Acne is a common skin condition affecting up to 95% of adolescents. Adults also experience acne, with up to 54% being affected, which can persist into middle age. Acne can also lead to dark pigment changes (hyperpigmentation) and scarring that may last long after the acne itself is gone.
One of the most challenging aspects of acne is that its exact cause can be difficult to pinpoint. In functional medicine, acne is viewed as a visual sign that lifestyle and dietary factors might need adjustment.
This article will explore a functional medicine perspective on this common skin condition.
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Definitions Associated With Non-Inflamed Acne
Comedone: These comedones can be open or closed. Blackheads are referred to as open comedones and whiteheads as closed comedones.
Definitions Associated With Inflamed Acne
Papule: A type of inflamed acne with an early pimple
Pustule: When the papule becomes full of pus, it becomes a "pustule."
Nodulocystic Acne: As these pustules become more inflamed and infiltrate deeper into the skin, it is called "nodulocystic" acne.
What Causes Acne (Conventional Causes)
When you visit any dermatology website, you'll see that the common causes of acne are described as:
- Follicular hyperkeratinization means that the follicles in our skin get clogged with keratin and skin cell remnants during normal skin turnover and shedding.
- Excess sebum (oil) production.
- Bacterial colonization by Cutibacterium acnes (formerly known as Propionibacterium acnes) thrives on excess sebum.
- Inflammation of the acne lesions.
Root Causes of Acne
The above four points only describe the possible pathology directly at the skin surface. Functional medicine's possible causes include:
Skin Microbiome Dysfunction
Our skin has its complement of bacteria, viruses, fungi, and protozoa that make up a healthy community. This community interacts directly with our immune system to regulate immune responses and detect threats when the community is disrupted or pathogens are detected. Disturbance of the skin microbiome with personal products, antibiotic use, antibacterial cleansers, etc., can lead to the overgrowth of commensal or pathogenic organisms that may contribute to acne.
Sex Hormone Imbalances
Sebaceous glands can become overactive due to excess androgens. Sex hormone imbalances can be associated with:
- PCOS
- Androgen excess (multiple causes)
- Pregnancy and the postpartum period
- Menopause
- Endocrine disrupting toxin
Food Allergies & Sensitivities
Food allergies and sensitivities can lead to gut dysbiosis and increased intestinal permeability. One of the significant symptoms of a food intolerance is skin disorders, including acne.
Excess insulin-like growth factor-1 (IGF-1)
IGF-1 is one of our major growth hormones and is elevated during puberty. IGF-1 increases sebaceous gland growth and sebum production (sebaceous lipogenesis). Consumption of refined carbohydrates and dairy may contribute to elevating IGF-1 levels.
Omega 3-Omega 6 Ratio
The standard American diet contains a higher ratio of omega-6 to omega-3 fatty acids, which can increase systemic inflammation and is thought to affect acne. Omega-3 fatty acids have been used to support skin health in various conditions. Studies have explored the effects of Omega 3 on acne, showing potential benefits in reducing the size and amount of active acne lesions.
High B12 Levels
Several clinical studies reported that over-supplementation of vitamin B12 could be associated with acne in a subset of individuals. The studies suggest that high levels of vitamin B12 may influence facial bacteria, potentially contributing to inflammation and acne development.
Labs to Test for Root Cause of Acne
The first step when dealing with acne is to see a qualified health care provider for a complete medical history, family history, and physical exam. There could be medications, lifestyle factors, or other concurrent illnesses contributing to your acne. Also, getting a correct diagnosis is essential, as rosacea and acne can often be confused.
Exposure to Toxins
A urine toxin test like Great Plains Laboratory GPL-TOX may provide information about toxins that could be affecting your skin and gut microbiome.
Hormone Imbalances
Serum testosterone, estrogen, and progesterone levels are complemented by a urine hormone test like DUTCH Complete to provide a comprehensive look at hormone imbalances that may be contributing to acne.
Food Sensitivity Testing
Testing for food sensitivities ensures that no significant food or dietary triggers are promoting ongoing inflammation and altered intestinal permeability.
Altered Intestinal Permeability
A comprehensive stool test can identify inflammatory markers in the stool and any underlying dysbiosis. A zonulin marker can help identify leaky gut. If a blood test instead of a stool test is preferred, consider the Cyrex 2 Array.
Dietary Contributors
- IGF-1
- Fatty Acids (Omega-3 & Omega-6)
- Vitamin B12
Conventional Treatment for Acne
When you visit your primary care physician or dermatologist, the first treatment prescribed for acne will almost always be a topical antibiotic (like clindamycin), benzoyl peroxide, or a retinoid product (like adapalene or tretinoin). Other topical medications include salicylic acid and azelaic acid.
If this regimen is unsuccessful, oral antibiotics (like doxycycline) are usually added to the topical treatments.
Females are sometimes prescribed hormonal treatments like oral contraceptives (the "birth control pill") or spironolactone (a diuretic and androgen blocker).
Oral isotretinoin (commonly referred to as "Accutane" or "Myorisan") is usually prescribed when other treatments have not been effective. Isotretinoin has an FDA black box warning for the potential to cause severe, life-threatening congenital disabilities. It is contraindicated during pregnancy or in females who may become pregnant.
*Things to Keep in Mind if Prescribed Isotretinoin:
Females who are prescribed isotretinoin are required to:
- Provide initial and monthly negative pregnancy tests
- Prevent pregnancy with two forms of birth control (or abstinence)
Isotretinoin can affect your body in the following ways:
- May increase triglycerides and lead to pancreatitis.
- Baseline and regular monitoring of lipids are necessary.
- May increase liver enzymes.
- Baseline and regular monitoring of liver enzymes is required.
- May lead to decreased bone mineral density leading to osteopenia, osteoporosis, or fractures.
- May lead to idiopathic intracranial hypertension (also called pseudotumor cerebri)
- May cause extremely dry skin and eyes
- May cause Nosebleeds
- May cause depression, psychosis, and rarely, suicidal thoughts
- Blood donation from males or females is prohibited while taking isotretinoin and for one month after discontinuation due to fetal risk if a pregnant female receives the blood.
3 Root Cause Approaches to Managing Acne
If a conventional approach isn't working for you, or you are concerned about some of the side effects of the commonly prescribed medications, a functional medicine approach may help address the underlying factors that could be contributing to your acne, potentially helping to manage it without the need for antibiotics, hormones, or prescriptive medications.
1. Nutrition
For decades, we have been told there is no link between diet and acne. Yet studies have shown this not to be the case. Below are some common foods we consider reducing when focusing on acne patients in functional medicine.
Dairy: products are thought to be acne-promoting foods, possibly due to the high levels of saturated fats, sex hormones, and increasing levels of IGF-1.
Cocoa: Several studies have demonstrated the link between acne, cocoa powder, and chocolate (even dairy-free dark chocolate). It's thought that chocolate may promote the development of acne by upregulating inflammatory chemicals in the skin.
High Glycemic Foods: Refined sugar, soda, candy, and refined grains may contribute to acne by causing a spike of insulin that inhibits a protein called FoxO1 and allows male sex hormones (androgens) to promote sebum production.
Saturated Fats and Trans/Hydrogenated Fats: may contribute to acne by activating a protein called mTORC1 that promotes sebum production.
Vitamin B12: Excessive vitamin B12 supplementation may allow for the overgrowth of bacteria on the skin and contribute to acne. It's essential to verify B12 levels before supplementing.
Based on the above studies, it may be beneficial to trial a dairy-free, lower glycemic index diet with healthy fats (like mono- and poly-unsaturated fats) and quality sources of omega-3 fatty acids.
Don't be discouraged if you make dietary changes and don't see results immediately. Healing takes time, and it commonly takes around 10-12 weeks to notice acne improvement.
2. Herbs and Supplements
Berberine: is known for its anti-inflammatory and antibacterial properties and may help reduce sebum production. A randomized placebo-controlled clinical trial of teens with acne were given oral berberine supplementation. After four weeks, the participants showed a significant reduction in both the number of acne lesions and the number of inflamed lesions.
Guggul: is an antioxidant and anti-inflammatory and may help reduce sebum production. A randomized clinical trial showed that three months of guggul supplementation led to a similar reduction in acne lesions as taking the antibiotic tetracycline; there were also fewer cases of acne relapse at the three-month follow-up.
Probiotics: Those who supplement with Escherichia coli Nissle had significant improvement. Some even had complete recovery in skin conditions, including acne. Lactobacillus rhamnosus supplementation decreased IGF-1 gene expression in the skin and improved acne and skin appearance.
3. Topicals
Green tea extract: has antioxidant and anti-inflammatory properties. It has been shown to reduce sebum production when used topically.
Tea tree oil: Also known as Melaleuca has effective antioxidant and anti-inflammatory properties. It also has antimicrobial activity against bacteria, viruses, and fungi.
Amla powder: Also known as Indian gooseberry or Phyllanthus emblica is used extensively in Ayurvedic medicine for skin health due to its antioxidant and anti-inflammatory properties.
Summary
Acne is a prevalent yet frustrating skin condition affecting adolescents and adults. Acne can lead to depression and self-esteem issues. Its cause is complex and multifactorial, yet research continues to uncover the root causes.
A functional medicine approach can evaluate possible root causes of acne, including inflammation, dysbiosis, hormone imbalances, and nutritional contributors.
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