Gabor Szendi:
The causes and treatment of acne

Acne and pimples can sometimes disfigure the face and the back for a lifetime, or at least ruin adolescence with the feeling of inferiority that these cause. As usual, medicine has no clue on the issue, and has taken heavy measures, not infrequently with only temporary success, but with lasting damage.

 

 

Acne is a problem for 85% of adolescents, and 50% of 20-30 year olds (Lolis et al., 2009). A variety of theories and methods dominate dermatology about its origin and treatment. It's common with theories that the problem is considered eternal, and so the evolutionary perspective is rarely raised. However, in the course of animal and human phylogenesis, there was a selection against all that was to the detriment of the individual. So if acne became this common in the 20th to 21st century, then it would be well-founded to look for an explanation in lifestyle changes. Of the many lifestyle variables, the most significant is the change in our diet. The following is an overview of the probable and real causes of acne that will lead us to the problem's solution.

Acne and evolution

Mostly acne appearing on the face causes serious problems in both genders. From an evolutionary point of view, a face disfigured with acne and remnant scars is a serious reproductive disadvantage, as it scares off the other sex away. As a result, unfortunately acne-related depression or suicide is not uncommon, which in itself indicates the severity of the problem (Sundström et al., 2010). For this reason alone, it can be assumed that there was a strong selection against this skin defect over the two million years of mankind's development. This is supported by the fact that in those who live by traditional diets such as the Inuit, Aché, Bantu, and Kitava, European physicians found either rare or no acne at all in adolescents or young people (Cordain et al., 2002).

Traditional nutrition protects against acne

Immediately after World War II, many doctors investigated Okinawa, looking for the secret of the many who live more than 100 years there, and found no trace of acne in young people. In Brazil, nearly 10,000 school children were studied, and acne was found in 2.7% of them. Bantu people had an acne incidence of 16% in adolescence, compared to 45% among whites. For the Zulus the first time acne arose was during urban life. Studies of the inhabitants of Kitava island stated that obesity was unknown to them, their insulin levels were low and acne or its traces could not be found. 115 members of the Aché tribe were studied several times every six months, and traces of acne were found in only one man, while traces of acne or other skin defects indicating acne in the past were not found among the other Aché (Cordain et al., 2002). Acne was unknown to the Canadian Inuit until they switched to a Western diet (Spencer et al., 2009). Acne was found among 5% of 2,250 Ghanaian people hospitalized with skin complaints (Doe et al., 2001). Another study in Ghana compared 572 rural youths to 489 attending city schools. Among rural people, 1 (0.2%), whilst among urban people, 63 (12.9%) of the youth had acne (Hogewoning et al., 2009). According to a study performed of Dogon people living in Mali, acne is 85% less prevalent among rural youth (Campbell and Strassmann, 2016).

Dermatologists explain the development of acne by the increased production and death of cells in the sebaceous glands on the face and on the back, which, when mixed with sebum, block the sebaceous gland's duct. Propionibacterium acnes, a bacterium living on the skin, causes inflammation, which in response the immune system starts attacking, and the dead blood cells, bacteria and tissues develop pus in the blocked duct of the sebaceous gland. The high incidence of acne in adolescence is explained by hormonal changes, as male sex hormones, which are also produced in women, stimulate sebum production. This fatalism is amplified by research on twins, according to which the development of acne is explained by 81% genetic predisposition (Bataille et al., 2002). Mostly however, the fact the effects of genes interacting with lifestyle variables is ignored, because if genes were the only cause, Natural People would just as likely have acne.

Acne treatment methods

Knowing the mechanism of acne formation, many treatments have been developed, and many people treat their skin on the basis of various beliefs. Cleansing the skin with various agents is based on the assumption that acne is caused by dirt or infection. These treatments can result in some improvement, but in many cases they worsen the situation (Magin et al., 2005).

Attack against bacteria

Because of its supposed bacterial origin, the use of oral antibiotics has been in fashion for 50 years in dermatology. However, this has serious consequences, as not only Propionibacterium acnes becomes resistant over time, but also other bacteria that are normally harmless in the body, causing severe disease. Long-term antibiotic treatment also destroys the intestinal flora, which can have further serious consequences. In addition, Propionibacterium acnes, according to many, is 'only an eyewitness' and not the cause of acne: Antibiotics only improve skin with acne predominantly because of their anti-inflammatory effect (Sardana and Garg, 2014).

The key role of Propionibacterium acnes is also questioned by the fact that this bacterium is present in the same proportion on healthy skin as on skin with acne (Leyden et al.). Nonetheless, it has many effects in the already developing acne, for example the anti-inflammatory effect (Dessinioti et al., 2010). The antibiotic-resistant Propionibacterium acnes mutant is becoming more and more common all over the world, so antibiotic treatment has proven to be a dead end (Dessinioti et al., 2017).

Maybe hormones are guilty?

Hormones also appear to play a major role in the development of acne. Androgens (testosterone, dehydroepiandrosterone (DHEA) and androstenedione) are produced in the gonads, and in the adrenal glands in both men and women, and the dihydrotestosterone (DHT) produced from these, which is 5-10 times more potent than testosterone, stimulates sebum production in the sebaceous glands of the skin (Ebede et al., 2009). Androgens are also synthesized in the skin itself and, interestingly, this stress response is regulated by the Corticotropin-releasing hormone (CRH), which is consistent with the experience that stress stimulates acne (Ebede et al., 2009).

In Polycystic Ovary Syndrome (PCOS), the ovaries produce androgens, which cause acne, hair growth, and hair loss. A contraceptive is often prescribed for this, which only suppresses the symptoms but does not help the metabolic disorder that sustains PCOS. In many cases, women with acne have normal DHEA and testosterone levels. Acne in them is induced either by the androgens produced in the skin, or by the hypersensitivity of androgen receptors (Ebede et al., 2009).

Naturally, hormone theory has produced therapeutic approaches with a hormonal point of attack. Androgen receptors can be blocked, DHT-producing 5-alpha reductase enzyme can be inhibited, and as is usual in PCOS, contraceptives can be given as well to prevent ovarian androgen production (Ebede et al., 2009).

It certainly contradicts hormonal theory, that acne cannot be found in Natural People, although sex hormones are produced in the same way in these people. That is, hormonal treatments can be considered unjustified and risky interventions in the hormonal system, and do not address the underlying problem.

The role of retinoids

Vitamin A has a known role in the skin's health. Vitamin A-like compounds are called retinoids and they regulate the cells' division by binding to their receptors (Evans and Kaye, 1999). At one time, retinoids were thought to play a role in the treatment of cancer, and it was found incidentally, that certain retinoids inhibited acne formation. Isotretinoin (Accutane, Roaccutan) was registered in 1982 to treat acne. Isotretinoin causes cell death in the sebaceous glands (Nelson et al., 2011). Therapy is highly successful, but over the years acne returns in 30-40% of patients (Del Rosso, 2011). Fetal damage is considered one of the major risks of isotretinoin because of its known teratogenic effect. However it is common that pregnancy is only discovered during treatment, but congenital lesions were found even in pregnancies that started after suspending the therapy. Therefore many women abort their pregnancies or face a high rate of spontaneous abortion, premature birth, or facial and skull deformities, congenital heart disorders, and neurodevelopmental or immune defects (Sladden and Harman, 2007).

The other major risk is depression that occurs while taking the drug, aggravation of manic depression, and - rarely - psychosis, and the increased risk of suicide resulting from these. These effects are stated by many, citing research data, while others debate it. It is difficult to see clearly in this issue, because dealing this drug is big business and the pharmaceutical industry is doing its best to prove the agent's safety. However it is a fact that in the brain of those taking the drug, in many areas, including the prefrontal lobe, which plays a critical role in depression, malfunction can be detected (Ludot et al., 2015). If so many risks arise from use of a drug, only misinformation about the risks, the lack of treatment alternatives, and despair caused by acne can make people take the treatment.

Hyperinsulinism

People who regularly develop high blood sugar and high insulin levels after meals will develop greater or lesser amounts of insulin resistance in the short term. Insulin resistance means that cells have reduced insulin sensitivity, and are less willing to take up sugar due to excess sugar supply. The persistently high blood glucose levels caused by cellular resistance causes the pancreas to release another dose of insulin. However, this only increases insulin resistance and eventually hyperinsulinism develops. The sugars are converted into fats by the body, but the visceral fat in the liver and around the abdominal organs releases substances that also increase insulin resistance. Thus, high GI carbohydrates lead to a worsening metabolic disorder, one end of which is type 2 diabetes.

The real cause of acne

If a problem occurs as a result of changed living conditions, we need to look at the changes. Natural People do not consume milk and dairy products, and their diet does not contain high glycemic index (GI) fast digesting carbohydrates, which trigger high blood sugar and insulin responses, resulting in insulin resistance. Insulin-like Growth Factor-1 (IGF-1) levels increase accordingly to increasing insulin levels, while IGF-1 Inactivating Protein (IGFBP-3) levels are decreasing. Because both hormones stimulate cell division, they increase the growth and death of glandular cells in the sebaceous glands, as well as the production of sebum. Several studies have shown that reducing the GI of carbohydrates in the diet significantly affects the number and size of the acne (Smith et al., 2007; Kwon et al., 2012). The question is how can the efficacy of isotretinoin against acne be interpreted? High levels of IGFBP-3 are required for the cell division reducing effect of retinoids, which promotes the activity of retinoids and reduces the cell division stimulating effect of IGF-1. However IGFBP-3 is low at high insulin levels, so the body's own retinoid compounds cannot function (Cordain et al., 2002). Isotretinoin causes a 3.5-fold increase in IGFBP-3 levels in the cells of sebaceous glands (Melnik, 2014).

Numerous studies have shown that the consumption of milk and dairy products has a significant impact on the development of acne (Adebamowo et al., 2006,2008). This is because cow's milk contains an insulin secretagogue. If you eat a bun alone, or with a glass of milk you get a threefold insulin response. Interestingly, the consumption of skimmed milk is most likely to increase acne development. People who drink two or more glasses of milk a day are 44% more likely to have acne on their skin (Adebamowo et al., 2005). The insulin secretagogue is contained in whey, and bodybuilders like whey protein powder also because it has a muscle-building effect due to containing growth hormone. However acne is more common as its side effect (Simonart 2012), especially those that appear on the trunk (Cengiz et al., 2017).

Summary

The various theoretical and treatment approaches to acne have ignored the root of the problem, which is nothing more than the western diet relying on fast digesting carbohydrates. Persistent high insulin levels due to high blood sugar triggers a chain reaction in the body. Insulin itself is a growth hormone, but it increases the level of active IGF-1 by decreasing the level of its inactivating protein (IGFBP-3). High insulin levels increase the levels of androgen hormones, and decrease levels of its inactivating protein (SHBG). Both growth hormones and androgens enhance the growth of the sebaceous gland cells, and their production of sebum. The situation is exacerbated by the fact that low IGFBP-3 inhibits the activity of retinoid compounds that regulate cell division. The end of the process is a blocked sebaceous gland in which the Propionibacterium acnes bacteria multiply and increase inflammation (Cordain et al., 2002).

According to anthropological studies and the mechanism of acne development, it is clear that acne is a disease of civilization that can be cured by dietary changes: fast digesting carbohydrates, milk and dairy products should be eliminated from the diet, and it would be advisable to avoid inflammatory vegetable cooking oils. In addition to many other problems, acne can be resolved.

 

References

Adebamowo CA, Spiegelman D, Berkey CS, et al. Milk consumption and acne in adolescent girls. Dermatol Online J. 2006;12:1.

Adebamowo CA, Spiegelman D, Berkey CS, et al. Milk consumption and acne in teenaged boys. J Am Acad Dermatol. 2008;58:787-793.

Adebamowo CA, Spiegelman D, Danby FW, Frazier AL, Willett WC, Holmes MD. High school dietary dairy intake and teenage acne. J Am Acad Dermatol. 2005;52:207-214.

Bataille V, Snieder H, MacGregor AJ, Sasieni P, Spector TD. The influence of genetics and environmental factors in the pathogenesis of acne: a twin study of acne in women. J Investigative Dermatology 2002; 119: 317-1322.

Campbell CE, Strassmann BI. The blemishes of modern society? Acne prevalence in the Dogon of Mali. Evol Med Public Health. 2016 Oct 2;2016(1):325-337.

Cengiz FP, Cevirgen Cemil B, Emiroglu N, Gulsel Bahali A, Onsun N. Acne located on the trunk, whey protein supplementation: Is there any association? Health Promot Perspect. 2017 Mar 5;7(2):106-108.

Cordain L, Lindeberg S, Hurtado M, Hill K, Eaton SB, Brand-Miller J. Acne vulgaris: a disease of Western civilization. Arch Dermatol. 2002 Dec;138(12):1584-90.

Cordain L, Lindeberg S, Hurtado M, Hill K, Eaton SB, Brand-Miller J. Acne vulgaris: a disease of Western civilization. Arch Dermatol. 2002 Dec;138(12):1584-90.

Del Rosso JQ. Face to face with oral isotretinoin: a closer look at the spectrum of therapeutic outcomes and why some patients need repeated courses. J Clin Aesthet Dermatol. 2012 Nov;5(11):17-24.

Dessinioti C, Katsambas A. Propionibacterium acnes and antimicrobial resistance in acne. Clin Dermatol. 2017 Mar - Apr;35(2):163-167.

Dessinioti C, Katsambas AD. The role of Propionibacterium acnes in acne pathogenesis: facts and controversies. Clin Dermatol. 2010 Jan-Feb;28(1):2-7.

Doe PT, Asiedu A, Acheampong JW, Rowland Payne CM. Skin diseases in Ghana and the UK. Int J Dermatol. 2001 May;40(5):323-6.

Ebede TL, Arch EL, Berson D. Hormonal treatment of acne in women. J Clin Aesthet Dermatol. 2009 Dec;2(12):16-22.

Evans TR, Kaye SB. Retinoids: present role and future potential. Br J Cancer. 1999 Apr;80(1-2):1-8.

Hogewoning AA, Koelemij I, Amoah AS, Bouwes Bavinck JN, Aryeetey Y, Hartgers F, Yazdanbakhsh M, Willemze R, Boakye DA, Lavrijsen AP. Prevalence and risk factors of inflammatory acne vulgaris in rural and urban Ghanaian schoolchildren. Br J Dermatol. 2009 Aug;161(2):475-7.

Khondker L, Khan SI. Acne vulgaris related to androgens - a review. Mymensingh Med J. 2014 Jan;23(1):181-5.

Kwon HH, Yoon JY, Hong JS, Jung JY, Park MS, Suh DH. Clinical and histological effect of a low glycaemic load diet in treatment of acne vulgaris in Korean patients: a randomized, controlled trial. Acta Derm Venereol. 2012;92:241-246.

Leyden JL, McGinley KJ, Mills OH, et al. Propionibacterium levels in patients with and without acne vulgaris. J Invest Dermatol 1975;65:382-4.

Lolis MS, Bowe WP, Shalita AR. Acne and systemic disease. Med Clin North Am.2009 Nov;93(6):1161-81.

Ludot M, Mouchabac S, Ferreri F. Inter-relationships between isotretinoin treatment and psychiatric disorders: Depression, bipolar disorder, anxiety, psychosis and suicide risks. World J Psychiatry. 2015 Jun 22;5(2):222-7.

Magin P, Pond D, Smith W, Watson A. A systematic review of the evidence for 'myths and misconceptions' in acne management: diet, face-washing and sunlight. Fam Pract. 2005 Feb;22(1):62-70.

Melnik, BC: Acne and Genetics. in: Zouboulism CC; Katsambas, AD; Kligman, AM (eds.) Pathogenesis and Treatment of Acne and Rosacea.Springer-Verlag Berlin Heidelberg 2014. pp: 109-130.

Nelson AM, Cong Z, Gilliland KL, Thiboutot DM. TRAIL contributes to the apoptotic effect of 13-cis retinoic acid in human sebaceous gland cells. Br J Dermatol. 2011 Sep;165(3):526-33.

Sardana K, Garg VK. Antibiotic resistance in acne: is it time to look beyond antibiotics and Propionobacterium acnes? Int J Dermatol. 2014 Jul;53(7):917-9.

Simonart T. Acne and whey protein supplementation among bodybuilders. Dermatology. 2012;225(3):256-8.

Sladden MJ, Harman KE. What is the chance of a normal pregnancy in a woman whose fetus has been exposed to isotretinoin? Arch Dermatol. 2007 Sep;143(9):1187-8

Smith RN, Mann NJ, Braue A, Makelainen H, Varigos GA. The effect of a high-protein, low glycemic-load diet versus a conventional, high glycemic-load diet on biochemical parameters associated with acne vulgaris: a randomized, investigator-masked, controlled trial. J Am Acad Dermatol. 2007;57:247-256.

Spencer EH, Ferdowsian HR, Barnard ND. Diet and acne: a review of the evidence. Int J Dermatol. 2009 Apr;48(4):339-47.

Sundström A, Alfredsson L, Sjölin-Forsberg G, Gerdén B, Bergman U, Jokinen J. Association of suicide attempts with acne and treatment with isotretinoin: retrospective Swedish cohort study. BMJ. 2010 Nov 11;341:c5812.