ACNE: 5 CONSIDERATIONS FOR INSIDE-OUT HEALING
Acne is the most common skin issue that presents in the Western world. Interestingly, it didn’t exist historically, and its prevalence seemed to coincide with the move toward Western diets. This in itself can tell us a lot about where to focus! Herein we will discover five areas of consideration we need to have on our radar for acne treatment. Acne affects areas of the skin that contain sebaceous glands. So our face, back and chest are vulnerable zones. It is an inflammatory condition that recruits immune cells and has a strong interplay with many systems in the body beyond the skin—gut, immune, brain, liver and other elimination organs. In this way, it is paramount that acne is not treated in a reductionist way. It’s important to call upon all areas of significance that relate to a case to assist in clearing acne for good. Let’s dive in…
1 - gut-skin axis
Our skin is actually not too dissimilar to our gut in that it has a barrier function protecting us from the outside world. And, like our gastrointestinal tract, there are numerous microbes and immune cells inhabiting the land of our skin playing vital regulatory roles. There is a beautiful bidirectional link between our gut health and skin homeostasis, which the immune system also modulates. Any disruption to the symbiotic nature of the diverse species that inhabit our intestines can impair our barrier function in the gut and flow on to create a dysbiotic nature in the skin’s microbiome. Skin dysbiosis associated with Cutibacterium acnes (C. acnes) specifically has been linked with acne, which is why antibiotic treatment is used in treatment. Skin dysbiosis can fire up the immune response, which increases inflammation. This becomes a slippery slope for the development and maintenance of acne. Research shows that lower gut diversity is found in those with acne, presenting a key area of focus when it comes to root-cause healing.
SUPPORTS
- Heal gut-related issues
- Ensure adequate intake of prebiotic fibres that fuel gut diversity
- Investigate the microbiome with GI mapping functional testing
TO NOTE: Antibiotics will also wipe out beneficial species, and this can actually worsen symptoms in the long run. Be wary of only using antibiotics without any other plan in place to support skin and gut microbiota repair, whilst addressing any other factors that could be contributing to acne.
2 - stress
Psychological stress evidently has an important role to play in acne pathogenesis. Alterations to the pilosebaceous unit (hair follicle, hair shaft and sebaceous gland) are seen with increased stress. This is due to the increased production of hormones, neuropeptides and inflammatory cytokines, which can kick off and exacerbate acne. Catecholamines (neurohormones related to stress) can also interact with C. acnes. This can be a tough space to remedy, because we also know how emotionally stressful acne can be for someone, further perpetuating their presentation.
SUPPORTS
- Taking stock of life stress and considering any adjustments that can be made
- Building on our nervous system/stress support toolkit (i.e. meditation, yoga nidra, binaural beats)
- Looping a psychologist into the treatment team to provide therapeutic emotional support
3 - Dietary intake
There are many ways our diet can influence acne. Processed and inflammatory foods impair our gut barrier function, which we now know is associated with skin dysbiosis. High fat diets have been associated with acne via stimulating growth of C. acnes because of increased concentrations of fatty acids and triglycerides in sebum. Excessive sugar can increase insulin levels, impacting release of insulin-like growth factor 1 (IGF-1), which creates the inflammatory cascade that kicks off acne. Consuming dairy products with high casein can also increase IGF-1. This IGF-1 can stimulate androgen production as well. So there is a tight interplay between diet and hormones, as well as gut health, which exacerbate and maintain acne. There are also specific nutrient deficiencies, such as zinc, which contribute to acne and must be considered.
SUPPORTS
- The Mediterranean Diet is a good nutritional framework
- Consider removal of dairy whilst actively treating
- Balance blood sugars and insulin response
- Investigate nutrient deficiencies with bloodwork
4 - hormonal dysregulation
Fluctuations in hormones, as well as levels that are too high, or too low, are triggers for acne. If acne flares cyclically at specific times in the menstrual cycle, this hints at hormonal involvement. We know that oestrogen plays a beautiful role in skin elasticity and hydration. However, steep rises or drops in oestrogen can exacerbate acne. A rise in androgens increases sebum production. Testosterone increases at ovulation, and so excess sebum production creates a vulnerability to acne at this time. If androgens are consistently elevated (as in conditions like Polycystic Ovarian Syndrome), then these need to be addressed in the treatment plan to assist in resolution of acne.
SUPPORTS
- Investigate hormones with bloodwork and make a plan
- Track the menstrual cycle and understand trigger zones
- Support hormonal balance with nutrition (high fibre, blood sugar balance etc)
TO NOTE: The oral contraceptive pill (OCP) is commonly used to ‘treat’ acne. However, we must be mindful that this is not treating anything; it is simply switching off the hormonal cascade, which is one element that could be playing into acne. We also know the backlash of post-pill hormonal regulation can be a disaster, skin-wise.
5 - elimination pathways
The body’s elimination and detoxification pathways are extremely important when it comes to removal of waste products, hormones, and debris no longer needed in circulation. Our organs of elimination are the kidneys, liver, colon, lymph, lungs, and the skin. If we aren’t clearing our bowels daily, this is a huge red flag when it comes to acne. Getting the bowels moving would be the first point of call before emptying buckets of money on skin products, dermatologists and skin treatments. A stool sitting in our colon for extended periods of time allows for the reabsorption of toxins and hormones back into circulation, where the body has to deal with them again. This is a huge burden. Remember the skin is an elimination organ too and we don’t want the skin to have to pick up the slack. Overloading this channel of elimination aggravates acne. As we know, excess hormones can play a role in acne and so ensuring their clearance is paramount for healing acne as well.
SUPPORTS
- Regulate bowels (at least once daily!)
- Move the body daily and work up a sweat
- Ensure adequate hydration to help with waste excretion
- Boost fibre in the diet as fibre is an escort, binding to toxins and hormones to ensure their removal
- Implement lymphatic support (i.e. body brushing, sauna, lymphatic massage)
ON ROACCUTANE (ISOTRETINOIN)
Isotretinoin is mainstay medical treatment for acne. It is a retinoid that essentially works by decreasing sebum production, lowering levels of C. acnes by making the environment less favourable for the bacteria, reducing hyperkeratinisation, and decreasing inflammation. This is all wonderful. However, without understanding an individual’s mechanisms in play for acne development, what will happen when this medication is withdrawn? The relapse rate is pretty significant. And, the medication does not come without pretty nasty side effects, of which need to be considered.
In summary
Acne is a multifaceted presentation that deserves a holistic approach. Reductionist treatment is incomplete, potentially leading to issues down the road and extending healing time. From the skin-gut axis, to diet, to hormonal balance—there are lots of ways we can move. Understanding where the focus needs to be is step one. Then, lovingly working on addressing the contributing factors will provide the grounds for clear, glowing skin, from the inside-out.
