Acne is a frustrating hormonal and genetic condition that causes significant emotional distress in people who are afflicted. Acne in the teenage years is common and is caused by the combination of hormonal changes and the generalized growth that the body experiences through doing that time1. Both growth factors and hormone changes account for an increase in the prevalence of acne during these developing years1.
In adults, persistent acne is mostly driven by genetics and increased sensitivity in the skin to androgens such as testosterone. Patients of all genders can be afflicted with acne and is also very common in people with PCOS, otherwise known as polycystic ovarian syndrome1. There are very few tests that can be conducted in patients with acne. Screening for vitamin D deficiency2, endocrine disorders or PCOS can help doctors understand if people have an underlying disorder worsening their acne. Most adults with acne do not have an underlying hormonal condition, and the levels of testosterone in the blood are similar to people who do not struggle with their skin3.
Androgens such as testosterone increase sebum production in the skin. Some people have greater androgen sensitivity than others, and have higher levels of testosterone conversion in the skin1. Testosterone converted in the skin into DHT or, dihydroxytestosterone, which is a potent form of testosterone that increases oil production in the skin. Bacteria on the skin also contribute to acne, and many of the historical solutions for acne focused on reducing bacteria on the skin1.
How is acne assessed?
When people are assessed acne, a practitioner may ask about the number of spots on the face or body, how long they typically take to heal and whether the lesions are painful and inflamed4. Acne spots may be small and red, form pustules or a “whitehead” appearance or form a blackhead or comedone. Spots may be swollen and inflamed or may not affect the surrounding skin. Acne can appear on the face, back and chest with other body areas being relatively spared.
People who suffer from significant acne in adulthood may be screened for other conditions that are linked to acne such as PCOS or hirsutism (excessive unwanted hair growth and crown hair loss in people with ovaries). Most people who have acne in adulthood do not have another underlying disorder. Between 40-85% of menstruating people will report a worsening of acne around the cycle, which makes adult acne an almost universal experience5
Acne, Health and Lifestyle
Although the cause of acne is almost exclusively genetics, there are other lifestyle factors and behaviours that can worsen the experience of acne. Acne has been shown to be worsened by increasing BMI6, stress7, smoking5 and from lack of sleep8,9.
How to support your acne
Acne is a chronic condition that most patients can manage with changes to diet and lifestyle. The genetic nature of acne means that patients may have to work on the health habits that affect their acne ongoing. Many acne commercials can make patients feel as though they can “spot treat” or “cure’ their acne, which can leave people feeling frustrated when their spots return. Most changes that support acne need to be part of a lifelong management plan to support a patient’s nutrition, nutrient status and habits.
Simple habits to try
Given the bacterial causes of acne, it is not surprising that simple lifestyle tips that decrease bacteria on the skin can have an impact on the development and persistence of acne spots. People who wash their face two times per day10, use antimicrobial cleansers, and who frequently change their pillowcases and bedding can reduce their acne flare ups by decreasing the amount of bacteria on their skin. Use of masks through the covid-19 pandemic have worsened acne in some people11, which emphasizes the need for effective cleansing to help reduce the effect of bacteria on the face.
Nutrition and Acne
Nutrition has the potential to impact skin health in a positive or negative way. Research points towards a Mediterranean diet including nuts having a positive impact on skin health and reducing the likelihood of acne lesions12. A typical Western diet (which is defined by more refined foods, fast foods and high glycemic index) appears to worsen acne3. Choosing lower glycemic index grains such as whole grains, and fruits and vegetables over simple sugars has been shown to improve acne lesions over time13.
Some foods have been implicated in the worsening of acne. Chocolate has been studied in various forms (even in capsules) and may contribute to the worsening of acne in some people14. People who have a worsening of acne with chocolate may be sensitive to small amounts with chocolate causing an increase in acne lesions as quickly as 3 days15,16 and as long as 4 weeks after adding chocolate to the diet14,17.
Dairy has also been implicated in acne because of the molecular mechanism that dairy impacts growth hormones and testosterone production in the skin3. There are many population studies that have linked high dairy intake to higher levels of acne18. That said, many studies find that the serving size and frequency in the week can likely stay at modest levels in most patients with acne, without causing a worsening of spots19,20.
Nutritional Supplements and Acne
Green tea appears to possess some antimicrobial properties that have been studied to support patients with acne. Both topical and oral green tea extract (not drinking the loose tea) appear to help reduce acne lesions21
Zinc supports a healthy immune system and decreases acne lesions.22 Zinc has also been studied in combination with other treatments for acne such as antibiotics and enhances the overall treatment effect.22
Vitamin D deficiency also appears more common in patients with acne, however it’s difficult to determine if levels are lower due to a reduction in sun exposure or for some other reason2. If a person’s vitamin D levels are low, they may have an improvement in their acne lesions by being supported with vitamin D.23,25
Probiotics are an emerging area of dermatology and have been studied as a way to combat the overgrowth of acne forming bacteria such as Propionbacterium acnes.26 Probiotics may help to decrease the growth of P. acnes on the skin and also appear to reduce sebum production, improving acne by two mechanisms of action. Some preliminary trials have also considered probiotics as a therapeutic option for treating acne. The results have been promising and also showed a reduction of antibiotic-related side effects typically seen when treating acne with antibiotics alone. 26
Healthy oils such as omega-3 and borage oil both equally improve skin health and reduce acne lesions.27
Smart Solutions GLA oil provides the skin with anti-inflammatory benefits of Omega-6 while also supporting skin hydration and elasticity. It also helps reduce redness and & skin inflammation, commonly associated with acne.
One of the most empowering messages to deliver to people about their adult acne is that it is not their fault. Although there are lifestyle and nutrition options that may improve the management of acne, acne is a genetic condition that is worsened by hormones and bacteria, not something that patients cause by their lifestyle or choices.
People can feel empowered in their acne journey to know that there are simple strategies that can reduce the frequency and severity of acne spots over time and can support people alongside their conventional care or as a stand-alone treatment option.
If your acne is creating a challenge for your mental health, ensure that you talk to your health care provider about treatment options. Skin health is an important part of overall health and can have a significant impact on quality of life and self-esteem if left untreated.
- Sutaria, A. H., Masood, S. & Schlessinger, J. Acne Vulgaris. in StatPearls (StatPearls Publishing, 2022).
- Acharya, P. & Mathur, M. Vitamin D deficiency in patients with acne vulgaris: A systematic review and meta-analysis. Australas J Dermatol 61, e146–e149 (2020).
- Melnik, B. C. Linking diet to acne metabolomics, inflammation, and comedogenesis: an update. Clin Cosmet Investig Dermatol 8, 371–388 (2015).
- Tan, A. U., Schlosser, B. J. & Paller, A. S. A review of diagnosis and treatment of acne in adult female patients. Int J Womens Dermatol 4, 56–71 (2017).
- Romańska-Gocka, K., Woźniak, M., Kaczmarek-Skamira, E. & Zegarska, B. The possible role of diet in the pathogenesis of adult female acne. Postepy Dermatol Alergol 33, 416–420 (2016).
- Heng, A. H. S. & Chew, F. T. Systematic review of the epidemiology of acne vulgaris. Scientific Reports 10, 5754 (2020).
- Jović, A. et al. The Impact of Pyschological Stress on Acne. Acta Dermatovenerol Croat 25, 1133–1141 (2017).
- Schrom, K. P. et al. Acne Severity and Sleep Quality in Adults. Clocks Sleep 1, 510–516 (2019).
- Misery, L. et al. Consequences of acne on stress, fatigue, sleep disorders and sexual activity: a population-based study. Acta Derm Venereol 95, 485–488 (2015).
- Choi, J. M., Lew, V. K. & Kimball, A. B. A single-blinded, randomized, controlled clinical trial evaluating the effect of face washing on acne vulgaris. Pediatr Dermatol 23, 421–427 (2006).
- Falodun, O. et al. An epidemiological study on face masks and acne in a Nigerian population. PLoS One 17, e0268224 (2022).
- Skroza, N. et al. Mediterranean diet and familial dysmetabolism as factors influencing the development of acne. Scand J Public Health 40, 466–474 (2012).
- Smith, R. N., Mann, N. J., Braue, A., Mäkeläinen, H. & Varigos, G. A. 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 57, 247–256 (2007).
- Vongraviopap, S. & Asawanonda, P. Dark chocolate exacerbates acne. Int J Dermatol 55, 587–591 (2016).
- Caperton, C., Block, S., Viera, M., Keri, J. & Berman, B. Double-blind, Placebo-controlled Study Assessing the Effect of Chocolate Consumption in Subjects with a History of Acne Vulgaris. J Clin Aesthet Dermatol 7, 19–23 (2014).
- Block, S. G. et al. Exacerbation of facial acne vulgaris after consuming pure chocolate. J Am Acad Dermatol 65, e114–e115 (2011).
- Delost, G. R., Delost, M. E. & Lloyd, J. The impact of chocolate consumption on acne vulgaris in college students: A randomized crossover study. J Am Acad Dermatol 75, 220–222 (2016).
- Adebamowo, C. A. et al. High school dietary dairy intake and teenage acne. J Am Acad Dermatol 52, 207–214 (2005).
- Juhl, C. R. et al. Dairy Intake and Acne Vulgaris: A Systematic Review and Meta-Analysis of 78,529 Children, Adolescents, and Young Adults. Nutrients 10, (2018).
- Aghasi, M. et al. Dairy intake and acne development: A meta-analysis of observational studies. Clin Nutr 38, 1067–1075 (2019).
- Park, T. H. et al. Public Interest in Acne on the Internet: Comparison of Search Information From Google Trends and Naver. J Med Internet Res 22, e19427 (2020).
- Kim, S. et al. The effects of green tea on acne vulgaris: A systematic review and meta-analysis of randomized clinical trials. Phytother Res 35, 374–383 (2021).
- Cervantes, J. et al. The role of zinc in the treatment of acne: A review of the literature. Dermatol Ther 31, (2018).
- Lim, S.-K. et al. Comparison of Vitamin D Levels in Patients with and without Acne: A Case-Control Study Combined with a Randomized Controlled Trial. PLoS ONE 11, e0161162 (2016).
- Ahmed Mohamed, A. et al. The impact of active vitamin D administration on the clinical outcomes of acne vulgaris. J Dermatolog Treat 1–6 (2020) doi:10.1080/09546634.2019.1708852.
- Goodarzi, A., Mozafarpoor, S., Bodaghabadi, M. & Mohamadi, M. The potential of probiotics for treating acne vulgaris: A review of literature on acne and microbiota. Dermatol Ther 33, e13279 (2020).
- Jung, G. W., Tse, J. E., Guiha, I. & Rao, J. Prospective, randomized, open-label trial comparing the safety, efficacy, and tolerability of an acne treatment regimen with and without a probiotic supplement and minocycline in subjects with mild to moderate acne. J Cutan Med Surg 17, 114–122 (2013).
- De Spirt, S. et al. Intervention with flaxseed and borage oil supplements modulates skin condition in women. Br J Nutr 101, 440–445 (2009).