Ever suffered from acne or know somebody that does?
Well, you are not alone. 80% of people suffer between the ages of 11-30 years old and it also occurs later in life (1).
Acne is caused by a change in oil production in the skin, increased turnover of skin cells, and an increase in c. acne bacteria in the skin.
Hormones play an influential role in acne, hence we see flare-ups at times of life when there are significant changes in hormone levels. Puberty is the most common, but it is also seen in adult life. For example, acne can occur due to hormone fluctuations during the menstrual cycle. This is known as adult female acne (“AFA”). So if you’ve just got your first spot at the age of 35, again you’re not alone. In fact, a study in 2017 showed that 26% of women aged 31-40 and 12% of women aged 41-50 are affected by acne (2).
Acne can have a big impact on quality of life and is also associated with depression and anxiety. It is often difficult to know where to turn for help.
As a doctor with 15 years of clinical experience treating hundreds of patients I have learned what does and doesn’t work for this complex problem. If you’re interested in the science we have also referenced the latest research behind the approaches we use.
Acne is complex and often poorly treated by medics and non-medics alike. Being a doctor I used to be one of those that was quick to reach for medications that treat the symptoms without trying to understand the causes. I have learned, however, that quick-fix cures just don’t work in the long term. What does work is to understand and then address the root causes of your acne.
Understanding what type of acne you have is the first step to understanding what is causing it. This then allows for a more targeted and personalised approach to treating it.
The following framework simplifies acne to make it easier to understand:
Causes → Mechanism → Management
Causes – hormonal or non hormonal
Mechanism – sebum, skin production, bacteria invasion, inflammation
Management- reduce sebum, unblock pores, reduce inflammation, balance hormones
In this article
- Types of acne
- Grades of acne
- What goes wrong in the skin to cause acne?
- Management and treatment of acne
- Get your skincare right
- The acne skincare ladder
- Fixing the root cause of your acne
- Can supplementation help with acne?
- The link between hormones and acne
The first step to understanding how best to treat your acne is to work out what type of acne it is and how can you manage it in the long term.
Types of acne
- Whiteheads: are raised bumps on the skin that remain closed by sebum (oil) and dead skin that has been moved off into the pore. It gives the skin an uneven appearance.
- Blackheads: are another type of acne involving blocked pores. The pores are open, but are blocked by oxidised sebum and dead skin. Although they may look like dirt, blackheads are actually clogged follicles.
- Papules: these are raised red bumps that have become inflamed and are tender.
- Pustules: are surrounded by inflamed skin. A build up of white cells inside the pore forms pus. They can be deep and leave scarring.
- Nodules: occur when deep pimples form in the skin. They are painful and can take weeks to resolve, often leading to skin discolouration and scarring.
- Cysts: are larger pus-filled pimples that can become large and inflamed. A combination of nodules and cysts is called nodule-cystic acne and can cause scars when the skin heals.
- Fungal acne is caused by a yeast overgrowth in the skin.
The other acne we are NOT talking about is acne rosacea, which is a completely different condition and is now just called rosacea. These are small acne-like spots (pustules) that appear when rosacea symptoms flare up. Treatments that help with acne will not help. For more information refer to our article on SIBO and rosacea.
Grades of acne
- Grade 1 acne is mostly whiteheads and blackheads with minimal pimples (papules and pustules).
- Grade 2 acne is mostly pustules with multiple pimples, mostly on the face.
- Grade 3 acne is moderately severe. Both nodules and cysts can be present that can lead to scarring. There are usually over 15 pimples and these may also affect the back and chest.
- Grade 4 acne is severe scarring acne. There are over 30 pimples of the large nodule and cystic type. They are inflamed and painful.
Sometimes Grade 3 and 4 acne needs a doctor’s input and prescription medicine to get it under control and to avoid scarring.
What goes wrong in the skin to cause acne?
Acne is caused by four important mechanisms, all of which have been well studied. These four mechanisms are also are the targets of treatments:
- Excess sebum production (very oily skin) or abnormal sebum. Too much oil can clog up pores.
- An increased shedding of skin cells in the oil-producing glands (sebum glands) causing blockage of the glands / pores.
- A proliferation of cutibacterium acne, the bacterium after which acne is named. This causes inflammation when it becomes trapped inside a blocked gland.
- Inflammation of the skin.
Management and treatment of acne
In nearly all acne cases there are a number of problems that have combined to result in those annoying spots, which are also known as pustules.
The best acne treatments are those that give a long term solution, not just the quick fix of antibiotics. Be aware that antibiotics can cause long term issues in the gut microbiome which can affect your overall health. In some severe cases of acne, however antibiotics are required to get things under control.
This approach is based on targeted skincare, diet, supplementation, and, where needed, hormonal support.
Get your skincare right
There is a misconception that acne skin needs to be scrubbed and cleaned. Although there is some truth in this, scrubbing skin which is already inflamed is a bad idea. It just creates more inflammation that becomes red and painful.
Gentle cleansers with a low pH are key. Many soaps have a high pH, which strips away the protective layer of acid on the skin that contains the essential antioxidants that are required to keep a healthy skin microbiome. Companies like Neostrata or Cetaphil make excellent cleansers that can cleanse the skin without irritation.
The ideal pH of the skin is 4.7, which is acidic. Every time you wash you increase this by 1.5-2 moving it towards neutral and creating a more favourable environment for bacteria. This requires more essential fatty acids to balance the pH and if you already have low levels of fatty acids in your body then it compounds the problems. Cleanse gently with a low pH cleanser.
Comedones are pores that have become blocked with bacteria, oil, and dead skin cells to form bumps on your skin. These blocked pores can lead to acne. One of the reasons for this is low levels of omega 3 and linoleic acid.
In the long term this should be addressed by diet and this is an area where supplementation can help.
However, in the short term using products with alpha and beta hydroxy acids (3), like salicylic (4) or glycolic acid (5), is a gentle way to dissolve these comedones without causing further skin inflammation. So put away the scrubs! Products like Epionce lytic lotion or Neostrata glycolic products work well without irritating the skin and they also maintain the acidic pH of the skin.
Be gentle with your skin – it is already inflamed, so scrubbing it aggressively will only make things worse.
The acne skincare ladder
We recommend the following steps to treat your acne, starting with cleansers then working your way up the ladder until you see improvements:
- Cleansers. Gentle low pH skin cleansers like Cetaphil, Epionce and Neostrata help to rebalance the oil in the skin and to remove comedones.
- Glycolic and salicylic washes are the next step to treat acne and are available over the counter. They help the remove the dead skin cells that have clogged your pores and also remove damaged skin.
- Benzyl peroxide (6) helps to reduce the c. acne bacteria in the skin (7). Care should be taken to use the correct strength, because benzyl peroxide can increase inflammation in the skin, which often leaves it dry.
- Vitamin A retinoid derivatives include combinations of vitamin A derivatives and other active ingredients. They usually require a prescription, but can be very successful. They reduce whiteheads and prevent pores from getting blocked (8, 9).
- Antibiotics can be applied to the skin and are often combined with benzoyl peroxide.
Medications taken orally:
- Antibiotics taken in long courses can help with severe acne (9), but can often be avoided. These are often incorrectly used as the first step on the ladder. They also tend to be overused, can cause long term issues, and acne often recurs when they are stopped. They also damage the gut microbiome, which can take up to two years to recover, wiping out types of beneficial bacteria for good! (10)
- Hormone-balancing medication. Oral contraceptives and other medication to balance hormones are used when breakouts are associated with AFA and the menstrual cycle.
- Roaccutane oral retinoids are strong doses of vitamin A derivatives that have a long term effect on the oil-producing glands in the skin. It is usually only used for severe, difficult-to-treat cases as it has been linked to gut problems, severe depression, and birth defects.
Fixing the root cause of your acne
Balance your IGF-1
Acne comes from an imbalance of nutrients, hormones and genetics. This is driven by poor diet and lifestyle.
In particular, dairy, sugary foods and beige carbohydrates (high glycemic index foods) increase a powerful messenger in the body. This messenger causes weight gain and bad skin and is called insulin-like growth factor (“IGF-1”). It is also a key player in acne (11).
IGF-1 increases the shedding of skin cells (hyperkeratinisation) into the skin pores, which leads to the pore becoming blocked. IGF-1 also increases sebum production and sensitivity to testosterone. It increases in response to growth hormone, which is why acne often occurs during growth spurts like puberty. Likewise, its activity quietens down as we age, which is one of the reasons we get fewer spots when we get older unless we have a poor diet (12, 13, 14).
A diet low in essential fatty acids (both omega 3 and linoleic acid) can also cause acne, especially comedogenic acne (15, 16). Linoleic acid found in primrose oil and borage oil is key to healthy skin. It has a key role in allowing the other fatty acids to get to the right part of the skin and maintain the acidic environment that stops bacterial overgrowth.
Foods which contain essential fatty acids include fish (such as salmon, mackerel, herring and sardines), nuts, seeds, and eggs.
Cut back on dairy
Milk is not your friend if you have acne. People who drink a lot of dairy have 20-30% higher levels of IGF-1, which as mentioned above is one of the main drivers of acne. If you don’t cut back on the milky lattes and milk on breakfast cereal then you will really struggle. (17)
This makes sense if you take the perspective that milk is designed for babies to grow quickly in order to survive. The energy of milk itself is a growth stimulant. But milk also contains proteins that subtly encode messages that say ‘grow’. These proteins gently reach out to boost IGF-1 and influence it to work harder to make cells grow and multiply.
Look after your gut health
Until recently both diet and gut health were dismissed as unimportant in relation to acne, but research has now proven that inflammation driven by poor gut health can be major factor in causing acne. (20)
Furthermore, patients with acne have distinct gut microbiota (microorganisms), but the exact mechanism of why this causes acne is still not fully understood. (21)
Can supplementation help with acne?
Yes. Let’s have a look a vitamin A in a bit of detail and then move on to other supplements.
Vitamin A is essential for healthy surface skin cells (also gut and lung linings). Tretinoin, retin A, Roaccutane, and retinol are all vitamin A or derivatives of vitamin A that are used very successfully both orally and topically to treat acne.
Although oral vitamin A is a relatively low dose it does build up over time because the body can store it. So taking it regularly will help.
A topical retinol or retin-A can be very effective and is definitely worth trying if you are struggling to control your acne. It helps to control inflammation as well as to produce healthy new cells.
Dr Vicky Dondos’ 3-2-1-go retin A method.
Retin A often irritates the skin when it used topically, which is why it’s important to start slowly. Dr Vicky Dondos is an expert in skincare and is one of our medical advisors. She recommends the following protocol: start applying topical retin A every third night for a week, then every second night for a week and then try to increase its use to nightly. If that causes irritation reduce to every other night.
Some other tips:
- Use it at night and avoid the neck and areas close to the eyes
- Do NOT moisturise on top of the retin A. If you have very dry skin areas apply small amounts of moisturiser sparingly
- It’s common to get a break-out when you first use retin-a in the first couple of weeks. It will settle
- It’s common to get some skin dryness and flaking as the oil levels rebalance
- Make sure to wear sunscreen because your skin will be more sensitive to the sun
- Results don’t appear overnight. It can 4-6 weeks for the skin to settle
Roaccutane is a very high dose oral vitamin A that shrinks sebum glands by 90%. If you have severe acne you may need a long term dose, but it can have strong side-effects so should only be taken under the guidance of an experienced dermatologist.
Which supplements can help hormonal acne?
Hormonal acne is caused by an imbalance between oestrogen, testosterone, and progesterone. Rebalancing hormones, skin turnover and normalising sebum production is key. A low sugar and low dairy diet will help to reduce IGF-1 one of the key drivers of acne. Although nutritional supplements are not a replacement for a good diet when there are skin problems sometimes extra support is needed. These are the ones that I have seen make a difference and have the clinical trials (see appendix) to back them up.
- Vitamin A: helps to normalise sebum production in the skin.
- Resveratrol is a powerful anti-ageing supplement and antioxidant that has strong anti-inflammatory properties.
- Krill oil and linoleic acid help to rebalance the skin barrier.
- Also contains antioxidants astaxanthin, vitamin C, vitamin E and selenium.
- DIM helps detoxification process and reduce high levels of oestrogen.
Each of humanpeople’s adult acne packs contains 28 daily sachets of the following supplements:
- Vitamin A 10,000IU
- Resveratrol 150mg
- GLA (linoleic acid) 500mg
- Vitamin C, vitamin E and selenium
- DIM 150mg
- Krill oil (for omega 3 and astaxanthin) 1000mg
Acne is more than skin deep – it is a reflection of what is happening in the body. Sometimes this is a natural process like puberty. Supporting the body and skin during this time can help to reduce the depressing and scarring skin damage that can occur. At other times, it may in part be caused by diet and other lifestyle factors. The good news is that these are all things we can do something about.
Although there are many options available for treating acne many of them do not look to address the underlying causes. We therefore recommend a two-pronged approach:
- Start treatment following the guidelines set out in the acne skin care ladder. Beware of quick-fix options such as antibiotics.
- Address the root cause of the problem by making lifestyle changes:
- Avoid dairy and sugary foods
- Increase intake of foods rich in omega 3, vitamin D, vitamin A, vitamin E and zinc. Consider supplements.
- Address hormonal imbalances by increasing exercise and taking steps to reduce stress (e.g. mindfulness or meditation).
Finally, it may take a couple of months to see real improvements, but remain positive and stick with it – the results will come.
- Acne: Causes & Treatment. 2020, September 1. Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/12233-acne.
- Zeichner JA, Baldwin HE, Cook-Bolden FE, Eichenfield LF, Friedlander SF, Rodriguez DA. Emerging Issues in Adult Female Acne. The Journal of Clinical and Aesthetic Dermatology. 2017;10(1):37-46.
- Kessler E, Flanagan K, Chia C, Rogers C, Anna Glaser D. Comparison of α- and β-Hydroxy Acid Chemical Peels in the Treatment of Mild to Moderately Severe Facial Acne Vulgaris. Dermatologic Surgery. 2007;34(1):45-51.
- Lu J, Cong T, Wen X, et al. Salicylic acid treats acne vulgaris by suppressing AMPK/SREBP1 pathway in sebocytes. Experimental Dermatology. 2019;28(7):786-794.
- Sharad J. Glycolic acid peel therapy – a current review. Clinical, Cosmetic and Investigational Dermatology. 2013;6:281.
- Mills OH, Kligman AM, Pochi P, Comite H. Comparing 2.5%, 5%, and 10% Benzoyl Peroxide on Inflammatory Acne Vulgaris. Wiley Online Library. Published December 1986.
- Tan AU, Schlosser BJ, Paller AS. A review of diagnosis and treatment of acne in adult female patients. International Journal of Women’s Dermatology. 2018;4(2):56-71.
- Lee D-D, Stojadinovic O, Krzyzanowska A, Vouthounis C, Blumenberg M, Tomic-Canic M. Retinoid-Responsive Transcriptional Changes in Epidermal Keratinocytes. Journal of cellular physiology. 2009;220(2):427-439.
- Thiboutot DM, Dréno B, Abanmi A, et al. Practical management of acne for clinicians: An international consensus from the Global Alliance to Improve Outcomes in Acne. Journal of the American Academy of Dermatology. 2018;78(2 Suppl 1):S1-S23.e1.
- Jernberg C, Löfmark S, Edlund C, Jansson JK. Long-term ecological impacts of antibiotic administration on the human intestinal microbiota. The ISME Journal. 2007;1(1):56-66.
- Melnik BC, Schmitz G. Role of insulin, insulin-like growth factor-1, hyperglycaemic food and milk consumption in the pathogenesis of acne vulgaris. Experimental Dermatology. 2009;18(10):833-841.
- Podgórska A, Puścion-Jakubik A, Markiewicz-Żukowska R, Gromkowska-Kępka KJ, Socha K. Acne Vulgaris and Intake of Selected Dietary Nutrients—A Summary of Information. Healthcare. 2021;9(6):668.
- Burris J, Shikany JM, Rietkerk W, Woolf K. A Low Glycemic Index and Glycemic Load Diet Decreases Insulin-like Growth Factor-1 among Adults with Moderate and Severe Acne: A Short-Duration, 2-Week Randomized Controlled Trial. Journal of the Academy of Nutrition and Dietetics. 2018;118(10):1874-1885.
- Kwon H, Yoon J, Hong J, Jung J, Park M, Suh D. Clinical and Histological Effect of a Low Glycaemic Load Diet in Treatment of Acne Vulgaris in Korean Patients: A Randomized, Controlled Trial. Acta Dermato Venereologica. 2012;92(3):241-246.
- Yoon Jung J, Hoon Kwon H, Soo Hong J, et al. INVESTIGATIVE REPORT. Randomized Controlled Trial. 2014;94(5).
- Baldwin H, Tan J. Effects of Diet on Acne and Its Response to Treatment. American Journal of Clinical Dermatology. 2020;22(1)
- Melnik BC, John SM, Schmitz G. Milk is not just food but most likely a genetic transfection system activating mTORC1 signaling for postnatal growth. Nutrition Journal. 2013;12(1).
- Leyden J, Stein-Gold L, Weiss J. Why Topical Retinoids Are Mainstay of Therapy for Acne. Dermatology and Therapy. 2017;7(3):293-304.
- Bagatin E, Costa C. The use of isotretinoin for acne – an update on optimal dosing, surveillance, and adverse effects. Taylor and Francis Onlnie. Published June 7, 2020.
- De Pessemier B, Grine L, Debaere M, Maes A, Paetzold B, Callewaert C. Gut–Skin Axis: Current Knowledge of the Interrelationship between Microbial Dysbiosis and Skin Conditions. Microorganisms. 2021;9(2).
- Lee YB, Byun EJ, Kim HS. Potential Role of the Microbiome in Acne: A Comprehensive Review. Journal of Clinical Medicine. 2019;8(7):987.
- Ju Q, Tao T, Hu T, Karadağ AS, Al-Khuzaei S, Chen W. Sex hormones and acne. Clinics in Dermatology. 2017;35(2):130-137.
- Farage MA, Neill S, MacLean AB. Physiological changes associated with the menstrual cycle: a review. Obstetrical & Gynecological Survey. 2009;64(1):58-72.
- Qidwai A, Pandey M, Pathak S, Kumar R, Dikshit A. The emerging principles for acne biogenesis: A dermatological problem of puberty. Human Microbiome Journal. 2017;4:7-13.