Not too long ago a person at acne.org forums was complaining that despite ‘doing all the right things’ her acne just wouldn’t go away. She then went on to complain how acne is maddeningly confusing and how nothing seems to work. Needless to say, acne, and trying to get over it, had made her utterly confused.
I believe this confusion as to what acne is how to treat is the biggest obstacle between you and clear skin. It leads you to merry-go-round where you try one thing after another. Desperation starts creeping in when you don’t see the results you expect, and that makes you vulnerable to quacks promoting unscientific and dubious methods.
Today I’m going to share with you a couple of studies that provide antidote to the confusion. We are going to talk about 3 new studies that provide even more evidence that inflammatory damage at the skin is the root cause of acne.
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Read moreAcne severity correlates with inflammation level
A study published in January 2013 provides quite damning evidence. In the study Saudi Arabian researchers compared measures of inflammatory damage between acne patients and people with clear skin. They further divided the patients to three groups: mild, moderate and severe, according to acne severity.
This graph shows measures of inflammatory damage. For copyright reasons I can’t use their graphs, but I reproduced them from the data.
As you can see, there’s a clear correlation between acne severity and inflammatory damage. The graph shows measures for both protein oxidation (the blue bars) and lipid peroxidation (damage to fats, the red bars). But the details don’t really matter to us. What matters is the overall trend showing higher levels of inflammatory damage as acne goes from mild to moderate to severe.
On the flip side, they also looked into antioxidant activity. Here are the results for antioxidant enzymes. This chart shows measures for two very important antioxidant enzymes glutathione and superoxide dismutase. Much like vitamins C and E, these enzymes neutralize free radicals and other inflammatory molecules.
Again we see a similar pattern. People with clear skin show higher levels of these antioxidants and that the levels drop as acne gets worse.
Of course correlation doesn’t equal causation. These data don’t prove that inflammation causes acne. And if these were the only data, I would be careful not to jump to unwarranted conclusions. But these are not the only data, not even close. In the earlier posts I have covered more data on inflammation and the potential role of topical antioxidants.
Acne lesions show inflammatory damage
Another study published in Novermber 2012 provides more evidence. The earlier study measured markers of inflammatory damage and antioxidant enzymes in the blood. This study measured similar things in actual pimples. For the study the researchers took skin samples from people with varied severities of acne, again divided into mild, moderate and severe categories. They also took control samples from people with clear skin.
Unfortunately I don’t have access to the full-text of the study, so I can’t give you all the details. But in the abstract they mentioned that people with severe acne showed 2 to 4 fold higher levels of inflammatory damage than people with mild or moderate acne. Similarly, antioxidant enzyme readings were significantly lower in people with severe acne than the other participants. Unfortunately the abstract made no mention of how people with mild acne relate to those with clear skin. If someone has access to the full-text, please contact me, and I’ll add the data here.
Study: Antioxidant supplements reduce acne by 50%
Late 2012 Iraqi researched published a study that shows antioxidant supplementation can reduce acne by 50%. A few such studies have been published earlier, but those were quite low quality and as such we can’t draw strong conclusions from them. This study was placebo-controlled, which makes this much better.
Placebo control is important because, though it doesn’t seem like that, the placebo effect is very strong in acne. For example, it’s been pointed out that the placebo effect may account for about 50% of all the positive effects seen in studies using oral and topical antibiotics. Without placebo-control we can never know how much of the observed effect was due to the treatment and how much due to various placebo effects. The internet is full of stories of people getting better after ridiculous and implausible ‘therapies’ – most such stories can probably be explained with placebo, and that’s another reason why you shouldn’t put too much faith into those stories. What ‘works’ for them may not work for you.
Back to the study. At the beginning of the study they measured the levels of glutathione (GSH), malondialdehyde (MDA) and interleukine -8 (IL-8). Glutathione is an antioxidant enzyme and malondialdehyde and interleukine -8 are measures of inflammation.
|
Acne |
Clear skin |
Difference |
|
| GSH |
0.65 |
1.61 |
60% lower |
| MDA |
8.68 |
5.46 |
59% higher |
| IL-8 |
61.17 |
36.65 |
66% higher |
Again the same pattern emerges. Acne patients show much higher level of systemic inflammation (they are under higher oxidative stress in medical speak).
Here’s a graph from the study that again shows a correlation between glutathione (antioxidant) level and acne severity. As antioxidant level drops the number of pimples goes up.
The study also showed similar graphs for other measures of inflammation. I’m not going to post them here, but the study is open-access so you can check them out for yourself.
In the study 56 acne patients were divided into 4 groups. 3 of the groups received one of the 3 studied antioxidant supplements while the 4th group received a placebo pill. The antioxidants were silymarin (milk thistle) (210 mg/day), N-Acetylcystein (NAC) (1200 mg/day) or selenium (200 mcg/day). NAC is a precursor to glutathione and can increase glutathione level in the body. Similarly selenium acts as a coenzyme in glutathione antioxidant reactions. The authors write that silymarin is believed to act as a potent antioxidant in human tissue.
Here are the results.
As you can see, the reduction in pimple count is practically linear for both N-Acetylcystein and silymarin supplements. After 8 weeks both supplements reduced acne lesions by about 50%. Selenium supplementation also showed a nice reduction, if not quite as quick as with the other 2 supplements. In contrast, there was no real change in the placebo group. I should note that this study was single-blinded, so the participants didn’t know which supplement they received.
This reduction in acne lesions was mirrored in increase in glutathione levels and reduction in measures of systemic inflammation. In other words, acne and systemic inflammation went down hand in hand.
Pretty encouraging results – especially considering what we discussed above.
There’s also older data that show low levels of glutathione in people with skin problems, and that combined supplementation with selenium and vitamin E increases glutathione levels and improves skin condition.
What does this mean to you?
By now you may think ‘OK, this is mildly interesting. It looks like inflammation can cause acne, but what does it mean to me? Eat more fruits and vegetables?’ Good point, so let’s move away from the dusty scientific papers and back to the real world where acne doesn’t obey fancy Excel-graphs.
This may be stating the obvious, but preventing and controlling acne means keeping inflammation in check. Unfortunately this is where neat the theory ends and the messy real world begins. The problem is that inflammation is such a fundamental function in the human body that there are countless things that affect it.
How you can reduce inflammation depends on what causes the inflammation in your body. Here are some common possibilities:
- Gut problems allow inflammatory molecules to escape the gut and into systemic circulation. I believe that this is one of the little-known and the most underestimated causes of acne.
- Chronic stress and persistent negative emotional states are very likely to trigger inflammation in the skin. In Clear for Life I wrote how a neurotransmitter called substance P can trigger an inflammatory response in the skin. There’s also evidence that substance P can increase sebum production and contribute to clocked pores. There’s no data on acne, but a study on psoriasis patients showed that injection of substance P triggered a psoriatic flare – even in people not prone to getting psoriasis. Substance P is released during psychological stress.
- Sugar and dairy products can increase sebum production and thus increase antioxidant demand in the skin.
- Inflammatory reaction to gluten is a possible cause, as are other allergic or sensitivity reactions to food.
- Chemicals in acne treatment and personal care products can cause skin irritation for some people.
The exact treatment plan is different for everybody, but here are some things that are likely to be helpful:
- Healthy diet that’s low in sugar and refined carbohydrates and high in fruits, vegetables, protein and healthy fats.
- Drinking 4 to 5 cups of green tea per day.
- Use antioxidant cream or moisturizer.
For more details feel free to read other posts on the skin, or, even better, get my book. Clear for Life packs all of this into an easy to understand and follow program. You can get it from Amazon either as a paperback ($19.97) or on Kindle ($9.97 – Amazon may add various taxes and delivery fees to this depending on where you are).
Toggle references
- Biochemical Markers of Oxidative and Nitrosative Stress in Acne Vulgaris: Correlation With Disease Activity.
- The activity of adenosine deaminase and oxidative stress biomarkers in scraping samples of acne lesions.
- Effects of Oral Antioxidants on Lesion Counts Associated with Oxidative Stress and Inflammation in Patients with Papulopustular Acne.
- Low intrinsic drug activity and dominant vehicle (placebo) effect in the topical treatment of acne vulgaris.
- Oral tetracyclines may not be effective in treating acne: dominance of the placebo effect.
- Blood glutathione-peroxidase levels in skin diseases: effect of selenium and vitamin E treatment.
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Hey Seppo – thanks for your blog and your new work with Paul
I was wondering – in some people – where acne is maybe not primarily driven by increased IGF – 1 levels – could whey protein be beneficial because of it’s glutathione raising effects?
I personally don’t seem to have any effect either way eating both whey and other milk products.
http://www.ncbi.nlm.nih.gov/pubmed/22889987
It’s possible. Whey also contains lactoferrin, and there was one study that showed quite a nice reduction in acne from lactoferrin supplementation.
A very interesting study as always. I have now been drinking a Chinese green tea for almost two months and my skin looks much better. Of course I can`t be 100% that it is due to the great amount of antioxidants that the green tea contains but it feels like it has an impact. Nevertheless I am feeling so much better today and I am very grateful for the valuable information you share with us.
Thanks for sharing your experience. I’ve heard from quite a few people that drinking green/white tea helps their skin.
Another great article from you, thank you for sharing this. I also read that people with acne have low level of GLA and EFAs. Apparently, when our body is low of EFAs, our system tells the skin to produce more oil for the skin. What’s your thought in this? Thanks
I can’t say anything definitive about this. I’m not aware of any research that would show increased sebum production with low levels of EFA and GLA. I know that those fats play a role in the skin barrier function. There’s some evidence that GLA either topically or as supplement can help with eczema. It’s possible that topically they are also helpful in acne, but with so little research available it’s hard to say anything for sure.
seppo!! i just buy your book by amazon! i like it so much!! man you ar a genius
its insane!!! thanks for all the research!!! i apriciate your work!!
isidoro from chile
Thanks for getting the book. I really appreciate it. Glad to hear you found it informative.
Hey Seppo,
First off let me say I’ve been a long time reader and big fan of yours for several years now. We’ve actually had a couple back and forths on acne.org in the past. Recently I saw a post of yours on Chris Kresser’s site, which spurred me to read and re-read a ton of your writings. I would argue you are perhaps the most well-rounded educated pundit on the etiology of acne and it’s treatments. You clearly have a discerning, scientific mindset/approach to the subject. Now that my nose is sufficiently brown…
The post of yours on CK’s site was about FODMAPS, something I recently become more aware of as having a big influence on my skin. I’ve tried to avoid being entrenched in dogma over the years with my mostly-paleo lifestyle, but unfortunately there are still a few things I do b/c for whatever reason it is “necessary” or something to that attune. One of those things is feeling that I need to eat tons of vegetables every day, despite feeling good when eating more simple high-digestible fare. I feel great eating bananas, applesauce, hell even some real sourdough bread (organic, ~3 ingredients) but I have this habit of over-complicating my meals, thinking I must get all sorts of nutrients at once. I need to shake the monkey off my back and not stress about changing up my diet, when ultimately it may do me better. I was curious- are you still eating your one fruit-only meal each day and feeling good? Thanks man
Lol, thanks for the compliments Daniel.
I was eating mono fruit meals during my raw food phase. I rarely do that anymore as the low fat, high fruit raw food diet was really bad for me. Not sure exactly what it was, perhaps too much sugar, but I started getting serious joint pains and hitting almost diabetic blood sugar levels. I’ve since switched to a more paleo-style diet, with the exception that I still eat a reasonable amount of grains, not the least of which is my morning oatmeal. I still eat a reasonable amount of fruits, but I don’t consider them as a main source of calories anymore.
I also have some FODMAP issues. Shortly after eating onions I get gut issues and a few days later my scalp breaks out. Onions are the only problem food I can say for sure, but I also suspect problems with apples.
I don’t know what to say to you. You seem already aware that you don’t need to over-complicate your meals for health reasons, and that you don’t need to get all the nutrients from a single meal.
Perhaps it helps to think back in time. During our hunter gatherer evolution humans ate what they could get their hands on. It seems reasonable to assume that our ancestors lived through long periods of food scarcity where they had to live with a very limited diet.
The human body seems to be very good at making substitutions between nutrients. For example, look at the antioxidant study I referenced in this post, it shows all the antioxidant supplements increased antioxidant enzyme levels and reduced inflammatory markers. Both sillymarin and NAC caused a similar increase in blood NAC levels, so somehow the body substituted substances in sillymarin to perform the same function as NAC.
I won’t go into much detail but will answer any questions anyone has. I’ve had acne for 37 years – since puberty. Tried everything – antibiotics [worked while on them, came back when stopped, B5 zinc etc etc. I was diagnosed with acneiform follicultis recently. Gt erythromycin. Again worked but only while on it. Comes back just as bad when stopped.
LONG STORY SHORT. saw this blog...started taking milk thistle and NAC. within 3 days inflammation went down massively. rather than nastily inflamed lesions [I had over 300 at one time] I now have none. I’ve had a couple of new ones come up in 3 weeks, not as big and not as inflamed and they healed within 24 hrs and left far less of a scar or so rather than hanging round for weeks.
It’s early days. I’ve been expecting to wake up with with an outbreak but so far so good. I’m hoping my body doesn’t adjust.
WOW! That’s all I can say. Amazing story, thanks for sharing it! I doubt that your body will adjust so much that your acne would get as bad as it was. It’s possible it gets somewhat worse, but I doubt it’ll get as bad as it was. Now at least you know for sure what’s causing your acne and can start hunting down the sources of the inflammation.
300 inflamed lesions? I’m sorry to say, but that sounds almost unbelievable.
Sorry for the bad editing on my post above.
Seppo,
Just woke up – no fresh lesions, still.
Yes, believe it or not I woke up in December 2011, sat down exactly where I’m sitting now and jumped up. I was sore on my back leg. Looked in the mirror and I had dozens and dozens of what looked like acne but was diagnosed as acneiform folliculitis by a dermatologist. They ranged from thumbnail sized very inflamed ones to smaller down to pinhead ones. I counted over 150 on one leg and even more on the other. I counted as I couldn’t believe how many I had. I’d gone to bed with none there! I then developed them on my trunk, scalp and other places.
I’ve had my acne [not folliculitis] since I was13 including cystic acne. I’m pretty scarred by it. The folliculitis scarring is by far the worst though including scarring. Interesting, the erythromycin I was on for the folliculitis took 5 weeks [1G a day] to achieve what milk thistle and NAC did in 3 days.
The only period in my life, previously, that I was acne free was a 3 month period on the Atkins diet. I went on it just to lose a bit of weight. After about 6 weeks on it I realised I’d only had a few zits come up and they were smaller and not inflamed and healed without me applying anything to them, overnight, leaving no mark. That was 8 years ago. I’ve assumed since then that in my case my acne is a blood sugar issue. I must check your site and see if you’ve anyhting on that. I used to check my blood every morning and after meals and I’m always at the high end of normal or just into what some would call the pre diabetic level.. I know these machines aren’t totally accurate. It’s still high though especially if you’re on a low carb diet. I’ve never been able to replicate the results I had on Atkins. But I maintained a low carb diet as it certainly helped a huge amount. Low carb was far less good for my folliculitis though.
So, to find that milk thistle and NAC work is shocking. 37 years of this could so easily have been prevented [assuming it continues of course]. I’m thinking of going back to a low carb diet. Maybe that + milk thistle an NAC will work better. I’m also thinking of adding maybe selenium and/or ALA and/or CoQ10. We’ll see.
I’ll post again if I get an outbreak or have anything else to say.
Wow, it must have been an experience to wake up with so many lesions all over your body. Can’t imagine what that must have felt.
I find that low carb or reduced carb diets usually work well for hormonal acne. High blood sugar and insulin level causes a hormonal cascade that, for people prone to acne, leads to excessive sebum production and blocked pores. I also notice that when I eat fewer carbs my skin tends to be less oily. I haven’t measured my sugars in years, but when I did I was on the higher side.
Those additional supplements could help, but I wouldn’t bet on it. Maybe you’ve reached saturation level already with your existing supplements and adding more is just a waste of money. Or not. I don’t know. I’m sure it’s worth a try, just keep in mind more may not mean better.
Anyway, really happy to hear that your skin is doing so much better.