Study: Low Carb The Best Diet For Acne?

Few of us the in West would change the comforts of modern civilization to the nomadic existence of Eskimos. Yet they have something most of us glamor, no acne – or, I should say, had. When Canadian Eskimos started moving into towns and permanent settlements many notes changes in their health.

Another condition has become prevalent, one obvious even to the layman: acne vulgaris. The condition used to be unknown among Eskimos, but one can see it readily amongst teenagers on the streets of Inuvik, Frobisher Bay and Cambridge Bay.

This sudden appearance of acne is mostly attributed to change in their diet. Going from: “1 meal of high protein, high fat and practically no carbohydrates with frequent nibbling the rest of the day on fish” to “3 rich meals a day and seemingly endless sweet drinks, candies, and chocolates. More than half the total carbohydrates are consumed as refined sugar.” (from: When the Eskimo comes to town.)

This is just one example from the two recent papers (here and here) where Paoli et al. argue that many chronic health problems are the result of carbohydrate intolerance and could be solved with ketogenic diets, also known as very low carbohydrate diets.

In this post I’ll outline their rationale for using low carb diets to treat acne and show how they fit into the bigger picture of acne. I should say that the papers focus on ketogenic diets but the argument also stands for low carbohydrate and carbohydrate restricted diets, and I don’t think ketogenic diets are necessary for getting clear.

Insulin – the anti-acne magic behind low carb diets

Just like real estate can be summarized in 3 words: location, location, location, the hormonal side of acne can be summed up with: insulin, insulin, insulin (especially for people with insulin resistance).

Though acne is usually seen as androgen-mediated disease, in many cases it’s actually driven more by insulin (though there are cases where it’s driven by thyroid hormones or estrogens). Insulin acts as a cornerstone hormone in acne. It not only directly stimulates skin cells to produce more sebum and keratin but it also increases the secretion and bioavailability of other hormones related to acne.

The paper mentions that insulin affects acne-relevant hormones as follows:

  • Increases androgen secretion
  • Increase androgen bioavailability by reducing sex hormone binding globules (substances that bind to sex hormones and inactivate them)
  • Increase IGF-1 bioavailability by reducing IGF-1 binding proteins

Insulin also plays a part in activation of the mTor pathway that acts as a mastermind regulator behind acne. The mTor pathway cannot activate fully without excess insulin/IGF-1 signaling (less mTor action means lower risk of acne).

More evidence for the role of insulin comes from diet-acne studies. Traditionally scientists have been reluctant to investigate the connection between diet and acne, and we only have a limited evidence to draw from. I another post I went over all the diet-acne studies, but I’ll briefly summarize them here.

The studies that showed reduction in acne include:

  • Reduction of dietary glycemic index (GI)
  • Simultaneous reducing dietary GI and increasing protein intake
  • The now famous Kitava study. Drs. Cordain and Lindberg observed no acne among the traditional people living in the island of Kitava in Papua New Guinea. Though the people ate very high carbohydrate diet (70% of calories from carbs) they mostly ate low glycemic index root vegetables and fruits, with less than 0.2% of calories coming from ‘Western foods’.
  • Several large studies have shown that people who drink more milk have a higher risk of getting acne

And here are the studies that haven’t shown reduction in acne (these are also the same crappy studies some derms still point to and claim diet has no effect on acne):

  • Replacement of high-sugar chocolate bar with another candy bar equally high in sugar
  • Allowing students (who already ate a lot of sugar) to eat as much candy, chocolate and sodas as they wanted in one sitting and observing no incidence of acne.

It’s interesting to note that all the successful studies include diets that reduce insulin. The unsuccessful studies on the other hand just replaced one form of sugar with another or added some sugar to a diet already high in sugar.

Blood sugar and insulin levels in normal and low carb diets

The paper had an interesting table that perfectly highlighted why low carb diets can be helpful in acne, diabetes and other conditions. The table showed blood sugar and insulin level ranges for normal (typical Western) and low carb diets. I plotted the data into charts.

Little disclaimer, the paper didn’t specify whether these are post-meal or fasting values (I presume fasting) or the sample population. So don’t look at the individual figures too carefully, rather look at the differences between low carb and typical Western diet.

Let’s start with the blood sugar chart.

Blood glucose in normal vs. low carb diets

People on low carb diets had somewhat lower blood sugar level. While the difference may not look that dramatic it is significant. First, there’s a certain physiological minimum blood sugar level that the human body requires to function and survive. Even if you don’t eat any carbs your body will still produce some glucose from protein. That’s why your blood sugar level normally doesn’t go below a certain range.

The range for normal diet is also in the pre-diabetic range, meaning significantly higher risk of developing type-2 diabetes later on in life.

And here’s the chart for insulin level.

Insulin level in normal vs. low carb diets

Here we can see a huge difference. When dietary carbohydrates are reduced to minimum insulin levels drop significantly; though some protein foods also increase insulin, notably dairy products.

Acne – not just about insulin

By now it should be clear that insulin is an important factor in acne, but please don’t think it’s the only one. After reading hundreds and hundreds of studies on acne, I’ve realized there’s a simple explanation to it, as illustrated by this masterpiece of PowerPoint art:

What causes acne

Without going into details (detailed explanation of the graph here), acne starts with oxidative damage (inflammation) to squalene, a fatty acid in sebum. Oxidative damage turns squalene into squalene peroxide, which is highly comedogenic. Research has quite clearly shown that there can be no acne without initial oxidative damage to sebum. Sebum oxidation leads to blocked pores, allows bacteria to colonize them and sets the stage for acne, for details, see this paper.

Insulin stimulates sebum production and increases the proportion of squalene in sebum – reduction in insulin does the opposite. This of course means you have more sebum on your face that’s constantly exposed to inflammatory damage (think UV rays, air pollution, skincare products, etc.) Without sufficient antioxidant protection sebum will suffer oxidative damage and you’ll get acne. There’s good evidence to show that the antioxidant system just cannot keep up with the demand in acne, see these posts for more details:

Bottomline

Clearly there’s a case to be made for using low carb diets to treat acne. They can be especially helpful for acne patients who are overweight or otherwise insulin resistant, because high insulin level stimulates skin cells and release and bioavailability of androgens and IGF-1, the two other hormones linked to acne. Reducing carbohydrate intake drastically reduces many hormones linked to acne.

That said, not everyone with acne is insulin resistant. In some cases acne is linked to PCOS, other hormonal abnormalities or is not caused by hormonal issues (think gut problems or stress). In such cases low carb diets are probably less helpful.

Also do keep in mind that going low carb is not the only way to reduce insulin. Reducing sugar and refined carbohydrates is what makes the biggest difference. Studies show that low GI paleo or Mediterranean style diets also work for insulin resistance and the kind of metabolic abnormalities behind acne.

The take-away from this is that you shouldn’t think of low carb diet as a be-all-end-all solution to acne. They work on one part of the ‘acne formula’, and while reducing insulin level may help your skin a lot, you should take a broader view and also address the other aspects behind acne.

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About Me

Hi, I am Acne Einstein(a.k.a. Seppo Puusa). I'm a bit of a science nerd who is also passionate about health. I enjoy digging through medical journals for acne treatment gems I can share here. You can read more about my journey through acne and how I eventually ended up creating this.

36 thoughts on “Study: Low Carb The Best Diet For Acne?

  1. Brilliant as usual! I gladly say that low carb seems to work for me (been 2 months now), along with no traditional shaving (no razor but nail scissors) 🙂

    • Why are you interested of squalene (just wondering)?

      High-fat foods should be good for your skin, but I can’t say anything about squalene in foods. Probably has no effect.

      • You mentioned “acne starts with oxidative damage (inflammation) to squalene”, hence I was wondering if consuming high-squalene foods would help, perhaps by supplying the body (and skin) with healthy squalene?

        • Can’t say for sure, but I’m pretty sure your body makes squalene from other fatty acids in your diet. I doubt you’ll get any additional benefit from eating squalene rich foods.

  2. Hi seppo,

    Does this article mean you now recommend actual low carb diets instead of 50% carb diets?

    I am having a lot of trouble getting healthy carbs into my diet. Between FODMAPS and GI, they only starchy things I am comfortable with are pumpkins, carrots and fruits.

    But I just realized that all the pumpkin i’m eating have practically no carbs (it’s like they are made of air or something, they have practically nothing but feels pretty fulfilling), so i’m probably getting around 60g of carbs a day or so (half of it from bananas).

    So, What is the amount of carbs per day that I should aim for.

    Also, are there other more carb dense things that are perfectly safe? I was thinking about sweet potatoes, yams or eddoes, but considering I cook all my veggies in the microwave, I thought those might have higher GI (since they flactuate more).

    Thanks.

    • Btw,

      I am asking because I don’t really want to be in ketosis because I don’t want to deal with carb starvation.

      It seems like if I use a ketogenic diet, then every time I cheat a little and have more carbs, I need to deal with low carb flu again.

    • We have to consider 2 things there: what’s optimal for health and what’s practical. Purely in health (acne) terms low carb is probably better than moderate carb diet. Especially for people who are insulin resistant or have other hormonal issues.

      But low carb diets are harder to stick to and less practical than moderate carb diets (say, 30 – 50% carbs). That’s why I’m hesitant to recommend then. I know there are many who can’t stick to them and it just causes them unnecessary stress and worry.

      Especially since there’s no clear evidence to show that low carb diets are better than moderate carb, low GI diets. I would say there are indications in the data that low carb could be better than moderate carb, low GI, but the evidence is too weak to base strong conclusions on. Sorry about the convoluted reply, sometimes it’s just impossible to draw straight conclusions from complicated data.

      Bottom line: People who are insulin resistant or have other acne-related hormonal abnormalities probably should restrict carbohydrates. How far to go, I leave for you to decide based on your situation. I would keep 50% as the upper limit (50% of your calories from carbs), but feel free to go lower than that. And keep sugar and other refined, high GI carbs to minimum.

      I am having a lot of trouble getting healthy carbs into my diet. Between FODMAPS and GI, they only starchy things I am comfortable with are pumpkins, carrots and fruits.

      Have you confirmed that FODMAPs are a problem for you? FODMAP-diet is very restrictive and I don’t recommend it unless you know they are a problem for you. With knowing I mean you at least have observed eating FODMAPs causes gut problems many times.

      All the carbs you mentioned should be ok to eat. Microwave cooking, to my knowledge, doesn’t change the GI of a food (anymore than other forms of cooking). Rice is fairly safe food to eat.

      I also like pumpin. I usually blend cooked pumpkin with coconut milk and spices for a delicious and skin-friendly soup.

      • Thank you very much seppo,

        I am just wondering what would be the best between sweet potatoes, eddoes, taro and rice? Those seem like good choices for more carbs (Pumpkin is certainly not enough).

        Also, do you know of a minimum amount of carbs I should eat per day just to avoid ketosis? Just to avoid the low carb flu.

        Thank you very much.

          • Hello, here I come with a new question: I have a very very oily T-zone, I make fun and say that if I was a pan, I could easily make a fried egg on it. My cheeks are normal/dry. However, in my long history of battling acne, I always got the pimples on my cheeks and not on my T-zone where it’s all oily and greasy. Any thoughts about this?

            Also, over the years my skin completely cleared up in the summer. I linked it to vitamin D because nowadays I’m supplementing with cod liver oil and even I’m staying in the house during the day (so obviously not making my own) – my skin is quite decent. And I’m having this theory: what if all this traditional cultures we talk about that have clear skin have it because of high levels of vitamin D? The Kitavans, Eskimos have it from fish, the Asians also live in more sun and eat more fish, Africans also live in the sun.. Another thing is that till recently, traditional cultures used way more lard. I think I read somewhere that lard is the second vitamin D source after CLO. It’s just a theory, I know you don’t fully support the vitamin D theory but I’d like to know your thought on this.

            Thanks in advance and I hope I’m not bothering you 🙂

          • Sorry about my late reply. Took a few days off the comp.

            Dry skin suggests damage to the skin barrier function, and because of that your skin can’t retain enough moisture. Damaged skin barrier also allows bacteria, dirt and other non-desirable stuff to enter your skin easier, which might cause more inflammation in those areas. In the areas that are oilier the sebum probably protects your skin from inflammation. I would suggest using some antioxidant moisturizer to protect and repair the dry areas.

            Regarding vitamin D. It’s certainly possible, maybe even likely, that vitamin D level plays a role in acne. Vitamin D can reduce insulin resistance to some degree and it’s possible it plays a role in hormonal acne, especially for women.

            I would be hesitant to say it has a big role in acne. Simple theories like that are rarely correct 🙂

            Let me give you an example from Thailand, where I happen to live at the moment. People here get exposed to sun a lot, but in the recent 10 to 15 years or so acne has become much more common here – as has obesity. It also happens that during the past 10 to 15 years Western-style food has become much more common here. With Western-style food I mean fast food, donuts, sugary drinks, bakery products, bread, etc.

            There’s quite convincing evidence to implicate sugar and carbohydrates and the metabolic consequences they have in acne. Vitamin D may help to mitigate the damage to some degree, but one can’t really say that lack of vitamin D would cause acne.

  3. No worries for the late reply! 😀

    Definitely diet is very important, I’m a proud follower of the paleo diet (I didn’t want to do it forever, but gluten upsets my stomach and I always had trouble digesting legumes.. so I have brown or white rice instead of other grains). When I started it I didn’t focus on fish consumption as recommended (from where I would have gotten my vit D and omega 3s) and rather stuffed myself with chicken and eggs. And definitely acne is not the same for everyone.

    Currently I’m using a B3 cream that also contains caffein, biotin, panthenol, some zinc.. I bought it about a month ago because I thought it has a good formula. Other thing I’m doing is to start my day with a cup of green tea and before I proceed to do other things, I take out the bag and apply it to my face and let it sit for 30 mins to an hour. And it tingles, so I know it’s working 😀
    For the night I’m using a peel with gluconolactone and zinc. I hope to get rid of these ugly marks before I start university, it would be like a fresh new start for me after 3 years of struggle. But if not, I became an expert on applying “my mask” 😛

    As usual, you opened my eyes. Omega 3’s, green tea and vit D are all knows to help with blood sugar issues, and this is what I’ve changed in my diet. I always had crazy hormones and I can confirm that they calmed down now.

    It’s a shame that we acne-sufferers have to go through years of self experimentation till we find our cure! And as you I’ve got into the alt-med and wasted so much time, but the worst part was putting all my hopes in every single new thing and seeing it’s not working! And yet, I was feeling like I have the Holy Grail. Disappointment after disappointment.. I first started to read on acne.org and other popular acne websites (I will not give any names but the kind that promote liver flushing and other “delights” – I didn’t try it, luckily), then when I started paleo my taste for science increased and on their community they have a lot of members that know their stuff. Unfortunately, as I told you, I didn’t follow it in the right way and I was feeling desperate (like if the cleanest diet out there is not helping, then I’m doomed and I will die sad and ugly). Then I’ve found you and I wasn’t afraid of using products on my face anymore. I realized eating garlic or putting it on my skin will never work (btw, I got awful burns once and they went away in a week!), that stuffing myself with chicken liver is insane, that the herbal teas are not doing anything and so on. I only focused on the important things and now I’m so close to the end of the tunnel.

    This blog is a bit like Myth Busters for the acne world 😀

    I will not ask anything else because everything is clear for me now. But I will definitely stick around and read every new article.

    Once again, thank you for your wonderful work!

    • Glad to hear I’ve been able to help you. ‘MythBusters for the acne world’, brilliant! I’m going to have to shamelessly steal that, lol!

      I also think it’s shame that we don’t hear this kind of information from doctors. I mean if I can dig out all these studies, then it should be 100 times easier for doctors and people who are trained to do so.

      For me not being able to get over acne was like a gateway to the ‘dark side of reason’ (aka alt-med), and I presume it’s the same for many other people. While people can benefit a lot by taking a more holistic approach to health, I think the outright hostility to science and evidence by alt-med proponents can cause a lot of harm for people.

      Like you said, you pin your hopes on these weird treatments and suffer one devastating failure after another. And with all the conflicting ‘advice’ out there you become utterly confused and have no idea what to do anymore.

      This is especially unfortunate since the answer doesn’t have to be so difficult. The evidence is out there, if the alt-med gurus and natural healers would just pull their heads out of their asses and actually look at the data.

      I’m with you on Paleo. I also eat Paleo-ish diet, as much as it’s possible without destroying my marriage to a non-Paleo woman. And yes, they seem to be the most scientific of all the diet and health movements.

      • “if I can dig out all these studies, then it should be 100 times easier for doctors and people who are trained to do so.”

        except doctors do not have time to study and sometimes have a conflict of interest.

        • This is a bit like saying aircraft engineers don’t have time to study latest safety regulations. Doctors are required to keep up to date on relevant topics. I understand that they don’t have time to dig up every latest study, but there are enough high level overview topics on medical journals that they should at least be aware of what research says on diet and acne.

  4. It looks like you haven’t researched PCOS because obviously, being a man, it’s not that interesting to you. PCOS is very, very closely related to insulin and insulin resistence and if a woman has PCOS one of the first things she should do is stop sugar consumption, especially if she is overweight. If she is normal weight or underweight then a low carb diet might not be the best option but even then carb intake should be limited (many women with PCOS have elevated androgen levels, the last thing they need is increased androgen secretion).

    • I have looked into PCOS, but I haven’t written much about it since I want to understand it properly. Despite being a man, it does interest me because a large portion of my readers are women and I want to do my best to understand their situation.

      That said, I do agree with your comment. In general carb restriction is good for acne, but thin women with PCOS need to make sure they get enough calories and avoid further weight loss.

  5. Do you think acne affects more women than men? Do you have any data on that subject?
    I think for women it’s easier to have hormonal imbalance because their hormones fluctuate through the month, not to mention the big changes during pregnancy and lactation. Do you think women are more vulnerable to acne?

    • I don’t have any studies on my fingertips now, but as far as I remember the studies on prevalence of adult acne show higher rates in women than in men. I’ve only glanced over those papers as the data is not that useful. I can’t really explain why women struggle more with adult acne, perhaps because of the monthly hormonal cycles.

    • Not to rain on your parade, but don’t think too much about that study. It’s a test tube study and more or less anything can look like an acne cure in a test tube.

  6. Hey Sep, I started eating white rice after I sent you that study that showed that combining fat,protein and fiber from other meals will reduce the Glycemic load, but it was also the fact that brown rice contained phytic acid and the stuff that I’ve been reading from Fiber menace about fiber from grains can damage the intestine and, I noticed that my digestion system did improve a little bit after reducing the fiber that I received my grains so the only fiber that I got was from eating vegestables and fruits.

    I honestly can’t tell if it has had any effect on my skin to be honest I mean, my skin has pretty much stayed the same, and well.. I got a few new pimples throughout the weekend (But to my defense, I ate a lot of christmas candy and sweets that probably have sent my blood sugar levels throughout the roof and maybe that’s why my skin took a beating throughout the weekend) But I don’t know, I would like to eat that is low GI but at the same time doesn’t contain too much phytic acid.

    Any clues?

    • I’m not quite sure what you want to ask. I’m assuming you ask whether it’s ok to eat white rice even though it has high GI? If you keep your overall carb intake in check, the GI of those carbs becomes less important. The total amount of carbs you eat will affect the insulin load on your body more than the GI of those carbs. So I wouldn’t worry about it too much, especially since mixing carbs with fat and protein slows the release of glucose and makes GI even less important.

      For what it’s worth, I eat white rice almost every day here in Thailand – since the vast majority of Thai restaurants serve white rice and if you want to eat Thai food, there’s no avoiding rice.

  7. I also eat white rice every day and it’s not a problem. The only issue is that if you eat too much white rice it can make you (or at least me) constipated. I try not to eat too much and never eat it alone.

  8. I realize this is an old message board, but it would be interesting to see where people are on this.

    I’ve had serious adult acne after I delivered my daughter. My hormones reset and I had a jaw full of zits, like a teenage boy.

    This message board came up in the same google search as an article on acne and ketosis on the Paleo Solution site. In that article, the author focused on female acne as being different than male. Her assertion is that females may see an uptick in acne once becoming ketogenic. She suggests that women add in a few starches to increase carbs a bit.

    I found this to be interesting seeing as I have suffered the greatest amount of acne when I am very low carb (lots of meat and eggs) and working out most regularly.

    At this time, I’m on ortho-cyclen, which has resulted in skin so clear that I could slather butter on it without the tiniest bump. It has also saved me from crippling monthly pain as well as the monthly crazy cravings. I’m just stable. I love it

    Now for the downer. I gained 10 lbs in two weeks. I came to terms with my new weight and decided my curvier self is worth having perpetually clear skin. I hovered at my new high weight for four months. All of a sudden, another 10 lbs in 8 days. I now find myself in a jean size I’ve never been and terrified to go off birth control. I don’t know if it is truly more fun to have more ab definition (which rarely see the light of day in SF anyway) or perfect skin that everyone sees.

    I’m boot camping and low carbing myself into a coma just trying to keep my gain at only 20 lbs. sheesh!

    As an aside, I cut out caffeine and dairy before finally resorting to birth control. I’m still caffeine and dairy free.

    I’m at 30 carbs per day. For me, that’s not quite ketogenic. The dilemma is to go full coconut oil-chomping ketogenic or add a few carbs and stay away from ketosis as per Paleo Solution’s advice for women specifically.

    Any insights? Similar situations? Updates?

    • I normally don’t recommend very low carb diets. I think moderate carbs where you keep carn intake at 20% to 30% of total calories is the best. Ketogenic and very low carbs diets may trigger ‘adaptive insulin resistance’ (or so I’ve read). Keeping some carbs in your diets maintains your body’s ability to properly handle them. In your situation moderate carb diet could work better.

  9. I recently started the atkins diet and noticed a significant difference in my skin’s appearance. I’m 29 and have battled acne for years. Luckily my acne wasn’t severe or scarring, but breaking out here and there is still very frustrating, you would think it would all be over after high school. I have noticed a dramatic difference in my skin and have a very healthy glow. I’ve never been so happy with having started a diet for a different reason and benefitting on another front. I also have become a huge fan of a skin care line from ASDM, their all natural products are amazing. So I think coupling the diet with the natural skin care products has resulted in the best skin I’ve ever had.

  10. Seppo,

    Which one do you prefer based on the science?

    Mark Sission’s Primal Blueprint Carbohydrate Curve:

    300 or more grams/day – Danger Zone!
    150-300 grams/day – Steady, Insidious Weight Gain
    100-150 grams/day – Primal Blueprint Maintenance Range
    50-100 grams/day – Primal Sweet Spot for Effortless Weight Loss

    Or Paul Jaminet’s Perfect Health Diet, which seems to be way beyond the Danger Zone according to Mark Sission.

    1 pound of (454 grams) safe starches
    1 pound of sugary in-ground vegetables

    How many grams of carbs does this add up to?

  11. What would you recommend me to do. I have acne on my face. Try the no carb diet or maybe something else what works. Should i take some carbs cause some people say that it would not be healthy leaving carbs out so dilemma what benefits my acne and overall health. And do you have replacements recepies for carbs. Because im always hungry

  12. I can’t afford to go to a dermatologist. …I have sebaceous hyperplasia which is similar to acne …only does not go away… the oil gland’s are completely damaged.. and forms unsightly lesions on the surface of the skin…it’s not a health risk but it’s not attractive. …thus the reason health insurance can’t cover it. I use to have great skin but in my 30s it started…and with each passing year it gets worse…I have tried many things and it overwhelming and discouraging…I’d rather have acne at least that could go away…this sebaceous hyperplasia is a different animal.

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