Antioxidants have emerged as health silver bullets, at least if you pay attention to the popular media. It’s clear that media hype far outruns scientific evidence when it comes to antioxidants and in some cases antioxidants may even be harmful. But acne is one area where reality slowly catches up with the hype. Emerging research implicates inflammation (oxidative stress) as one of the causes of acne, and trials with antioxidants show promising results.
In this post I’m going to take an in-depth look at the role of inflammation in causing acne and how you can use antioxidants to treat acne.
Before we get started I want to thank Dr. Whitney Bowe. She kindly gave me material and guidance as I was researching this post.
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Acne patients under high oxidative stress
Several studies now show that acne patients are under higher levels of inflammation (oxidative stress in medical speak). As this review study concludes:
These studies provide indirect, yet very obvious indicators of a mismatch between an oxidative stress burden and a diminished antioxidant defense system capacity in acne…
It appears as though these antioxidant enzymes might be depleted at a faster rate in those who suffer from the chronic inflammation that characterizes acne.
And we are talking about significant differences here. For example one study found 43% higher hydrogen peroxide (inflammatory chemical) production in acne patients when compared to healthy controls.
One study showed also significant differences in inflammation markers and anti-inflammatory substances between those with mild and severe acne. People with severe acne had much more inflammation and fewer antioxidants than those with mild acne.
In the name of intellectual honestly I have to note that results vary from study to study. Some find no correlation between acne severity and inflammation status, and other studies find only minor differences between acne patients and healthy controls. This is normal as science is messy. But when you look at the evidence as whole it shows that acne patients suffer from higher levels of inflammation and have fewer antioxidants to protect them.
This inflammation can come from many sources, such as gut problems, eating foods you are sensitive, stress and sleep deprivation.
How inflammation leads to acne
OK, fine. So we have a bit more inflammation coursing through the body. But what does it have to do it acne? Good question (especially since I asked it, lol).
Science hasn’t answered this definitively yet, but the answer is probably just a simple depletion of antioxidants in the skin (at least one study showed that acne-prone skin has fewer antioxidants than healthy skin). The skin is constantly exposed to the elements, many of which cause inflammation (such as UV rays from the sun).
Without adequate antioxidant protection sebum gets damaged (oxidized). Sebum composition is somewhat different in acne patients. Our sebum has more squalene (a fatty acid), perhaps because squalene is quite resistant to oxidation (i.e. it can take more abuse than many other fatty acids).
The problem is that when squalene gets damaged (oxidized) it’s highly comedogenic, that is, it causes acne. The damaged form of squalene is called squalene peroxide. Squalene peroxide in the skin starts an inflammatory cascade that further depletes the protective antioxidants from the skin.
Vitamin E is one of the most important antioxidants in the skin. It protects sebum from inflammatory damage. But of course vitamin E levels in acne-prone skin have been measured and found wanting.
Inflammation as the trigger for acne
Researchers now speculate that this initial inflammation is the trigger that starts the acne formation process. As researchers study the progression of a pimple they find inflammation in the earliest stage of the pimple.
In the review paper she co-authored Dr. Bowe says that this initial inflammation helps the P. Acnes bacteria to colonize the skin pore. I didn’t really understand the mechanism of how it happens, but people smarter than me have spoken about altered oxygen tension and how it creates an ideal environment for the acne causing bacteria.
Under these ideal conditions the bacteria rapidly multiplies. Exposure of skin cells to the bacteria triggers further inflammation and turns a harmless blocked pore into an angry, red pimple.
Antioxidants as acne treatments
If inflammation causes acne can we treat it with antioxidants? We don’t have enough studies to say for sure, but initial results suggest we can. Studies with treating acne with both topical and internal antibiotics have provided good results.
For example studies using sodium ascorbyl phosphate (SAP), a vitamin C precursor, topically show that SAP is more effective than benzoyl peroxide and clindamycin creams. Similarly, studies on topical use of zinc show promising results.
Vitamin B3 is another possible treatment. In one study 4% vitamin B3 cream was a bit more effective than antibiotic cream. 82% of the patients treated with the B3 cream showed improvements as compared to 68% treated with the antibiotic cream.
The effect of antioxidant supplements on acne has also been studied. For example in one study 30mg of zinc gluconate reduced inflammatory acne by 57% after 2 months. In another study zinc supplementation was compared to oral antibiotics. Antibiotics produced better results, but zinc was judged as clinically effective in 31% of the patients. Clinical effectiveness means more than 2/3 reduction in inflammatory acne.
And in yet another study 79% of the people taking an antioxidant supplement had 80-100% improvement after 12 weeks. The daily total from the supplement contained zinc, vitamin C, mixed carotenoids, vitamin E and a chromium. There are some problems with how this study was done, so it’s highly unlikely that you will get such good results in real life.
Then there’s also the fact that many antibiotics are also anti-inflammatory. Take Metronidazole as an example. It has no real effect on P. Acnes bacteria, but effectively treats acne.
There are also other studies, but I don’t want to turn this into a medical review. The point I want to make is that antioxidants, both topical and supplements, can help with acne.
So how can you use this information to make a difference on your skin? It’s hard to turn preliminary data into real treatment strategies, but here’s something you could try.
Shift your topical treatment strategy from slaying scores of bacteria to supporting the health of your skin.
- Avoid the use of harsh chemicals, especially benzoyl peroxide. BP can be used effectively, but you have to be careful with it. BP can deplete vitamin E from the skin and make it more vulnerable to inflammation. Use carefully and judge how your skin reacts to it.
- Use moisturizer. Moisturizers can repair the skin barrier function and that way reduce inflammation from the skin. Choose a moisturizer that’s formulated for facial skin, and try to find something containing the following: vitamins C, E, and B3, zinc, and green tea. It’s unlikely you’ll find anything with all (if you do, please let me know), so go with the one that has most of them.
- Use essential oils. Acne-prone skin has been shown to be low in linoleic acid (LA). LA is a fatty-acid that can reduce inflammation in the skin. Evening primrose oil is a good source, and many skin patients (psoriasis, eczema and acne) say topical application of evening primrose oil helps.
You’ll probably get better results when you combine topical treatment with antioxidant supplements. Here are some that you could try:
- Zinc, most studies used 30mg dose
- Antioxidant vitamins (A, C and E)
- Vitamin B3
I don’t know enough to recommend specific brands, so please don’t ask. The evidence is still quite flimsy to make specific recommendations. But if I were to try this I would probably get a dedicated zinc supplement and then try to find a multivitamin/mineral supplement that covers the others.
Also, more is not necessary better. There’s no good reason to believe that mega-dosing vitamins gets better results. Also, vitamins are bioactive compounds, and taking too much can cause real harm.
One thing I noticed from these studies is that it takes time to get results. Some studies made a specific mention that real improvements started happening only after 6 to 8 weeks of treatments. So please don’t expect quick miracles.
Conclusion: protect your skin
All this underscores the need to protect the skin from inflammation. Because of excessive sebum production acne-prone skin needs more antioxidants, and becomes sensitive if it doesn’t get them (a bit like my girlfriend becomes moody with the lack of attention).
Jokes aside, there’s a good reason to believe both internal and external inflammation play a role in acne. Internal (also known as systemic) inflammation can come from things like diet, stress and lack of sleep, whereas UV rays from the sun, pollution and chemical exposure can cause external inflammation on the skin. Inflammation damages sebum, and many researchers now believe that this initial inflammatory damage to sebum is what really triggers acne. Bacteria come to play later and aggravate the problem further.
Supporting this theory is the fact that treatment with antioxidants produces good results. Both oral and topical antibiotics have shown promising results in preliminary studies.
But before you get too excited you should keep in mind that these are still preliminary results. Science needs to grind its wheels still many years before we have enough data to reach scientifically valid conclusions. That said, I think this is worth a shot. The costs are minimal and there is no real risk in trying this.
- Acne vulgaris: the role of oxidative stress and the potential therapeutic value of local and systemic antioxidants.
- Tissue and blood superoxide dismutase activities and malondialdehyde levels in different clinical severities of acne vulgaris.
- Superoxide dismutase and myeloperoxidase activities in polymorphonuclear leukocytes in acne vulgaris.
- Oxidative stress in patients with acne vulgaris.
- Oxidative stress in acne vulgaris.
- The role of the antioxidative defense system in papulopustular acne.
- Oxidant/antioxidant status in obese adolescent females with acne vulgaris.
- Decrease in glutathione may be involved in pathogenesis of acne vulgaris.
- Erythrocyte glutathione peroxidase activity in acne vulgaris and the effect of selenium and vitamin E treatment.
- Blood glutathione-peroxidase levels in skin diseases: effect of selenium and vitamin E treatment.
- The possible role of reactive oxygen species generated by neutrophils in mediating acne inflammation.
- Effect of zinc gluconate on propionibacterium acnes resistance to erythromycin in patients with inflammatory acne: in vitro and in vivo study.
- An observational study of methionine-bound zinc with antioxidants for mild to moderate acne vulgaris.
- Topical nicotinamide compared with clindamycin gel in the treatment of inelammatory acne vulgaris. [sic]
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