Acne is perhaps the most common skin disease, particularly in adolescents but also in adults and often leads to numerous visits to dermatologist for treatment with a range of topical creams, antibiotics or use of drugs like Isotretinoin, in cases of severe acne, despite its numerous side effects. In the United States of America alone, the cost of Acne treatment currently exceeds US$3billion a year. Interestingly, while Acne is common in westernized populations, it has been documented as being virtually unknown among non-westernized population such as the Aceh of Paraguay and Kitivan Islanders.
Text by: Dr. Gitahi Theuri, PhD
Acne is often an emotionally distressful skin disease owing to its being unsightly and therefore a source of low self-esteem not only in teenagers but in adults as well. Acne vulgaris as it is known medically, is the occurrence of infected or inflamed oil glands in the skin and marked by red uncomfortable pimples on the face, neck, back, chest and shoulders that can last for months and leave scars. There are generally two types of acne: inflammatory acne, this presents as nodules, papules or cysts or non-inflammatory acne which may have whiteheads or blackheads.
Acne occurs in several stages several weeks after the overproduction of sebum mixing with dead skin cells, produced during the normal thirty day turn-over of skin cells, forming a sticky substance that then plugs the skin pores. Sebum is an oily-waxy substance that useful for lubricating and water- proofing skin and hair. Continued production of sebum accumulates behind the plug blocking the skin pore causing a build-up of pressure while at the same time providing food and an optimal environment for skin bacteria such as proprionibacterium acnes (p.acnes) to multiply. However the continued digestion of the sebum by these bacteria produces inflammatory substances that leak out into the hair follicles. The human body quickly recognizes this as a threat and launches an immune response that manifests as fiery red and painful pimples we call acne.
Hippocrates the father of modern medicine posited that all disease begins in the gut, could he have been wrong about Acne? The answer would be Yes, if one were to believe the Guidelines of Care for Acne Vulgaris Management, approved by the American Academy of Dermatology, it advises against dietary restrictions as a form of therapy for Acne. This position is in tandem with a study, long held as sacred truth, by Fulton et al in 1969. In this study participants were either fed on chocolate or on a placebo without chocolate for one month. Counting of all the lesions on one side of the face before and after each ingestion period indicated no difference between the groups, however only later was the fundamental flaw in this study pointed out, that the placebo intended to be healthy was rich in transfats hence the outcome of this study and thus shutting down the notion that diet could be responsible for Acne.
However a look at medical therapy for Acne during the late 1800’s and early 1900’s had diet as adjunct therapy. Similarly the ever growing body of epidemiologic and experimental evidence suggests a relationship between diet and acne suggesting that after all Hippocrates was spot on in his assessment of the cause of disease even in the case of Acne.
Does a gut-brain and skin axis exist?
Consumption of foods rich in prolamins, also known as gluten, such as Barley, Rye, Wheat and Soy (BROWS) leads to formation of Zonulin, a protein that controls permeability of the tight junctions of the walls of the gastro-intestinal tract. The continued exposure to dietary prolamins causes chronic gut permeability, this unfortunately allows the entry of partially digested proteins into the blood stream, the body’s immune system then goes into high gear, causing inflammation, this in essence is an allergic response. Intestinal permeability facilitates greater Insulin Growth Factor 1 (IGF-1), absorption across tissues of the colon and thereby increasing not only the risk of Acne but also the intensity of Acne. Strickler et al in 1916 in a paper on compliment fixation in Acne vulgaris found positive reactivity to stool-isolated bacteria in 66% of 57 patients with Acne compared to the patients in the control group who did not have any skin disease suggesting intestinal permeability is an underlying issue in Acne patients.
High consumption of grains such as those in the BROWS family, fructose (fruit sugar) and sugar are known to induce secretion of both insulin and Insulin Growth Factor 1 (IGF-1), IGF-1 also increases production of the outermost layer of skin, the perfect ingredients for Acne. High Insulin and IGF-1 also lead to an increase in Testosterone which in turn increases sebum production and thus attracting more Acne promoting bacteria. In the same vein, high sugar diets generally provide a perfect environment for colonization of the gut by harmful bacteria than. Stokes and Pillsbury way back in 1930 are credited with hypothesizing that gut micro-flora influence skin conditions and that one’s emotions could alter gut micro-flora and thereby contribute to systemic inflammation that could exacerbate Acne and other skin conditions. Both inflammation and stress can further increase the severity of infection and inflammation of the skin. This occurs because alteration of gut microflora causes an increase in substance P, a neuropeptide, produced in the gut, brain and skin, and known to be involved in skin disorders thus echoing the results of association of disrupted gut micro-flora and Seborrheic dermatitis (a red itchy rash that appear on the scalp) or Acne patients having significant alteration of gut micro-flora.
Consumption of unfermented dairy can also trigger an Acne flare up due to the presence of the milk protein Casein and the mineral Iodine which tends to be higher in pasteurized milk in contrast to raw milk.
On the other hand, consumption of fermented dairy with the pro-biotic strains of Lactobacillus acidophilus and Bifidobacterium bifidum have shown marked improvement of Acne. These pro-biotics work by reducing oxidative stress and regulation of pro-inflammatory cytokines within the skin, they also reduce the levels of IGF-1 during fermentation of dairy by up to 4 times significantly reducing inflammation.
Manipulation of dietary glycemic loads has been shown to improve the symptoms of Acne when protein and low glycemic index carbohydrates have been maintained at 25 and 45% respectively causing a significant decrease in lesion counts supporting the idea that lifestyle factors revolving around nutrition may play a key role in the pathogenesis of Acne. Indeed Hippocrates was a really smart guy, whose thoughts and ideas have had profound positive impact on humanity, any chance he could be nominated for the Nobel Prize for Science posthumously….just a thought, then again, it may be the effect of the cold Nairobi weather affecting my brain!
Dr Gitahi Theuri is a physiologist specializing in Lifestyle Diseases Intervention using non-pharmacological interventions to restore health. He has over 16 years of clinical experience, 10 of which at a leading cardiology practice in Kenya. He did his clinical rotation in the Department of cardiology at Memorial Hospital in Maryland, USA. He has studied: Advanced Clinical Nutrition under the ESPEN program at Maastricht University in the Netherlands, Prevention and Management of Diabetes and Cardiovascular Disease at the University of Køpenhagen, Denmark. He has published over 10 abstract and full length articles in clinical research journals. He is has presented research papers on non-drug interventions in Cardio-metabolic Diseases at International conferences In Africa, Europe and the Middle East. His research interests include: the role of Vitamin D and nutrient optimization in chronic disease intervention, and sex hormone balancing. His doctoral research focused on cardiovascular disease bio-markers in pastoral Vs urban living people. He is a lecturer in the Department of Exercise Science at Kenyatta University, in Kenya, where he co-ordinates the Human Performance Lab, alongside teaching classes in Laboratory methods, Nutrition, Applied physiology and use of exercise in management of chronic diseases. He is a strong advocate of organic and nutrient dense food.
