I get grumpy when I read that acne only occurs in teenagers. Either the dermatologists saying that have particularly youthful looking patients or they assume that their older patients are the exception rather than the rule. In a study of acne that noted it was universal in young people, researchers found that: “Acne persists into the 20s and 30s in around 64% and 43% of individuals, respectively.” So what we really should be saying to teenagers is that they have a roughly fifty-fifty chance of having zits through their thirties. Keep in mind that acne is already associated with depression.
I’ve put together a summary of the information on acne. Because much of the information may vary from elsewhere online, I’ve included the studies I used. I hope this information can be of use to many of you.
Although acne is largely due to hormones, most dermatologists pooh-pooh any link to diet. Yet we see as a culture shifts to a more western-style diet acne levels rise. Rural cultures with low sugar, low dairy diets have much lower acne levels.
In a study of 47,000 nurses, researchers found a 44% increase in acne among those who drank the most milk, even if it was skim milk. Another smaller study on adolescents found a roughly 20% increase in acne in weeks when they consumed two or more servings of milk a day. Factors in milk may elevate testosterone levels through increased insulin. Studies show that a low sugar diet helps elevate the binding of testosterone, resulting in less acne.
We have no large studies, but more omega-3 (fish) and less omega-6 (vegetable oil) and saturated fat (lard) oils may be helpful. (All studies found in this review).
Now, how else can we treat acne?
Despite all the pounding of desks, one 2005 reviewer states it plainly: “(b)ased on the present state of evidence, clinicians cannot be didactic in their recommendations regarding diet, hygiene and face-washing, and sunlight to patients with acne.” In other words, your dermatologist doesn’t have a conclusive study to back up her recommendations. You need to individualize your own treatment based on your results.
Let’s look at the review’s findings.
“Several studies found improvements in acne following the use of a medicated face wash, addition of an abrasive to the face wash, and medicated soaps. Other studies have been unable to identify the effective component of interventions.”
“Two RCTs, one CCT and two before-and-after studies found improvement associated with different light sources. One cross-sectional study found that there were more patients seen in the winter months, while another study found that a third had exacerbation of symptoms in winter, a third in summer and a third did not vary according to season.”
“Two before-and-after studies and one crossover study found no association between chocolate consumption and acne, although high fat content of the placebo bar may have been acnegenic.”
“One cross-sectional study found no difference in sugar consumption between controls and acne sufferers, one found that 20- to 40-year-old acne sufferers were heavier (but not 15- to 19-year-olds) compared with controls, and one found that stress and self-assessed dietary quality were correlated with acne severity.”
“In terms of methodological quality, most of the studies had a small sample size, were uncontrolled, or were not blinded.” (This review was done in 2005, before the other diet review above).
Since 2005, has the face of acne research changed beyond the diet review above?
We have a another tiny study that judged between washing your face once, twice, three or four times a day. There was no significant difference between the groups, but twice a day looked a little better than once a day.
Adaptalene and Tretinoin Topically
Adaptalene has been marketed as a newer, less side-effect prone version of the retinoic acids. But rats treated with adaptalene showed inflammation and a thickened dermal layer, even as they had fewer blackheads. Compared to tretinoin, “Cutaneous side effects were limited to a mild “retinoid dermatitis” occurring in both treatment groups.” Adaptalene was initially seen as more effective in the 1990’s but now it is clear that tretinoin and higher doses of adaptalene are comparable in side effects while weaker doses of adaptalene are less effective with fewer side effects.
Antibiotics, Topicals, and Mixing the Two
In a review from this year: “While acne was previously perceived as an infectious disease, recent data have clarified it as an inflammatory process” yet the review goes on to list the inflammatory retinoids (above) and antibiotics as the main treatments. It only mentions modest results from laser treatments. When we look at studies of the antibiotics compared to each other and topical treatments, oral antibiotics and benzyl peroxide were both the most effective and the most likely to have side effects. At the end of all the comparisons of all the treatments, researchers noted that: “Residual acne was present in most participants (95%) at the end of the study.” More importantly, “Topical antimicrobial therapies performed at least as well as oral antibiotics in terms of clinical efficacy.” As a surprising side note, antibiotic resistance of the surface bacteria did not greatly impact treatment.
Cheapest and Best?
In that review, benzyl peroxide was the most cost effective intervention. 5% tea tree oil is also effective. In a head-to-head trial with 5% benzyl peroxide, tree tree performed as well with fewer side effects though it had a slower start of action. Another compound, gluconolactone, performed as well as benzyl peroxide with fewer side effects. In a recent review of herbs for acne, there are dozens of options, but few human studies.
Retin A Orally
Oral retinoids have fallen out of favor, as they were heavily overused. “For severe nodular acne, isotretinoin is the treatment of choice. In addition, over recent years dermatologists have increasingly used this drug to treat patients with moderate acne which has not responded to other systemic therapies, particularly when associated with scarring or significant psychological disability. However, this use is outside the current license of the drug (bold added).”
Hormonal treatments make the most sense when dealing with a hormonal problem. In a recent study women taking birth control reported around a seventy percent improvement in mild or moderate acne over six months. Reviews show a consistent drop in acne, with little variation in the type of contraception used. No trials exist on males given hormones, and no trials compared hormonal use to other treatments.
When looking for a moisturizer, look for one that contains Lauric acid, which has shown to block bacterial growth.
Among the treatments I won’t be recommending today is the injection of bee venom into acne sufferers faces. While the mouse study (cue screaming mouse) showed inflammatory changes, bee venom would be an extremely painful route to cure.