The idea that chocolate and greasy foods can cause acne has been long dismissed as an old wives’ tale, but research over the past 10 years suggests that diet actually does contribute to whether you do or don’t break out with pimples. Dermatologists now think that changing the diet in specific (and healthy) ways should be part of an overall prescribed acne treatment regimen.
Dermatologists used to think acne started with an overabundance of skin cells and sebum (oil). This buildup clogged skin follicles that were then colonized by the bacteria P. acnes, resulting in inflamed, reddened papules and pustules of acne.
Dermatologists typically prescribe topical acne treatments such as benzoyl peroxide, Retin-A and isotretinoin (Accutane, an oral treatment prescribed for severe acne) to correct that buildup of skin cells and oil, but little heed is given to the patient’s diet, says Whitney Bowe, MD, assistant medical director of advanced dermatology in New York City and clinical assistant professor of dermatology at the Icahn School of Medicine at Mount Sinai Medical Center.
“My most recent reviews of the research on acne suggest that inflammation [at the cellular level, known as oxidative stress], might come before and actually cause the other events leading to acne lesions,” Dr. Bowe says.
A 2013 review published in the Journal of Clinical and Aesthetic Dermatology presents a large body of evidence supporting the conclusion that acne is an inflammatory disease and that inflammation is a cause of the development of the early stages of acne lesions.
This type of systemic inflammation has been linked to other skin conditions such as rosacea, eczema and psoriasis. In addition, inflammation in the body has been linked to the development of numerous chronic diseases such as heart disease, cancer, diabetes and even chronic pain from conditions such as rheumatoid arthritis and osteoarthritis. We also know that inflammation can be controlled by diet, so the newest thinking is that using diet to control inflammation can have a positive effect on controlling acne as well.
Many dermatologists are adopting this more holistic (or whole-body) approach to acne treatment and have had success with it.
“Now I talk to patients about their diet, their exercise, their stress and suggest appropriate changes in addition to following a prescribed traditional topical and/or oral acne regimen. With this approach, I don’t feel the need to prescribe strong medications with dangerous side effects such as isotretinoin, also known as Accutane, says Debbie Palmer, MD, a dermatologist at Dermatology Associates in Harrison, N.Y. “Thirty days later, you can really tell which patients have changed their diet accordingly.”
Here are 5 research-based, dermatologist-suggested, healthy ways you can change your diet to nip inflammation in the bud before acne pimples surface.
While we know that an anti-inflammatory diet is a low-glycemic diet rich in slowly digested carbohydrates, a few smaller studies have specifically shown that a low-glycemic diet reduced the severity of acne. A 2007 study of 23 males aged 15 to 25 who adhered to a strict 12-week low-glycemic diet had a marked improvement in acne severity.
In a more recent 2012 study published in the journal Acta Dermato-Venereologica, 32 20- to 27-year-old Korean patients ate a low-glycemic diet for 10 weeks and also experienced a significant improvement in acne severity. The Korean authors also performed skin biopsies and found that in the low-glycemic diet group, the size of sebaceous glands and number of inflammatory cells was also greatly decreased, while pro-inflammatory substances secreted by cells that can negatively alter cell behavior and even cause cell DNA damage were also reduced.
Dr. Bowe, who co-authored Diet and acne update: Carbohydrates emerge as the main culprit, published in 2014 in the Journal of Drugs and Dermatology, says, “We can see that the ingestion of high-glycemic foods triggers a cascade of endocrine responses that may trigger acne through androgens, growth hormones and cell-signaling pathways.” So she counsels acne patients about food’s potential to increase blood glucose and insulin and which foods are high and low on the glycemic index scale.
In a 2016 study published in the Journal of the Academy of Nutrition and Dietetics, 32 patients with moderate to severe acne had greater insulin and insulin-like growth factor-1 concentrations and greater insulin resistance as evaluated by a blood draw to measure biological factors associated with acne. They also reported a 5-day food record that showed those with the acne ate a higher carbohydrate diet than the 32 patients without acne.
In her new evidence-based anti-aging book, Beyond Beauty, Dr. Palmer points to research which suggests that insulin plays a role in acne causing the growth of pore-clogging cells, and increase in oil production and inflammatory mediators. Because of that, she advises patients to keep their blood sugar steady by following the glycemic index for choosing foods to eat.
“Glycemic index is a number that gives you an idea of how fast your body converts carbohydrates in specific foods to glucose,” Dr. Palmer says.” The smaller the number, the lower a food’s glycemic index, the slower it is absorbed and the longer it stays in the bloodstream.” 55 or less is a low-glycemic food, 56-69 is a medium-glycemic food and 70 or higher is a high-glycemic food.
Both doctors advise that acne patients avoid high-glycemic index foods such as white bread, white pasta, white rice, pretzels, sugary snacks and drinks and any white potatoes or potato products such as chips or fries. Instead, eat higher fiber content sweet potatoes, brown rice, whole grain breads, beans and nuts. (Want to check the foods you eat regularly? Here’s Harvard’s handy glycemic index chart for 100 common foods.)
2. Add antioxidants
One 2001 study done in Turkey found higher levels of oxidative stress and lower antioxidant levels in acne patients seeking treatment. Another Turkish study published in 2005 showed that antioxidant enzymes seemed to be depleted faster in those with acne, and a 2006 study conducted in Jordan found that plasma levels of antioxidant vitamins A and E were much lower than controls among 100 patients with untreated acne.
If oxidative stress (systemic inflammation) caused by free radicals circulating in an acne patient’s body is causing cellular damage, which leads to the beginning stages of acne, then adding antioxidants to the diet might help neutralize those free radicals, researchers concluded.
Dr. Bowe also co-authored Acne Vulgaris: The Role of Oxidative Stress and the Potential Therapeutic Value of Local and Systemic Antioxidants, which was published in the Journal of Drugs and Dermatology in 2012. Some of the preliminary studies in humans were compelling, she says, although no large-scale clinical trials have shown that antioxidants might alter the course of acne.
Nonetheless, she encourages acne patients to up their intake of antioxidant-rich foods such as squash, berries and dark leafy greens rather than supplementing.
Dr. Palmer encourages her acne patients to eat more of other colorful fruits and vegetables such as carrots, cantaloupe, broccoli, alfalfa sprouts and purple grapes (with the seeds), all of which are filled with antioxidant vitamins A, C, E and flavonoids. She also suggests acne patients add green tea and antioxidant spices such as cinnamon and turmeric to their food as much as possible.
“The closer to nature you eat them the better,” she says, favoring light steaming with a slight crunch and bright color as the hallmark of doneness instead of losing nutrients by frying or overcooking. She also suggests acne patients add green tea and antioxidant spices such as cinnamon and turmeric along with hot pepper (if you don’t have rosacea) to their food as much as possible.
3. Ditch the Dairy
In previous studies of milk consumption and teenage acne in both girls and boys, researchers found in girls, acne was associated with all types of milk but in boys, acne was associated with skim milk consumption mostly.
In a more recent 2016 study involving 225 teenagers published in the Journal of the of the American Academy of Dermatology, the amount of low-fat or skim milk consumed by participants was significantly higher in those teens with acne.
In a study published in BMC Dermatology, 88 Malaysian subjects 18- to 30-years-old kept a 3-day food diary that showed the frequency of milk and ice-cream ingestion was associated with a fourfold increase in acne risk (and a relationship between acne and cheese or yogurt was found), which was echoed in another published 2012 Italian study.
“While we still don’t know the exact mechanism by which milk causes acne’s cascade of events, whether it’s milk proteins, hormones, growth factors or the combination in dairy products, I do suggest acne patients steer clear of milk and try some low-glycemic index dairy-free alternatives such as almond, soy, or coconut milk,” explains Dr. Bowe. “Look for varieties fortified with calcium and vitamin D, and eat more leafy greens high in calcium such as kale and broccoli, to keep a calcium deficiency at bay, she advises.
4. Use Probiotics
Dr. Bowe is also a big proponent of the “gut-brain-skin axis,” and in 2011, co-authored an article published in Gut Pathogens explaining that psychological distress alone or in combination with overeating of processed, low-fiber foods may slow gastrointestinal movement and alter the gastrointestinal flora (bacteria) leading to “leaky gut syndrome.” Leaky gut syndrome can cause the type of systemic inflammation that causes both the acne and depression cycle. They found that in these patients, not only are markers of systemic inflammation increased, but Substance P (a peptide that causes pain in the body and also increases sebum production) is also elevated and insulin sensitivity is decreased.
“In those susceptible to acne, we think this cascade negatively influences the skin and potentially exacerbates acne,” explains Dr. Bowe. “Oral probiotics have been shown to regulate the release of inflammatory substances within the skin and improve insulin sensitivity,” she says.
A 2013 study testing whether coupling a probiotic with an antibiotic for the treatment of inflammatory acne found a significant decrease in total acne lesion count in the group which received both the probiotic and the antibiotic minocycline. The probiotic also helped avoid other side effects of long-term antibiotic use for controlling acne.
“Interestingly, of the large studies linking dairy and acne to date, there has been no association between fermented dairy (yogurt) and acne,” she continues. “I suggest my acne patients eat yogurt or kefir with live cultures (lactobacilli) or fermented veggies daily such as kimchi or take a daily probiotic supplement.”
Dr. Palmer says the research on the gut and disease also shows that a lack of diversity and fresh plant foods in the typical American diet leads to a lack of diversity in gut microbes which in turn leads to systemic inflammation and the cascade of effects, including acne. Along with taking a probiotic supplement, Dr. Palmer advises her patients to increase their intake of fresh fruits, vegetables, grains, beans and nuts to improve the gut microbiome for overall long- term health as well as for the treatment of their acne.
5. Find Omegas
Omega-3 fatty acids (EPA and DHA) contained in fish oil and some plant and nut oils suppress inflammation in the body, while omega-6 fatty acids — found in sunflower and palm oils, for example — increase inflammation in the body when eaten in abundance. Some foods high in omega-6 fatty acids include fatty red meat, fried poultry and pork products, eggs and dairy products, vegetable oils (canola oil, safflower oil, corn oil and vegetable oil) as well as fast food, processed snack foods and sweets made with these oils. A 2005 study found the omega 6 : omega-3 intake ratio in North America was 20:1, but the ideal ratio for humans is closer to 2:1.
“I explain to my acne patients that the relative intake of omega-6 to omega-3 polyunsaturated fatty acids appears to be an important modulator of inflammation. Eating foods rich in omega-3 fatty acids or taking fish oil supplements with 1,000 to 2,000 mg per day of EPA might benefit their acne,” says Dr. Bowe.
Dr. Palmer agrees and suggests that her acne patients add lots of naturally occurring omega-3s from avocados, salmon and flax seed oil to their diets.
“Instead of crunching chips, choose crunchy nuts such as almonds, pistachios and walnuts (without artificial flavorings other than salt), which also provide important minerals such as selenium and zinc,” she says, because, “Studies have found them lacking in acne patients.”
While topical treatments can help control acne breakouts, certain diet tweaks can help as well and they may costs less, aid your nutrition and prevent any troublesome side effects and improve your skin and overall health for the long term.