paul.

    I did a saliva hormone test a month or so ago and had mildly elevated dhea-s levels. Have also had pimples on again off again mainly around my mouth. Zinc supplementation and eating liver hasn’t seemed to help, nor a low carb type diet to control insulin levels. Any insight on elevated dheas levels, acne etc? I am 21, and have had since early teens. Started eating only whole foods (dropped grains, had dairy sensitivity) a year and a half ago…

    • I’m not sure that saliva hormone testing is reliable, see the point #5 in this article:

      http://www.sciencebasedmedicine.org/index.php/choosing-wisely-five-things-pharmacists-and-patients-should-question/

      It’s possible that you are barking the wrong tree entirely. Without knowing more it’s really hard to say anything.

      Have you found anything that has worked for you? That could give some clues as to the real causes in your case.

    • One thing I noticed that improved acne around my mouth was changing to a floride-free toothpaste.

      • This!!! It took me so long to figure out, but I think that quite a number of people are or will be come sensitive to fluoride over a lifetime. Dr. Mercola has an article about it, how it’s far too easy to swallow too much toothpaste and manufacturers are scared to put warning labels/correct the amount that people should really use for fear of scaring them off entirely. as PHD and Paul say – the dose makes the poison, and everything has economic utility, up to a point.

        • Fluoride thing is interesting, I have heard of it but havn’t tried it out as it would involve changing to only bottled water (I am cheap). However after looking into it a bit after this post I may give it a go. Thanks

          @Seppo I’ve eliminated dairy and grains, went through a phase off nightshades (tomatoes, eggplants, paprika mainly), same for low carb. Tried phd style starch diet now, previously have tried tried fruit instead of the starch, alongside the other macros. Had femernted foods (W.kefir, kraut, miso on and off along the way. I’ve done this over a couple of years and nothing really has seemed to change.

          It could be lifestyle (‘stress’) and or the fluoride thing, may have to get some cask water!
          Cheers

          • Diet is not a be-all-end-all treatment for acne. If PHD-style diet hasn’t helped you then I wouldn’t invest too much time into diet anymore. It’s of course possible that fluoride or some individual food triggers your acne, but those can be very hard to pin down. If you want to investigate this, I would recommend keeping a food and symptom journal. That’s almost the only way to track delayed reactions.

            On the other hand, you might get more bang for your buck by looking into stress, sleep and topical care.

          • In my admittedly inexpert opinion it seems misguided and dangerous to add fluoride to toothpastes and, especially, to drinking water. Mixing a chemical into drinking water because it latches onto tooth enamel and forms a hard coating? Pretty crude reasoning. Preventing tooth decay for most people can probably better be accomplished by a combination of optimising general health with the PHD and using reasonable care in keeping teeth clean. As for water in general; although our civilization has given us a reasonable expectation that our drinking water supply isn’t going to give us cholera or other dangerous microbes, it guarantees nothing about the mix of mineral salts it may contain. Treated water, like sources directly from nature, can contain anywhere from a lot of things to virtually nothing. It seems likely to me that we evolved to obtain minerals and micronutrients mostly from food rather than directly from ingested water. Plants incorporate minerals from water into complex organic compounds which animals including humans are then able to digest and assimilate. If dissolved minerals in drinking water were an important source of mineral elements in our diet, their extreme variability in the world’s various water supplies would probably have prevented us from making it this far. I think the best bet for maintaining our health is to pay close attention to food and supplements per PHD principles in order to be well nourished, and to drink as clean a supply of water as is possible. To that end, filters are good, reverse osmosis is better and steam distillation is best. (Bottled water isn’t even part of a sensible equation, being completely unregulated, overpriced, inconvenient, not to mention using a ridiculous amount of resources to package and be transported). With filters, maximization of surface area of the filtering substrate, and of the contact time of the water with it, are the keys to effective adsorption of contaminants. Most filters are pretty mediocre at accomplishing either of these. Reverse osmosis works pretty well but its effectiveness varies over time as the filtering membrane becomes contaminated, so maintenance is important. Steam distillation is effective, but some VOCs can make it through the process unless it’s combined with charcoal filtering. Distillation removes most of added fluoride, too, especially when combined with a carbon filter, is cost effective and quite convenient.
            Here’s what I use. http://www.h2olabs.com/?gclid=CO2Fs8vy57UCFexaMgodc1QAmQ

          • P.S. Re: Clean water. If you’d rather not use a distiller or have a situation where you don’t have electrical power, these guys http://residential.everpure.com/en-US/product/water-filtration-systems/ make genuinely high-quality filters. I use one of their dual-canister setups with a tank and pump in my van and it can convert any local water supply into good drinking water.

  12. Hi Seppo,

    Have you found any correlation between acne and body temp/high or low metabolism?

    Nice blog you have. Thanks Paul for bringing Seppo on.

  13. Thanks for the post, Paul and Seppo. I will be sure to check your your blog and book, Seppo.

    I find acne to be a very interesting topic, especially because of the idiosyncrasies people discover in trying to combat it. For me, whole milk (because of IGF-1?), iodine (because of bromine?), and especially lithium (something to do with inositol???) cause terrible acne. I gather these three triggers are pretty common. The lithium part is a shame because it really is beneficial and oddly, I think it has an anti-inflammatory effect. But a general framework of avoiding inflammation, such as a PHD diet, has seemed to help my skin.

    • Hi Thomas,

      I think lithium causes acne primarily via exacerbating hypothyroidism. In hyperthyroidism it reduces acne. Iodine might cause a reactive hypothyroidism as well as bromine toxicity. You might see if you have a treatable hypothyroidism.

      • Thanks very much, Paul! That’s interesting. I’ll look into the hypothyroidism angle.

      • I tried taking supplemental iodine several years ago but it consistently caused itchy, sometimes painful, acne breakouts mostly on my face such as just above the hairline, forehead but just above the eyebrows, or in the middle of my cheek, or even on my neck. I stopped the iodine and figured it wasn’t for me.

        However, in reading PHD and then following Paul’s advice to start with very small doses of iodine and work up very gradually to RDA and then beyond, that’s working beautifully with hardly any acne at all. I started with 1/4 tablet which is about 56 mcg, daily for 30 days, then doubled it to 112 mcg, for 30 days. I could’ve doubled it again but decided to go halfway with 168 mcg, then one whole tablet, Each change in dose lasted for a minimum 30 days, sometimes longer. I now take 1 1/2 tablets, will increase it soon to 2 tablets for a dose of 450 mcg and stay there to see if I need to increase it at all.

  14. Interesting post. Just linked to this story on the Syontix Facebook page today: http://medicalxpress.com/news/2013-02-people-zits-dont.html

    Acne appears to be caused by a strain-specific form of P. acnes. It would not surprise me to learn that gut bacteria influences skin bacteria much as they do with bacteria in the respiratory tract.

  15. Do you therefore think applying topical squalene is a bad idea? It is used in many moisturizers.

    • If you already have acne or oily skin there’s no need to use oil-based moisturizers. Water-based emulsions are a much better option.

      I have no knowledge of topical squalene use as such. But I wouldn’t say it’s necessarily bad. It’s quite resistant to oxidation, but it’s very inflammatory when it does oxidize.

      • I’m still confuesed how squalene produces the dreaded Squalene peroxides you write about. It is supposed to be very resistant to peroxidation.

        http://www.scienceforlife.eu/tekst%20squalene%20and%20its%20clinical%20uses.htm

        “Squalene as a Skin and Eye Antioxidant
        Squalene is not very susceptible to peroxidation and appears to function in the skin as a quencher of singlet oxygen, protecting human skin surface from lipid peroxidation due to exposure to ultraviolet light and other sources of oxidative damage.12
        In vitro experimental evidence indicates squalene is a highly effective oxygen-scavenging agent.13 Subsequent to oxidative stress, such as sunlight exposure, squalene functions as an efficient quencher of singlet oxygen and prevents the corresponding lipid peroxidation in human skin surface. Kohno et al found the rate constant of quenching of singlet oxygen by squalene to be much larger than those of other lipids in human skin surface, and to be comparable to 3,5-di-t-butyl-4-hydroxytoluene (BHT). They also reported squalene is not particularly susceptible to peroxidation and is stable against attacks by peroxide radicals, causing them to suggest “the chain reaction of lipid peroxidation is unlikely to be propagated with adequate levels of squalene present in human skin surface.”12
        In animal models, squalene also appears to play an important role in the health of the retina, with particular regard to rod photoreceptor cells and the assembly of rod outer segment (ROS) disk membranes. Both in vitro and in vivo, the majority of newly synthesized squalene in the retina is transported to the ROS, where it turns over in parallel with the disk membranes.14”

        12. Kohno Y, Egawa Y, Itoh S, et al. Kinetic study of quenching reaction of singlet oxygen and scavenging reaction of free radical by squalene in n-butanol. Biochim Biophys Acta 1995;1256:52-56.
        13. Saint-Leger D, Bague A, Cohen E, Chivot M. A possible role for squalene in the pathogenesis of acne. I. In vitro study of squalene oxidation. Br J Dermatol 1986;114:535-542.
        14. Fliesler SJ, Keller RK. Isoprenoid metabolism in the vertebrate retina. Int J Biochem Cell Biol 1997;29:877-894.

        • This is a bit of a mystery for me also. My guess is that acne-prone skin uses squalene to supplement lacking antioxidant defenses. Sebum composition studies have shown acne-prone skin has proportionally more squalene than non-acne prone skin. While squalene is resistant to oxidize, it’s not immune to it. And once it does oxidize it does a lot of harm to the skin.

          That’s my semi-educated guess, but I haven’t seen any research to address this.

          • The problem I have is that the two lightest and least irritating moisturizers I’ve ever found both have squalene in them: Toleriane Fluide Oil-Free Non-Cosmedogenic Moisturizer by La Roche-Posay and Hydralight Moisture-Infusing Lotion by Paula’s Choice. Do you think that UV rays hitting these moisturizers could produce squalene peroxides and therefore lead to breakouts? Why would so many reputable companies uses squalene if they knew this might happen?

          • The companies use squalene because it’s a natural ingredient in the skin. So it absorbs quickly, moisturizes well and doesn’t irritate the skin. If the squalene they use is identical to what the skin produces, then it stands to reason it could also suffer UV damage. Anyway, it’s a simple matter of protecting the skin with either a serum or cream that contains antioxidants. Supplementing with oral antioxidants can also help in moderate/severe acne cases.

  16. I know a way to get rid of acne… Induce near constant poison oak reactions. Actually maybe I still have acne, I’m just too busy itching and biting off my limbs to notice anymore…

  17. Two questions I have.

    Any tips on healing the skin that was damaged by acne ?

    Also have you looked in the effect of probiotics (like inulin) ? I did some experimentation with inulin and my face was a disaster the next day despite a supposedly beneficial effect on the gut flora.

    Thank you for this overview.

    • Dot, do you mean acne scars? If so, there’s no easy way to treat physical scars (scars that leave a physical deformation to the skin). You have to see a dermatologist for laser, chemical peel or other invasive treatment. Those are quite hard to get rid of.

      Inulin is a FODMAP. Have you noticed any problems with FODMAPs?

  18. Hi Seppo and Paul – thanks for doing this! I look forward to the role of gut issues (bacterial, fungal, biofilms, etc.) in treating acne.

  19. Creatine is known to increase DHT synthesis, and whey protein is of course a dairy protein. As such, should I be avoiding whey/creatine? Also, how much of a difference does consuming milk make compared to consuming something like greek yogurt?

    • If you are prone to getting acne it’s a good idea to avoid whey protein. I wrote about the connection here: http://www.acneeinstein.com/whey-protein-acne/

      Note also that there are quite a few commenters who say their skin got much better since switching from whey protein to soy protein.

      I’m of the opinnion that yogurt is less bad for the skin than milk. Yogurt has much less IGF-1 than milk does – though I’m not sure that IGF-1 gets absorbed, so that may be a non-issue.

      Fermented dairy products can help with gut issues. But they are still dairy products and as such will increase insulin and IGF-1 levels quite a bit. I would be careful.

      • Do you know of any connection between casein and acne? Curiously enough during weight loss I supplemented with whey protein (30-50g/day) and had no noticeable changes in complexion, but if I consume the same amount of casein over a few days to a week I get various inflammatory problems and skin flareups. (So now I stick to smaller amounts of aged goat cheese)

        • Perhaps you have an allergic or sensitivity reaction to casein? Do some searching on ‘milk protein allergy’ and see if anything you find rings a bell.

  20. Anyone else have any experience with coconut oil causing acne. I have an upper intestinal infection and thought it might have to do with the coconut oil making the gut more permeable and the bacteria (andtheir toxins) entering my system and causing inflammation.

    • Hi Travis, you might try less coconut oil, and these recommendations from Paul:
      “Dealing with chronic infections was in many ways the motive for our diet, optimizing diet helps defeat the infections. It sounds like you have a number of pathogens [note: see this page and search “bentonite” for the original question http://perfecthealthdiet.com/2011/04/how-to-raise-hdl/%5D so I would suggest our regular diet recommendations (ie not a ketogenic variant which is sometimes beneficial).

      Nutritional supplements are important, especially minerals.

      If mold toxicity is a problem [note: the original poster also had infections] you may benefit from detox aids like bentonite clay, charcoal, or cholestyramine. But don’t take much – small amounts will help clear toxins, but too much can sabotage immunity against bacteria.

      Then, antimicrobial medicines. To choose the medicines you need a diagnosis of your pathogens.”

      I was on the diet for about 4 months solid before trying bentonite and it helped stop myacne, so I assume it took the toxins out of circulation.

  21. John Henderson

    I would like to get some thoughts from you all on this…

    I first started noticing rosacea around mid 2008 on my nose. It was while I was trying to treat the acne on my nose (the combination of both made me look like rudolph!) with ProActiv acne treatment. I had had a couple of antibiotic treatments in the years before this that I can remember.

    I’ve been healing my gut for a couple of years in order to cure it. The acne I have reduced by 90% most of the time.

    The rosacea (on my nose) still lingers quite a bit.

    In late 2008 I was oversea’s in Nepal and got a stomach bug which made me really sick. I had treatment for it and I remember my acne disappearing completely and the rosacea disappearing around 95+%. This is before I was interested in health – I didn’t even know what antibiotics were or did, they were just a pill to me back then. I emailed the clinic and got a reply back today. Here is the treatment they said they give to people who have what I had:

    1.Inj. Ciprofloxin I / V B.D.

    2.Inj. Metronidazole I /V T.D.S.

    3. Inj. Amikacin 500Mg. I /V B.D.

    Any thoughts you have with the info I have given?

    Thanks

    • I don’t know about those drugs, but some researchers believe that the anti-acne effect of antibiotics is at least partially due to the anti-inflammatory effect of common antibiotics prescribed for acne.

      • John Henderson

        I think that the ‘Cipro’ antibiotic is commonly used for SIBO.

        I saw one study that showed 85% of rosacea cases went away with SIBO antibiotic treatment.

        Something to think about.

  22. Hello,
    Can someone please tell me what Fodmaps are???
    Thank you.

  23. Paul writes: “However, acne patients do not necessarily have higher levels of androgen hormones than people with clear skin. ”

    I wonder if androgen hormones were measured by serum or saliva. My understanding is serum measures what is bound and floating in the blood stream, and saliva measures what is free and available at the tissue level, therefore saliva is going to tell you what you need to know.

    • Some studies mentioned total androgens and some mentioned also free androgens (usually free testosterone). As far as I know, you can measure both total and free androgens also in blood.

      Most authorities on menopause say that saliva hormone measures are not reliable.

  24. Hi Seppo, you mention using products which contain things like vitamin C derivates, B3 and zinc. Any particular brand or specific cream you could recommend?

    • Not really. I buy the things I use from iHerb.com, but other than looking at the labels I can’t say which of those are good and which are not. Amazon also carries some 4% B3 lotions, 4% being the common concentration used in studies.

  25. When I started Perfect Health Diet I broke out pretty significantly which is pretty weird considering I’m almost 60! 😮

  26. I don’t know about studies backing this up but I would recommend trying magnesium and sulfur. Transdermal and oral magnesium. Also organic sulfur that’s not from China. If you can find a magnesium sulfate that may be even better.

  27. From personal experience: My acne was clearly caused by dairy from pasteurized milk, and to a lesser degree from eggs.

    Dairy from raw milk did cause (almost) no symptoms.

    From what I read, I can recommend the 3 papers from the Harvard acne study. And take a look at Triolo 2002 (Humoral and cell mediated immune response to cow’s milk proteins in Behçet’s disease).

    • And while I can only speak for my acne symptoms (which may be part of Behçet’s), I would say it is *NOT* milk hormones per se (or anything like that), but what happens with the content of milk during pasteurization.

      And if I had to bet what is the problem, I would say it is the immunoglobulins in cow milk that get changed during pasteurization.

      I speculated a bit about it here:
      http://parakoch.blogspot.com/2012/10/is-acne-caused-by-hormones-in-milk-and.html

    • And one more thing:

      Milk-Chocolate gives me acne.

      Dark-Chocolate with some minimal amounts of milk gives me acne.

      Dark-chocolate that is milk-free does *not* give me acne.

      So everybody, if you say “chocolate gives me acne” then go and check whether it contains milk.

      (BTW, I would classify milk-chocolate as dairy.)

    • I don’t think there are any studies on this, at least not that I’m aware of, but it’s possible that an immune reaction to milk proteins also causes acne. I believe that food allergies and sensitivity reactions can cause acne. There’s no data on this, but it’s plausible and there are a lot of anecdotal reports on it. Unfortunately diagnosing sensitivity reactions to food is difficult and that makes getting to the bottom of this issue problematic.

      I have to say that I haven’t looked into the raw vs. pasteurized milk in detail, but I’m no impressed by the evidence put forward Chris Kresser or other proponents. But I’m open to being persuaded otherwise.

      I don’t have access to the full-text papers of the acne milk studies (I presume these are what you were referring to), but I don’t think they made a distinction between raw and pasteurized milk intake. Dr. Whitney Bowe notes in her gut-skin axis paper [http://www.biomedcentral.com/content/pdf/1757-4749-3-1.pdf] that those studies did NOT find an association between fermented dairy products and acne.

  28. Thanks for addressing this topic! I have mild rosacea that has been helped a bit by a paleo/perfect health type diet, but it is definitely still there. I look forward to reading this series.

  29. Very Good Post and replies (as always) thanks.
    Interestingly a lot of points you touched upon has significant overlap in the themes of Male Patten Baldness. (Androgenetic alopecia)
    However hope nobody is fooled because Diet/Lifestyle can have significant influence on Acne but unfortunately thats not the case with hair loss.

    • I’ve also noticed this. Many of the papers that talk about hormonal aspects of acne also mention androgenetic alopecia. Perhaps it’s just that male pattern baldness is caused more by local factors in the scalp, whereas acne is also affected by systemic factors, usually insulin and inflammation.

  30. Well I’ve posted my experience with acne before, but I’ve been waiting for a PHD article on acne for a long time so to recount my progress… I have tried everything from Accutane to topical creams to antibiotics and after 20+ years of fighting to control my acne I’ve finally learned how to do it thru diet alone. No need to put anything on my face, I don’t even worry about washing it anymore, it all begins in my gut. And I’m tired of reading over and over about what may cause acne and what may help to control it, I want to know how to get rid of it. Permanently. So I’m still waiting for that article, Paul 😉

    Discovering the paleo diet about 3-4 years ago made a huge difference in my acne, probably because I was reducing inflammation thru my dietary changes but it wasn’t until I discovered the PHD a couple years ago and started to eat plenty of animal fat and organs, consume mass quantities of bone broth daily, and eat fermented veggies and fermented dairy that I really got my acne under control, and coincidentally at the same time I noticeably improved my gut health and bowel function. I still had occasional breakouts though and eventually I traced these down to consuming a meal with too much fiber and/or too much sugar. Small amounts are usually okay, but for example one time last year I ate dinner at a raw vegan place which was all raw fruit & veggies and nuts, “clean” and healthy right? Well after months of not 1 pimple my forehead was suddenly breaking out the next morning and took a week to clear up. Granted, when I do get acne these days it’s very different than it used to be and by that I mean that my skin just doesn’t get as inflamed and swollen as it would years ago, it even heals up differently, “better” perhaps? But if I “slip up” at just 1 meal I can expect acne soon after. So I strictly stick to a relatively low fiber diet, rice and cooked tubers don’t cause me any problems, even lately I’ve eaten 1/2 a cooked avocado without issue, but I completely avoid sugar, don’t eat fruit except berries occasionally, never snack on nuts anymore, yadda yadda yadda follow the PHD, etc. and my skin will look perfect. Perhaps this is just the way my body was designed to live, perhaps because I’m of northern European descent my genes are designed such that I’m susceptible to harmful gut bacteria when I eat foods that my ancestors probably never ate i.e. tropical fruits. Perhaps I’m looking for a cure that I will never find and I just need to eat this way for the rest of my life if I don’t want acne. It’s not that bad I guess, but I do miss bananas…

    • I’m in the middle of writing that article. I’m just a bit busy now picking up my Nobel price in medicine and making billions by commercializing the definitive cure that works for everybody… And then I woke up and let my cat out to pee.. It was raining and a dark morning.. But at least it was a beautiful dream 😉

      But yeah.. I don’t think such as article is coming anytime soon. Acne can be caused by so many things that it’s hard to get much more definitive than this article. Perhaps Paul can cook up something definitive on the gut healing area.

  31. So what should we do if we have dry skin? More milk and higher GI foods? More vitamin E foods?

    • Lol.. that’s certain ONE way to do it.. but not necessarily something I would recommend.

      Dry skin is not opposite of oily skin. Dry skin is caused by excessive moisture loss through the skin. There’s usually some defect in the skin barrier function and because of that the skin cannot retain enough moisture.

      The easiest solution is to use moisturizers. Big surprise there 🙂 Apply them straight after shower when your skin is still wet. This locks in some of the water into the skin and the moisturizer forms a barrier on the skin that reduces moisture loss.

      • It depends on if we’re talking dry skin or atopic skin. If it’s just toward the normal end of the spectrum that ranges from mildly oily to mildly dry, then my (anecdotal) experience is that dietary improvements involving micronutrient repletion and a more beneficial FA profile (very, very little PUFA) is quite beneficial.

        Oddly enough, over time, the judicious, moderate use of retinoids can improve barrier function and decrease TEWL though over the short term, it’s hard to ever imagine that could be the case.

        When my skin was very fragile (severe atopy in addition to what had always been “normal” dryish skin), I was able improve barrier function rather dramatically by using retinoids (buffered or diluted or used intermittently) and reducing sun exposure.

        If skin is extremely dry and atopic, and a significant oral doses of a high LA oil like corn oil or sunflower oil brings relief, it’s worth considering a chronic infection–Paul’s written about it here.

        • You are right. At least in acne patients it’s been shown that reduction in dietary GI changes the fatty acid profile in the skin. There’s also evidence that omega-6 fatty acids play a part in the integrity of the skin barrier function. If I remember correctly evening primrose supplementation has been shown to be helpful for eczema patients. Topical use of such oils can also help.

          I haven’t looked in detail into how retinoids work. But I seem to recall some papers mentioning they affect gene expression on the skin and can to some degree mitigate the genetic disposition to acne and other skin problems.

        • Some “food” for thought there, thanks! I used to have greasy skin but less so in my 30’s (and now 40’s), but I think it changed when I went paleo/PHD, it’s been very dry ever since then. Haven’t been eating many carrots/sweet potatoes recently so I could make sure I do that, and I eat a pound of salmon every week so I could cut back on that and see if it makes any difference.
          Will look out for the chronic infection link, haven’t found it with a quick look. I am wondering if I’m getting enough omega-6 fats, hardly anything I eat regularly has any amount, what should I be looking for, 5-10g omega-6 on a 2000kcal/day? Usual paleo comment is less 6 and more 3, but maybe I’ve gone too far? Might try one of the GLA supplements as well.

          • Paradoxically it’s possible that going paleo/PHD has fixed one skin problem but brought up another. While oily skin is not the opposite of dry skin, oil on the skin acts as a barrier and prevents water loss.

            GLA supplement could be helpful, but you could also try applying the oils directly on your skin. That’s where they are needed, so it’s not necessary to go through the systemic route. I would try a few drops of evening primrose oil in the evening and see what happens.

  32. Has anybody tried ozon aged olive oil?

  33. Make that ozonated olive oil

    • Am I missing something here? Ozone is strongly pro-oxidant and there’s research to show that ozone in air pollution is harmful to the skin. Why would bubbling ozone through olive oil do anything good? Wouldn’t it just destroy the fatty acids in the oil?

      Is this just another case of alt-med tortured logic? Or am I missing something?

      • I really don’t know much about it so cannot answer your questions. I can’t even remember how I heard about it initially. It may have been rthrough mention of ozone therapy in dentistry on a Dr Mercola interview with the woman who wrote this

        http://www.mouthmattersbook.com/2012/05/01/root-canal-roulette/

        And from there just what I have found from googling and all of that is from people who have used it and people who are selling it.

        http://www.ozonatedoilonline.com/O3oilhistory.html

        But I tried some on a facial rash on which nothing else topical has ever had any effect and it appears to be working. So might be worth a try for those willing to experiment.

        • OK, understand. I would advice you to be careful with it. I looked at the second link and have to say I get headache just reading the page. It’s full of misconceptions, outright falsehoods and general alt-med myths. Perhaps the most dangerous is that ozone therapy is safe. It’s true that ozone kills virus and bacteria, but it’s equally true that it also kills healthy human cells.

          There are documented cases of people dying from this: http://whatstheharm.net/ozonetherapy.html. To be honest, many of the untreated cancer patients would have probably died anyway, perhaps just with less suffering and money wasted.

          I looked into ozonated oil and many of the claims made by the proponents are quite ridiculous. Ozone is quite toxic to the skin and there’s evidence that exposure to ozone from air pollution increases the risk of skin problems. I don’t remember the exact figures now, but a Chinese study showed an increased risk in areas with higher air pollution.

          I think ozonated oil works like benzoyl peroxide. Ozone acts as free radical that destroys bacteria and skin cells. When used properly this can have a therapeutic effect, but keep in mind that it can also cause harm.

  34. This is a great post, many thanks to Paul and Seppo. I thought I would just chime in with my personal experience. I have suffered with acne since I was 13 (I’m 23 now), and the only things that have given me marked improvement are supplementing zinc and changing my diet. Even hormonal BC did not help (I have been on the pill since I was 16). I started supplementing with 50mg chelated zinc when I was still eating SAD, and I would not get any breakouts no matter what I ate. When I first went low carb and cut out grains and sugars, I found that I didn’t need the zinc anymore, and my skin would just stay clear. It only flares up now when I’ve “cheated” with chocolate and sometimes grains. I didn’t go on low-carb for my skin initially, but one of the side benefits has definitely been clearer skin!

  35. Never underestimate the role of stress in its effect on acne.

    An absolutely splendid way to make the drying and peeling topical agents work better is to ice your face for about 60 seconds, before applying them at bedtime. I use an ice cube or water frozen in paper cups. I didn’t come up with this idea on my own, but it is very helpful.

    Many years ago, dermatologists applied dry ice and sulfur as treatments to the epidermis of acne patients. But that was only, at best, a monthly thing. Icing every day produces better results.

    • @Sherry, very true. Icing a breakout (when it’s first beginning) for a few minutes can do wonders, as does an aspirin mask.

  36. Hi Paul! I was lookin for something like this! Anyways, I question how much of inflammation in each person is genetic and based off a genetic stress response. Some people can handle a lot more stress than others, be it physical or mental. I know for me, my acne is the result almost 99% of the time to androgen hormones. When i am trying to gain muscle, especially around my neck/lymph nodes, I WILL without a doubt get cystic acne. I havent found a correlation between natural PUFAs and acne though because I notice I won’t get my period if I do not include a hellacious amount of nuts around the time I should get my period. No nuts=no menstruation and I have a body fat sitting around 24% at the moment so it isn’t a lack of body fat anymore, and I have tried saturated fats and low and behold, missed period. Protein also i need to keep an eye on, too much and it effects my gut with constipation and that effects my acne. I am weary of any products or external anything on my face but maybe considering mixing some baking soda and olive oil for a scrub? Also, every time i put a supplement of any sort in me, I break out, multivitamin, krill oil, anything. Anyways, back to the original point, my dad has gut problems and stress problems much like myself, and had horrible acne just like myself. So, I question how much of this is hereditary as far as my ability to take on stress. Mentally I will take on anything because I am stubborn, but I think my body just responds with acne

    • I can’t say about how much stress disposition is genetic and how much environmental. Acne has a significant genetic part. If I remember correctly a twin study found that genes explained something like 70% of the variation in sebum production.

  37. Great article, Seppo!

    Years ago my acne was treated with Roaccutan (from Roche) over a 3 month period of time which removed 90-95% of my acne symptoms *permanently* (i.e. no drugs since). I am considering getting a second treatment which I have heard other people do with further improvement from the first treatment.

    Supposedly Roaccutan is quite similar to a super-dose of vitamin A. Do you have any thoughts of this? Does it fit into your framework or do you know why it seems so effective?

    Again, thank you for a very informative article

  38. Seppo,

    What is the best cleanser you can recommend for sensitive skin? What do you think of this one:

    http://www.vitacost.com/acure-organics-sensitive-facial-cleanser-with-argan-oil-probiotic-unscented-4-fl-oz-1

    • It’s hard to say anything about products that include a lot of plant extracts. Most of the research is done with purified vitamins and there’s very little done with plant extracts. That said, the cleanser you use affects acne probably less than most people think. Some studies show small benefit from using cleansers, but the benefit over soap is not that big. So the one you mentioned should work just fine.

  39. I’m really grateful that you are going to do a session on rosacea; mine seems decidedly food-allergy related and my face is getting worse, with more (and larger) lumps appearing on my cheeks by the week. It may be related to the fact that there’s a lot of aerobic bacteria in my gut (tho liver seems compromised too) but not being a scientist I’m not sure what to do about it. It’s very confusing. Would REALLY appreciate any proven suggestions for what changes to my diet etc I could make to actually heal my gut as limited diet is very difficult long term. Currently I eat rice, potatoes, meat, vegetables, spices, seeds, nuts and oils – but that’s about it. Haven’t detected much by way of bacteria – could it be that there are very different forms of rosacea?
    Thanks so much for doing what you do, Paul, I really appreciate it.

  40. Correct washing of the skin will eliminate oils and bacteria that can cause acne. However, when you already have serious acne breakouts, washing alone likely will not make it go away. Frequent and harsh washing can even make it worse.

  41. Seppo, what do you think of this study?

    http://www.ncbi.nlm.nih.gov/pubmed/19049938

    How do you think Topical cyclosporine might help?

    • That isn’t a study, not even a case report. That said, if this is true, it’s quite interesting. Cyclosporine seems to be an immune suppressing drug that reduces the activity of T cells. There’s some evidence that acne patients have an excessive immune response to P. Acnes bacteria and perhaps cyclosporine helps to reduce that. It’s also further evidence for the inflammatory nature of acne.

  42. Regarding this quote,”Just remember, where there’s insulin there’s oily skin, and where there’s inflammation there’s acne.”, I have 2 questions. Why does insulin cause oily skin? What other explanations could lie behind an increase in oil production?

    I ate starch-free for a year. After I added the starches back, a few months in, my face started to be very, very oily.

    Insulin?

  43. Insulin can affect sebum production in 2 ways. Insulin, via IGF-1, stimulated the release of DHEAS from the liver and it can make the skin more sensitive to androgen hormones. In vitro studies show insulin and IGF-1 stimulate sebocytes, providing another mechanism.

    Of course there can be other mechanism by which sebum production increases, and a quote like that is always an oversimplification of a complicated issue. Stress may affect sebum production, and there’s also some evidence oxidative stress can also increase sebum production. If I remember correct, it’s been shown that IL-6 and other inflammatory cytokines increase sebocyte growth.

    I decided to focus on insulin because it’s the mechanism you have the most control over.

    • And why would insulin or oxidative stress become suddenly worse? (Assuming either of these is the culprit.)

      • Are you really asking about why a person who has never had acne before suddenly starts breaking out? It could be because of many things; increase in stress, gut infection, skin is exposed to external irritants, dietary change that affects hormone levels.

        I don’t have all the answers to acne, but what I can say is that research does support the hypothesis that inflammatory damage to sebum triggers an acne breakout. As I described in this post, many factors lead to excessive sebum and keratin production in the skin and reduction of antioxidant defense.

  44. Is acne actually an inflammatory problem? This is my first time to get heard this. Does this mean that medication is the best way to cure acne? Or case by case?

    • Case by case, but I would say that most people with adult acne would probably benefit from diet and lifestyle changes. If those are not enough then you can consider medications and topical treatments.

  45. Yep, but the nasty side effects, such as colon removal, can be (hopefully) minimized with an ultra low dose regime. It really should not be used for anything but severe cystic acne. It would be much safer to try the third generation topicals first (tazarotene, adapalene).

  46. Also, you should get a Burdock Root 1:1 strength tincture and try it. It will bring up all the microcomedomes below the skin’s surface. If it results in little to no effect, then you likely have other issues going on than the typical non-inflammatory acne etiology.

  47. Excess keratin production and excess sebum production characterize seborrheic dermatitis too.

    So the solution must be the same : reducing insulin and inflammation, but what is the best way to do that?

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