Despite the dermatology party line, “the cause of acne remains unknown,” or the explanation that acne is a vague condition of “hormonal imbalances,” we actually know a lot about what causes acne—and what can help clear up your skin.
Far from a teenage nuisance, acne affects nearly 50 million Americans of all ages. To deal with it, the conventional route offers antibiotics, high dose vitamin A (known as Retin A) or of course, the Pill. And your drug store or department store makeup counter focuses mostly on topical treatments.
The trouble with all of these is that not one of them addresses the underlying cause, leaving many women still breaking out—or breaking out again as soon as they stop the medications—and leaving others wary of side effects from prescriptions or dried out and irritated from topical treatments.
So what is the underlying cause? In most cases, it’s the perfect storm of dietary issues colliding with hormone trouble.
This is awesome news, because it means there’s a lot you can do! Before we get to that, however, let’s address the long-standing position that diet has nothing to do with it.
The ”diet is irrelevant” advice is derived from two studies in particular. The main dietary-acne study is from 1969, in which chocolate’s effect on acne was studied with a control group receiving a placebo “chocolate bar” that still contained the same amount of sugar. You’ll soon learn that sugar, carbs, and the hormone insulin are big players in breakouts, so not controlling for sugar, merely chocolate, doesn’t tell us much.
The other frequently cited study from 2003 did not account for the subjects’ baseline or past diet, so there was no way to know how the studied diet differed from their old one. There was no control group, and they didn’t have a solid, objective measure of improvement, such as counting blemishes before and after. The takeaway that “diet doesn’t matter” from this study was highly subjective. Without an objective measure of improvement, it was hardly scientific! What’s more, there’s a whole lot of other science (not to mention much clinical experience by doctors) telling us just the opposite.
What is acne?
First, let’s review a little Skin Anatomy 101. Each pore is part of a pilosebaceous unit in your skin. The pore is the opening of a hair follicle (the pilo part) and within it there is a little gland that produces oil, or sebum (the sebaceous part).
There are two types of comedones (a.k.a. pimples): open and closed. Open comedones are what we call blackheads, they are pores plugged with dead skin cells from within the follicle and excess sebum that becomes grey or black in color when oxidized with outside air. Closed comedones are known as “whiteheads” and are closed to the outside air. That white stuff is indeed pus, the aftermath of inflammation at war with bacteria. These are often more swollen and red.
What causes acne?
We’ll start by looking at the immediate situation in your pores. This is the four-step process to developing a pimple:
- The pore or follicle opening gets blocked (usually with flattened, dead skin cells that don’t shed properly typically due to hormonal imbalances and dietary compounds like lectins).
- There is excessive sebum (a.k.a. oil) production due to excess testosterone, typically from insulin issues or poor hormone metabolism (like gallbladder sluggishness, slow digestion, or improper hormone metabolism in the liver).
- Bacteria grow and infect the pore. With the pore now blocked and sealed with dead skin and oil, this creates a happy little home for bacteria called Propionibacterium acnes, which normally live on the skin’s surface without issue. Once outside air is kept out, it creates an anaerobic (without oxygen) environment in the pore for bacteria thrive.
- Finally, inflammation occurs in the blocked pore and surrounding skin tissue. Locally, the hormones of the immune system (called cytokines) start an inflammatory reaction under your skin’s surface. Now you’ve got the red, swollen, possibly warm to the touch, and perhaps even painful pimples, pustules, and cysts.
Note: applying pressure and squeezing these type of blemishes will cause this inflammatory mess to leak into the surrounding tissue, spreading the infection and inflammation. So, hands off, baby!
How Diet Affects These 4 Steps
Insulin & Her Friends Increase Your Inflammation
Insulin is a hormone secreted to shuttle glucose into a cell. It’s released when you experience stress or when you eat—more so when you eat carbohydrates (whole grains, legumes, cereals, breads, pastries, candy, sweets, sugar in all its forms, chips, tortillas, potato, sweet potato, fruit, etc.). It is released when you eat protein also, but as part of a healthier hormone mix for most (although some women do get an exaggerated insulin response from protein as well). Through a series of events, insulin is triggered when you eat fat as well – particularly when it’s combined with carbohydrates.
Too much insulin will increase inflammation as well as testosterone (created from your progesterone in the ovaries), leading to more oil production, which in turn leads to more breakouts. Insulin also lowers something called sex hormone binding globulin, which normally binds up and inactivates much of our testosterone. As a result, you wind up with more active, free testosterone around mucking things up in your pores.
This problem is worse in women with polycystic ovary syndrome (PCOS), as they tend to also have metabolic issues that create an even more potent form of testosterone: DHT (di-hydro testosterone). Acne is a common issue for women with PCOS.
Insulin isn’t alone. Other insulin-associated hormones get in the acne mix, like IGF1 (insulin-like growth factor 1), a potent stimulator of cell growth throughout the body. High levels of insulin will cause higher levels of free IGF1 (remember it’s free hormones that are active). This free IGF1 may stimulate overproduction of the keratinocytes, causing them to overgrow and block your pores.
Then there’s ILGFBP3 (insulin-like growth factor binding protein 3), a key regulator in programmed cell death, or apoptosis (the normal ending of a cell’s life cycle, when it’s time to be replaced). High levels of insulin will lower circulating IGFBP3, delaying apoptosis of keratinocytes that line the follicle, which leads to more flaky cells to clog up your pores.
What’s more, these IGFs can further interact with one another—especially when there’s a high concentration of transglutaminase around—creating more inflammation. Transglutaminase is an enzyme in your intestines that digests wheat. The more wheat we’re eating, the more transglutaminase will be produced throughout your body, including in your skin.
With too many starchy and sugary carbs causing this whole insulin mess, you can see why gluten based carbs (bread, pasta, pastries, cookies, muffins, bagels, etc.) are double trouble for your skin, thanks to transglutaminase. What’s more, gluten contains something called amylopectin, which causes a really big insulin release. This makes wheat what I call a “supercarb. “ (More on wheat and gluten here.)
NOTE: there is a lot of variability in each individual’s response to wheat. If you tolerate wheat fine, have glowing clear skin, then this isn’t a biggie for you. Feel free to eat as you wish, as I’m not here to say gluten is the devil. But if you’re struggling with breakouts, it’s worth a try to eliminate it and see if your skin improves.
Personally, wheat gives me the worst, deep, red, painful breakouts whereas dairy gives me more superficial but greater in number breakouts. Basically mac and cheese is my skin’s worst nightmare!
Dietary Fat, Grain, and Dairy
One inflammatory cytokine involved in acne is IL1 (interleukin 1). Acne sufferers have elevated levels of the alpha form of IL1 and some studies show this inflammatory hormone causes increased skin scale formation (more stuff to block your pores). When bacteria in our pores cause an immune reaction, even more IL1 is secreted (by little white blood cells called monocytes) which can disrupt the normal sloughing off of skin and result in more breakouts.
IL1 can be elevated from too many omega 6 fatty acids in our diet. These fats come primarily from grains, seeds, nuts, and vegetables oils (sunflower, grapeseed, etc.) so it’s important to balance your intake of the more anti-inflammatory omega 3s from things like fish or taking fish oil supplements, as well as consider decreasing your Omega 6 intake when you have acne.
Lectins are common in plant foods (grains and legumes especially). When it comes to acne, they interfere with the dissolving and sloughing off of sticky corneocytes. This process requires enzymes called glycosidases (which dissolve the carbohydrate part of the cell) and proteases (which dissolve the protein part). It’s crucial that the glycosidases act before the proteases for the corneoycyte to degrade properly and not block the pore. Lectins mess up the order of this process. To make matters worse, lectins also stimulate IL1 alpha, so you get more inflammation and more pore blockage.
There’s one more way lectins make you breakout: wheat germ agglutinin is a particular lectin that impairs zinc metabolism. Zinc influences skin health in several ways. With this wheat issue we’re talking at the level of your cell’s nucleus. Long story short, wheat germ agglutinin blocks important aspects of zinc’s metabolism, triggering a whole lot of inflammation.
This leads to the next acne culprit in your diet: dairy. Milk, cheese, yogurt, and other dairy products are very highly concentrated sources of calcium. Calcium impairs zinc metabolism. Perhaps worse, dairy can have a very exaggerated insulin response (despite being considered low-glycemic, the insulin release it triggers is very similar to white bread). Dairy is also ripe with hormones, making it a triple threat to an acne-free face.
Paleo To The Rescue!
The popularity of Paleo as a weight loss and autoimmune panacea is at its peak – and for the most part, its reputation is rightly deserved. It is also a great template for clearing up acne.
A Paleo Diet isn’t magic, but it does remove all of the problem foods I just mentioned, which makes it a great diet for clear skin. Give something like Whole30 a try to clear up your acne, or at least consider drastically reducing some of the skin’s biggest offenders: sugar, wheat, and dairy for 30 to 60 days.
This will be enough for some women to achieve a clear complexion. For others, one or more additional issues may need to be addressed beyond diet, for example: further support of underlying insulin resistance, low estrogen or progesterone, poor testosterone metabolism, sluggish digestion or liver detoxification of hormones, poor nutrient status (i.e. low zinc is incredibly common) or issues like hyperpermeability of your intestinal lining, low digestive enzymes, or disruption of your gut flora (i.e. need for probiotics).
Acne on other areas of the body
What if you only have acne on your back, chest, arms? The underlying mechanism is the same, so diet and hormones are still the answers. However, if you only breakout along a bra line or where clothing has been rubbing your skin, that is more of a local vs. systemic cause blocking your pores.
One tip for avoiding breakouts that seem to be worsened with an active lifestyle (be that your sports bra rubbing against your skin, or just sweat) is to spray your body before and after with some sort of anti-bacterial spray like Earth Science Clarifying Herbal Astringent. And of course, wash your workout gear regularly, change out of sweaty clothes (even if it’s just for clean workout clothes), and shower as quickly as you can after getting sweaty.
Stress and sleep
Don’t underestimate the power of beauty sleep! Lack of sleep is stressful, and stress is inflammatory. The old adage is true, and you need your beauty rest. All other stress has a role as well, so when you feel your skin looks haggard, inflamed or you breakout during high stress, it’s not in your head.
Rest up, manage stress, take a pass at the Paleo diet, and if you need help, by all means reach out and let’s see what the bigger issues may be.