Acne is really hard to live with. I have seen many of my patients really struggle with self-esteem and confidence when their acne flares up, and what feels just as bad as the soreness, is concern about other people’s judgements when you have visible spots on your face.

Why does it happen?

Acne develops when dead skin cells and your skin’s natural oils block the hair follicles in your skin. Bacteria enter the blocked follicles and start multiplying. When your immune blood cells try to defend themselves against the bacteria, this can cause redness, swelling and spots.

Acne affects up to 85% of teenagers in the Western world, as for the first time, the hormones testosterone and oestrogen begin to affect how much sebum is produced, and how oily the skin becomes. But acne also persists into adulthood for many; I saw my mum suffer for years and feel unable to go out when her acne flared in her thirties and beyond. But some people and even certain cultures do not seem to have issues with acne at all. Although there are genetic, stress and hormonal differences that can predict sebum production, there are also lifestyle changes that can improve acne. Let’s find out more!

Does acne have anything to do with diet?

For many years, we were told that diet had very little to do with acne – that it was just stress, genetics and hormones – and bad luck. But much more research is now establishing specific enzyme pathways that can lead to acne in susceptible people - and that diet can indeed improve this. Some people will of course have the perfect diet and still suffer, and we can come on to the other causes in a moment. But first let’s deal with what’s easier to improve – food choices.

Dairy, junk foods, meat, and egg proteins in Western diets all conspire to raise the activity of the enzyme TOR, which regulates cell growth and metabolism and contributes to premature puberty and acne. Later in life it may also contribute to obesity, diabetes, cancer, and Alzheimer’s disease.

Milk, cheese and butter are not just foods, but they are also stimulators of the TOR enzyme pathway. How? Cow’s milk has three times more of the amino acid leucine, which is the primary activator of TOR, than human milk. This makes sense, as cow infants grow nearly 40 times faster than human infants. But over-activated TOR signalling in adulthood can pave the way for chronic diseases in humans. For example, a history of acne has been associated with breast cancer risk in women, and prostate cancer in men. This could be one of the underlying mechanisms for the link. Another mechanism is that animal products cause us to produce more IGF-1 (insulin like growth factor) which we do need. But in excess, it can increase sebum production and also increases risk of chronic diseases of inflammation.

Eating more fruits and vegetables will reduce these effects. Plant foods are packed with antioxidants, nutrients and fibre to improve your skin. Oranges and lemons contain Vitamin C, tomatoes contain lycopene, sweet potatoes contain beta-carotene, leafy greens and yellow vegetables contain lutein, spinach and avocado contain vitamin E – the bigger the variety of fruits and vegetables the better!

What about sugar? Refined sugar can cause inflammation in the body, and cocoa seems to be linked to acne outbreaks too – even in a blinded placebo controlled trial (where people were given cocoa powder in capsule form). So it could be wise to limit the chocolate!

Greasy foods have been shown to increase sebum production – so aim to limit pastries, pies and cakes as much as possible. Increasing the omega 3 fatty acids in the diet may be helpful, so increasing flax seeds, chia seeds and walnuts over other healthy fats is a good way forward. Algae supplements such as EPA/DHA contain the purest form of long chain omega three fatty acids, which is good for the heart and your skin.

Lastly for those who are gluten sensitive or with coeliac disease, a gluten free diet trial may help. This is because for some, even whole grains can potentially aggravate the gut lining, causing a cascade of inflammation that can also affect the skin. This is a trial-and-error approach. If you decide to eliminate gluten and notice no difference after 4 - 6 weeks of exclusion you will probably not have an issue with grains. For most of us, gluten is not an issue and whole grains are healthful for so many reasons. My favourites are brown rice, steel cut oats, wholemeal bread, barley, and rye bread.

Aim to eat your heaviest meals earlier in the day, as this is when our insulin levels are at their highest, which means we will be able to process and digest foods more quickly. Time restricted eating may also help with digestion and cellular repair – so limiting food intake to a 10 or 12-hour window could be helpful.

I have the perfect diet but I still have spots!

Stress

The number one cause of spots is stress. How to deal with this? Depending on the severity, you may need more specialist advice but some basic tips are included here as it is such an important factor with skin complaints. Good sleep is vital – aim to get a relaxing bedtime routine going, and turn off social media and phones from 9pm if possible, and be ready for sleep by 10pm. You could start in small increments and see what works for you. Find some time for you that is creative, away from the constant buzz and distraction of emails, Messenger, Facebook, Instagram, Snapchat, LinkedIn, Twitter, BBC News or whatever it is that you may use to distract yourself from creativity. 

Breathing, mindfulness and meditation. Your breath is the most effective emotional management tool that you’re probably not taking advantage of. Studies have shown inflammation and pain reduction benefits as well as increased oxygen saturation in cells from effective use of the 4-7-8 breathing technique. The next time you find yourself swept away by anger, anxiety, or extreme sadness, activate your built-in calming system. Exhale first, pushing your air out through your mouth as though you are blowing out a candle. Then inhale through the nose for 4 seconds, hold it for 7, then exhale through the mouth for 8 counts. Repeat the cycle 10 times and notice how different you feel.

Why not download an App on your smartphone to help start you off with a mindfulness or meditation practice? Once you find a style that resonates with you (some are mantra based, some are breath focussed) finding someone to teach you one to one can help it become a real habit. Make time consistently for it, and it will bring a lot of benefits. Even just 10 minutes once or twice a day can have a huge impact on wellbeing. One of my favourites is the ‘loving kindness’ meditation technique.

Over-cleansing

Although oily skin is a trigger for acne, you have to be careful that you do not remove too much oil and make your skin too dry. Stripping your skin of essential oils could equate to your glands going into overdrive to bring your skin’s oil level back into balance. This overdrive causes your skin to create too much oil. The moisture barrier (acid mantle) or the stratum corneum, protects the skin from harmful bacteria, pollutants and excess dryness - just as your gut has an ecosystem of billions of bacteria to protect your immune system, so does your skin. When your hormones, digestion or immune system are out of balance this can show in your skin. That’s why food and gut repair is so important. Also, just like the gut, the microbes on your skin can become unbalanced. That’s why anti-bacterials, drying alcohol-based astringents, and facial products that are too alkaline should be avoided. I would advise trying to cleanse the face each night and morning with a mitt which allows the acid mantle of the skin to be maintained, as you are cleansing with water alone, and doesn’t strip your skin of this layer of protection.

Chemicals

Chemical-based ingredients found in some skin care products can also irritate the skin, and this can cause inflammation leading to acne. High foaming agents like sodium lauryl sulphate (SLS) and certain high pH cleansers can be unhelpful (skin pH should be 5.5), causing dryness, flaking redness and sensitivity. It can also ironically make skin more acne prone. If you want to have a skin cleansing and moisturising regime, choose a cleanser with fatty acids and ceramides to help build back your skin protection. Try Hanna's gentle, non-foaming cleanser which is SLS free and contains amaranth oil, which is rich in linoleum, an omega 6 essential fatty acid. 

Lifestyle

Although we have already touched on this, daily habits play a role. Late nights, alcohol, coffee, junk food, lack of sleep or anabolic steroids for muscle building – all these things can worsen spots. Perspiration from exercise, saunas and especially outdoors activity is ideal for keeping the biome healthy because sweat supports the healthy balance of skin bacteria. Aim to make your daily habits as restorative as possible. We all have off days – just pay attention to them so you can get back on track more quickly.

Treatments

There are many prescription acne treatments. They often involve antibiotic use which has a negative impact on the microbiome, and astringents which can damage the upper skin layer. I do prescribe these, and am happy to do so, as acne can have such huge emotional and physical impact on people. If acne is severe or causing a lot of distress, I can also refer to a dermatologist for you to consider use of oral roaccutane – a highly effective acne medication.

The damage to self-esteem and confidence with acne can be crippling, which makes it even more important to be able to feel that you are doing something for yourself to improve your skin. This is why I urge you to fully embrace the things you can do to make your skin healthy, as in doing this you may save yourself side effects and risk of recurrence once treatments end.

And what about natural remedies?

Green tea is a powerful antioxidant which has been shown to improve acne.  Six weeks of a 2% green tea lotion cut the number of pimples more than half in one study, and significantly reduced the severity, making it a cheap, effective treatment for acne. Drinking a cup of green tea daily (preferably in the morning) can boost the microbiome, and using green tea left over from your morning cup as a night-time toner (just soak a cotton pad in green tea and place directly on the spots – leaving on if possible) will definitely be beneficial for reducing inflammation and severity of flare ups. This can also be done as a preventative measure.

References

• S Sutcliffe, E Giovannucci, W B Isaacs, W C Willett, E A Platz. Acne and risk of prostate cancer. Int. J. Cancer 2007 121(12):2688 – 2692.
• B C Melnik, S M John, G Schmitz. Milk is not just food but most likely a genetic transfection system activating mTORC1 signaling for postnatal growth. Nutr J 2013 12:103.
• B C Melnik. Excessive Leucine-mTORC1-Signalling of Cow Milk-Based Infant Formula: The Missing Link to Understand Early Childhood Obesity. J Obes 2012 2012:197653.
• B C Melnik. Diet in acne: Further evidence for the role of nutrient signalling in acne pathogenesis. Acta Derm. Venereol. 2012 92(3):228 – 231.
• B C Melnik, S M John, G Plewig. Acne: Risk indicator for increased body mass index and insulin resistance. Acta Derm Venereol. 2013 93(6):644 – 649.
• B C Melnik. Dietary intervention in acne: Attenuation of increased mTORC1 signaling promoted by Western diet. Dermatoendocrinol 2012 4(1):20 – 32.
• F W Danby. Turning acne on/off via mTORC1. Exp Dermatol 2013 22(7):505 – 506.
• B C Melnik, C C Zouboulis. Potential role of FoxO1 and mTORC1 in the pathogenesis of Western diet-induced acne. Exp Dermatol 2013 22(5):311 – 315.
• L Cordain, S Lindeberg, M Hurtado, K Hill, S B Eaton, J Brand-Miller. Acne vulgaris: A disease of Western civilization. Archives of Dermatology 2002 138(12):1584 – 1590.
• B C Melnik, S M John, P Carrera-Bastos, L Cordain. The impact of cow's milk-mediated mTORC1-signaling in the initiation and progression of prostate cancer. Nutr Metab (Lond) 2012 9(1):74.
• Elsaie ML, Abdelhamid MF, Elsaaiee LT, Emam HM. The efficacy of topical 2% green tea lotion in mild-to-moderate acne vulgaris. J Drugs Dermatol. 2009 Apr;8(4):358-64.
• Smith RN, Mann NJ, Braue A, Mäkeläinen H, Varigos GA. A low-glycemic-load diet improves symptoms in acne vulgaris patients: a randomized controlled trial. Am J Clin Nutr. 2007;86(1):107-15.
• Netea SA, Janssen SA, Jaeger M, et al. Chocolate consumption modulates cytokine production in healthy individuals. Cytokine. 2013;62(1):40-3.
• Vongraviopap S, Asawanonda P. Dark chocolate exacerbates acne. Int J Dermatol. 2016;55(5):587-91.
• Pierre Dougan and Naser Rafikhah, 2014. Dark and White Chocolate Consumption and Acne Vulgaris: A Case-Control Study. Asian Journal of Clinical Nutrition, 6: 35-40.
• Nguyen QG, Markus R, Katta R. Diet and acne: an exploratory survey study of patient beliefs. Dermatol Pract Concept. 2016;6(2):21-7.
• Block SG, Valins WE, Caperton CV, Viera MH, Amini S, Berman B. Exacerbation of facial acne vulgaris after consuming pure chocolate. J Am Acad Dermatol. 2011;65(4):e114-5.
• 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. 2014;7(5):19-23.