Acne—A Message to Get Your Internal House in Order
Acne vulgaris, as its name suggests, is so widespread as to be considered, in the general population, “ordinary” or “common” (which is what “vulgaris” means). Epidemiologists rate acne as the world’s eighth most prevalent disease, estimating that it afflicts 9.4 percent of the global population and close to fifty million Americans annually.1,2 In primary and secondary care settings worldwide, it is one of the top skin issues that patients ask clinicians to help them address.3
Although adults, and especially women, also experience acne, much of the focus is on teens, in whom acne is described as “virtually ubiquitous.”4 U.S. dermatologists state that up to 85 percent of youth between ages twelve and twenty-four experiences some form of acne, ranging from mild to severe.5 Beginning in the 1980s, however, twelve was no longer the “low end of the ‘normal’ range for onset of acne,” with a downward shift in facial breakouts starting to become apparent.6 Health websites now state that it is “perfectly normal” for “preteens” (defined as starting at age seven!) to develop acne.7
Swiss dermatologist Bruno Bloch declared in 1931 that acne is “a normal reaction to the physiological changes taking place during puberty.”8 Normalization has been the medical profession’s default stance ever since. On the other hand, wrote RNR Grant, MD, in 1951, “Acne cannot be regarded as a serious disease or measured in terms of life and death, but it has a nuisance value out of all proportion to its seriousness, affecting, as it does, young people at an age when they are most sensitive to any disfigurement.”9
Seventy years later, with far greater awareness of the role of the skin as the immune system’s first line of defense and with an understanding that skin issues may be an early warning sign of gut imbalances,10 it is debatable whether acne should be dismissed as merely a “nuisance.” At the same time, few would deny that for adolescents and young adults in their peak years of self-consciousness, acne can have spillover effects on mental health, including documented associations with anxiety, depression and “social impairment.”11 These impacts are apparently so common that a specialized field of dermatology called “psychodermatology” has stepped forward to help sufferers of acne treat both their physical condition and its social-emotional fallout.12
Age Old Problem of Acne
Although the term “acne vulgaris” was not coined until 1840, historians are convinced that acne is an “age-old problem,” citing descriptions of puberty-associated skin conditions dating back to ancient Roman, Greek and Egyptian times.3,13 Early physicians influenced by the Greeks linked skin disease to an imbalance of the four “humors” (blood, phlegm, black bile and yellow bile), with pores in the skin thought to be “orifices through which humors could pass”; a sixteenth-century acne-like condition, for example, was attributed to “melancholy blood.”3
With the invention of the microscope, practitioners turned away from trying to understand acne’s deeper causes, acknowledging only that “many morbid processes conspire to favour the existence of the disease.” Instead, they grew fascinated with the various “unpleasant appearances” that they could now observe up close.3 This was already evident in Shakespeare’s time; in his famous history play, Henry V,14 the bard colorfully describes Bardolph’s face as “all bubukles and whelks and knobs and flames o’ fire.”9
Modern dermatologists, alas, have transitioned to drier language, telling us that acne is characterized by “comedones, papules, cysts, nodules, and scarring” (in lay terms, skin bumps, lesions and pitted or raised scars).3 However, they are still visually fascinated, as a 2010 editorial in the Journal of Visual Communication in Medicine indicates, stating: “The wide variety of anatomical location, distribution, form and texture of skin lesions presents the medical photographer with many challenges, but nevertheless offers many opportunities to demonstrate his or her skills, arguably more than in any other medical specialty.”15
Microscopy’s rise encouraged acne’s chroniclers to try to squeeze the condition “into the elaborate classifications which were then becoming popular.”9 By the nineteenth century, “the literature on acne becomes voluminous, with division of opinion particularly on the subjects of classification and nomenclature. There is argument as to whether the primary lesion of acne is a pustule or a papule; whether all pustular conditions of the face should be called acne; whether it was necessary for any lesion to have a red areola for it to qualify for the name acne, and so on.”9
Skin is Our Largest Organ
People often forget that the skin is an organ—the largest organ in the body15 and also “a major organ of elimination, nutrient production, physical protection, and a major organ of the innate immune system second only in size and importance to the gastrointestinal [GI] tract.”16
The sebaceous glands, found on nearly all parts of the skin, play a pivotal role in skin and whole-body health. The glands produce and secrete the oily substance called sebum, which protects and helps hydrate the skin, but in addition the glands possess “an innate antibacterial activity and. . . a pro- and anti-inflammatory function,” as well as transporting antioxidants, helping with wound healing and regulating the activity of xenobiotics (chemicals foreign to the body).17
Importantly, the sebaceous glands are also a site for the formation of hormones,18 notably the class of “male” sex hormones called androgens (several of which are also quite normally present in women19). Many researchers believe that androgen overproduction plays a causal role in acne by ramping up sebaceous gland activity.17 Other researchers, however, describe the role of androgens as “complicated and incompletely understood,”19 and some hypothesize that the higher-than-normal androgen levels observed in acne could be a result rather than the cause of the skin problem.20
More than Skin-Deep
While conventional dermatologists maintain a narrow focus on things like “clogged pores” and “acne bacteria”—leading to recommendations for topical and oral antibacterials and other toxic symptom suppression measures—those adopting a whole-body approach recognize that skin problems are often the first alarm bell that something is wrong inside.21 Another clue that the problem is more than skin-deep is the rare form of acne called “acne fulminans,” which presents not just with “painful, hemorrhagic pustules” but sometimes with systemic symptoms such as arthritis.22
A holistic skincare company founded by nationally recognized skincare physician Dr. Ben Johnson bluntly describes acne as a “toxin purge” and asserts that the treatment goal should be “to detox your skin and remove the source of the toxicity internally.”23 Gut imbalances and liver congestion are two key contributors to toxicity. In a skin-mapping tool24 that matches facial zones with body organs, Johnson suggests that acne on the forehead, cheeks or nose point to digestive system imbalances and toxicity related to candida overgrowth, while acne on the jawline, neck, chest or back may signal a liver overwhelmed by endocrine-disrupting xenoestrogens (including pesticides, chlorine, BPA and food additives).25 Johnson also views each individual’s gut microbiota as unique—the commensal equivalent of DNA.
Johnson’s skin-mapping tool points the way toward a view of the skin as “a mirror to the gut.”26 Many others acknowledge that candida (principally Candida albicans) often plays a significant role in acne. Acne websites put it this way: “If you have acne it is very likely you also have Candida overgrowth.”27 C. albicans, naturally present in many areas of the body and notably in the GI tract, is the most prevalent fungal species of the human microbiota and one of the very few capable of wreaking health havoc.28 In healthy individuals, C. albicans is generally harmless, but factors that alter the gut microbiota or the immune response—such as a sugar-heavy diet, glyphosate exposure,29 heavy metal toxicity,30 fluoride,31 antibiotics, oral contraceptives,32 other medications or stress—can opportunistically drive it into overgrowth.28 This more aggressive form of candida is capable of releasing over eighty different toxins; these can cause a wide variety of symptoms, some of which are skin conditions.33
High percentages of adolescents and young adults report depression and anxiety (with the numbers rising dramatically since Covid), and many are quite willing to resort to medication as a response.34 Perhaps young people would be less willing to do so if they knew of the relationship between antidepressants and acne—a relationship that is both direct35 and probably also indirect via antidepressants’ reshaping of the composition of the gut bacteria.36
Following World War II, the prevalence of and growing attention to acne proved to be fortuitous for chemical-pharmaceutical conglomerates pivoting from chemical production to drug development.37 By the 1950s, the U.S. pharmaceutical industry had a “plethora” of acne treatments on offer—including creams like Clearasil as well as tranquilizers and antidepressants—all promising “the hope of both clear skin and psychic succour to the acne sufferer.”8
Acne drug and skin product development has continued apace ever since, even producing billionaires such as the two dermatologist founders of the skincare company Rodan + Fields; the two admit, “the need for acne [products] is pretty sizeable, and that’s why we’re going after it.”38 For over-the-counter acne products alone, U.S. sales amounted to over six hundred million dollars in 2017—a quarter of global sales.38
As for prescription treatments, it is questionable whether the options currently available are much better than the ammonia, mercury and arsenic that Victorian-era women once used to tackle problem skin,13,39 for the modern arsenal of acne drugs comes with adverse effects that insiders admit “pose a significant health risk to the patient.”40 Moreover, modern-day dermatologists typically prescribe topical or oral acne treatments (“based on disease severity, patient preference, and tolerability”2) only with the limited goal of controlling acne, preventing scarring or making scars less noticeable.41 In general, they do not profess to tackle underlying causes.
Commonly recommended topical agents— including synthetic derivatives of vitamin A called retinoids,42 topical antibiotics and an antibacterial gel called dapsone—routinely come with side effects discounted as “minor” (such as increased sun sensitivity, skin dryness, skin redness or discoloration and skin irritation), but also with effects that are undeniably serious.41 Serious side effects of dapsone are listed as facial swelling, rash, numbness or tingling of the extremities, muscle weakness, back pain, shortness of breath and dark brown urine, among others.43 Many of these topical agents require weeks or months of use to produce any results.
Oral acne options include antibiotics, combined oral contraceptives, the anti-androgen agent spironolactone (prescribed for females due to its “undesirable” tendency to cause breast growth and other “feminizing” effects in men)44 and a drug called isotretinoin. Hoffmann-La Roche removed its isotretinoin brand, Accutane, from the U.S. market in 2009 (though the drug is still sold in other countries as Roaccutane), but many generic versions of isotretinoin remain on the American market.45 In its first twenty years of U.S. use, Accutane generated twenty-three thousand adverse event reports to the Food and Drug Administration (FDA),45 with many other adverse events likely going unreported. Due to the risk of severe birth defects in offspring, pharmacists, prescribers and patients must register with an FDA-mandated isotretinoin “risk management program.”2
The website acne.org describes isotretinoin as a “powerful drug that changes the skin and the body forever” by reducing skin oil production, adding, “Once you take it, there is no going back.”46 Prescribed for “severe, recalcitrant acne,”2 isotretinoin is also, says acne.org, “the ‘nuclear option’ due to its ability to provide remission of acne in about 2/3 of people who take it, while at the same time causing troubling, potentially lifelong side effects.”46 The latter—including not just the fetal abnormalities but also joint pain, depression, suicidality and permanently altered eyesight—seem like grave risks for young people and reproductive-age women to take, particularly given the conclusion of a 2018 Cochrane review of randomized clinical trials indicating no clear evidence “that isotretinoin improves acne severity compared with standard oral antibiotic and topical treatment when assessed by a decrease in total inflammatory lesion count.”47
“Standard” topical and oral antibiotic treatment comes with its own set of problems, with a principal one being antibiotic resistance— “a major concern in dermatology since the 1980s.”48 For the patient, antibiotic resistance can lead to bad outcomes such as treatment failure, alterations in normal skin flora, eradication of gut flora and “induction of opportunistic pathogens locally and systemically”; for wider society, problems include “dissemination of resistant strains to both healthcare personnel and the general population.”48
Nonetheless, though oral antibiotics produce only “moderate results,” “only work for some people” and come with potentially harsh side effects, the dermatology profession continues to prescribe them.49 A shocking case report published in 2019 described the development of acute respiratory failure in five previously healthy adolescents (ages thirteen to eighteen) who had taken a recent two- to four-week course of a widely prescribed combination antibiotic called trimethoprim-sulfamethoxazole (TMP-SMX); four took the drug for acne and one for a urinary tract infection.50 Upon hospitalization, all five needed invasive respiratory support, and four required mechanical life support, in some cases for months. Despite these measures, two of the adolescents died. In an understatement, the authors of the study concluded, “The findings from this case series is [sic] a reminder that the benefits must be weighed against the known and unknown risks of any medication.”50
The Nontoxic treatment of choice: A Wise Traditions Diet
Although some researchers still describe the relationship between acne and diet as tentative or “controversial,” the general consensus is that the association between the two “can no longer be dismissed.”51
Noting the substantially lower prevalence of acne in non-Westernized cultures eating traditional diets characterized by few high-glycemic carbohydrates, some experts recommend ketogenic (very-low-carbohydrate) diets. The pathway to acne, these researchers argue, arises through the carb-heavy Western diet’s stimulation of insulin and insulin-like growth factor-1 (IGF-1) activity as well as greater androgen bioavailability.52 Other researchers concur that populations such as the Canadian Inuit, South African Zulus, Japanese Okinawans, the Aché of Paraguay and the Kitavan islanders of Papua New Guinea did not show signs of acne until they began eating processed foods and refined sugars.53 It is likely that these latter two items—with their additives and negative impact on gut bacteria—bear the lion’s share of responsibility for the burgeoning skin problems. Certainly, a ketogenic or GAPS diet may play a role in restoring gut health, but beyond that point, there is little reason to avoid properly prepared grains or other Wise-Traditions-compatible carbohydrates, as long as they are consumed with plenty of animal fats containing the all-important fat-soluble vitamins.
Where refined carbohydrates are concerned, many people intuit that overconsumption of sugar, in particular, has something to do with hormonal acne. Researchers have uncovered one reason why this may be the case. A diet with too much sugar gets the liver’s metabolic state “out of whack”—with the liver converting the sugar to fat—and this conversion process reduces a protein (sex hormone binding globulin or SHBG) that plays an important role in maintaining testosterone and estrogen at appropriate levels.54 With reduced SHBG in the blood, the body will release more testosterone and estrogen, leading to an increased likelihood of acne.55 Lower SHBG is also associated with other hormone-imbalance-related conditions such as polycystic ovary syndrome (PCOS) and type 2 diabetes.56
Modern acne advice often comes with a warning that milk consumption is linked to acne, but the beautiful skin of the milkmaids of yore provides a clue that these dairy naysayers are barking up the wrong tree. The fact is that virtually all studies involving dairy include only pasteurized milk or, even worse, pasteurized skim milk. For example, a 2008 study with over four thousand teenage boys, conducted over several years, found a strong correlation between acne and consumption of skim milk.57 Other studies confirm that skim milk is more “comedogenic” (“pore-clogging”) than whole milk and also float the notion that the hormonal balance of skim milk itself is “impaired.”51
Although such studies make a good case for jettisoning pasteurized milk from the diet, raw milk is a different story altogether.58 High-quality raw milk—which builds gut integrity and supports balanced gut flora—is more likely to contribute to glowing skin than acne outbreaks.59 Dr. Josh Axe notes that success stories of raw milk improving skin conditions such as psoriasis, eczema and acne are widespread, with the healthy fats in raw milk supporting skin hydration and the milk’s probiotics helping to balance the gut flora.60
As already discussed, the possibility of candida overgrowth must be considered in cases of entrenched acne (especially if on the forehead, cheeks or nose). Because C. albicans readily forms into densely packed communities of cells called biofilms,61 it can be challenging to kick it off center stage and back into microbial balance. Bill Thompson’s Earth Clinic book Candida: Killing So Sweetly outlines a number of anti-candida strategies—including anti-biofilm protocols using substances like turpentine,62 iodine, humic acid and borax—that have proved helpful to many.63 Thompson notes that the anti-biofilm measures should be considered only if other anti-candida steps have not produced the desired progress.
There are also simple natural remedies for acne that may not help in all cases but certainly will not hurt.64 These include apple cider vinegar (both internally and externally), turmeric (a blood purifier), Lugol’s solution applied externally, vitamin C (needed for skin regeneration) and probiotic-rich foods. Topically, substances such as honey, oatmeal and calendula-infused witch hazel can help cleanse, sooth and tone. The Earth Clinic website has many other suggestions. Sunlight also plays an important role in skin health.65
The Rise of Adolescent Medicine
Medical historians suggest that the history of acne “provides an excellent lens through which to understand both the development of adolescent medicine and rising concerns about youth mental health” after World War II.8 By constructing a view of teen acne “as a threat to the emotional well-being of teenage Americans,” budding adolescent health professionals took the stance that acne was “an ailment which had to be overcome at all costs.”8 If this could guarantee a steady (and lucrative) stream of ongoing and future patients, so much the better.
Interestingly, the late 1950s also saw acne constructed (via the mass media) as a “threat to the social order,” with news accounts rife with descriptions of young hoodlums with “pock-marked faces” and disfiguring acne. The linking of physical deformity to anti-social behavior, in one historian’s view, is similar to the “moral panic” later whipped up surrounding illnesses such as AIDS (and Covid-19).8 Across the fields of medicine, journalism, sociology and criminology, experts “warned of the significant impact acne could have on the psyche,” linking acne concerns to “wider cultural anxieties about youth mental health, juvenile delinquency, sexual promiscuity and racial unrest.”8
Arguably, acne today is still bound up with culture. Reflecting such manifestations of the zeitgeist as “body positivity,” journalists started reporting in 2018 on an “acne positivity” movement after “influencers” began declaring that “pimples are in.”66 (There is even a hashtag, #freethepimple, to “destigmatise acne and empower others to embrace the skin they’re in.”67) This movement has also dovetailed with another prominent zeitgest narrative—“diversity”; a lifestyle writer recently complained, “Even beauty promotions emphasising the importance of diversity will feature an array of models who, despite their physical differences, will still have one thing in common: the same crystal-clear, flawless complexion.”68
As for the field of adolescent medicine that was so bound up with acne in the 1950s, now that it is established as a “legitimate” medical subspecialty,69 it has moved on to more contested terrain. With parents vociferously disagreeing with practitioners’ willingness to sideline or exclude mothers and fathers from their children’s often momentous health care decisions, freestanding teen and college clinics are handing out like candy not just acne drugs but body- and life-changing interventions like oral contraception, vaccines and cross-sex hormones as well as referrals for “top surgery.”70 Teens’ complaints about acne seem almost quaint by comparison.
One of the biggest lies about acne—stemming from conventional medicine’s focus on symptom suppression rather than investigation of root causes—is the assertion that the condition can be treated but not cured. Fortunately, many can testify that this is a false narrative. For those willing to unravel hidden sources of toxicity and tackle the job of restoring gut health, radiant skin is more than possible.
Not Just Kids Acne
Kids are not the only ones susceptible to acne, although in adults the condition is more common in women. Dermatologists describe two main categories of adult acne, with “persistent acne” (skin problems that follow an adolescent into adulthood) estimated at 80 percent of cases and “late-onset” acne (for example, in women going through menopause) estimated at 20 percent.71 However, other expert groups hypothesize that there may also be a third category, “recurrent acne,” that is “present in adolescence, improves for a variable period of time, and returns in adulthood.”72
The toll is heaviest in younger adults. Researchers state that more than half of young women in their twenties and more than 35 percent of women in their thirties have acne (presumably of the “persistent” or “recurrent” varieties).73 The quality-of-life impacts on adult women are, according to qualitative researchers, substantial, ranging from the psychological to the social and emotional.71
Although adult women may be eager to banish their bumps and lesions by whatever means necessary, caution is in order, particularly for reproductive-age women. The teratogenicity (propensity to cause birth defects) of isotretinoin, formerly Accutane, is one obvious warning sign. Other “treatments,” such as oral contraceptives and antibiotics, will damage the gut74—a counterproductive state of affairs for women as well as their future babies. Research shows numerous correlations between maternal gut dysbiosis and adverse outcomes in infants.75
What About Rosacea?
Another skin condition called rosacea, uncommon before age thirty and experienced by roughly sixteen million American adults, is often confused with acne. Skincare guru Dr. Ben Johnson argues that rosacea, like acne, is largely the result of digestive issues and candida overgrowth (not mites in the pores, as dermatologists often claim).76 An interesting study that examined the intestines of cadavers with rosacea found that about 35 percent contained “profound alterations in the lining of their guts.”77 Studies have linked small intestinal bacterial overgrowth (SIBO) and rosacea.
The tyrannical lockdowns and masking requirements imposed worldwide under cover of Covid-19 have introduced new challenges for skin health. For example, with the increased use of mobile phones, clinicians are witnessing a novel epidemic of “cell-phone acne.” An India-based case series described thirteen patients (healthcare workers and others) “who complained of eruption or flare up of acne, mainly involving one side of the face.”78 As the authors of the study explained, “All the patients reported increased cell phone use and cell phone-skin contact time during the lockdown period,” and the acne displayed a unique pattern: “There was a predilection or more number/flare up of acne lesions on the side of the face, which came in contact with a cell phone while talking.” While there are other websites (both in India and America) that acknowledge “cell-phone acne,” others tend to blame it on “germs and dust” on the phone.79 The authors of the case series suggest that “dissipation of heat” could be a contributor, ignoring the vast body of evidence describing non-thermal biological effects—including dermatological disease—of the non-ionizing radiation emitted by phones and computers.80
There is also growing evidence that Covid masking can trigger both acne and rosacea through its modification of the “cutaneous facial environment,” so much so that dermatologists now have coined the term “maskne.”81 Italian researchers who conducted a “real-world” study involving sixty-six patients with either acne or rosacea found that constant mask wearing (at least six hours a day) resulted in significantly increased “Global Acne Grading Scale” (GAGS) scores or a worsening of rosacea after six weeks of masking and quarantine, as well as “a statistically significant decrease in their quality of life.”81 Though the authors noted that mask wearing dehydrates the skin, dysregulates sebum and alters pH, all of which are “pro-comedogenic” and capable of leading to inflammatory lesions, unfortunately they had little to offer by way of remedy. Yale Medicine dermatologists acknowledge that maskne cases may not resolve easily, especially since “typical acne medications often don’t work on maskne.” The Yale doctors’ apparently sincere consolation is that “if the maskne sticks around for a little while, there is one saving grace: The mask will hide it.”82
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This article appeared in Wise Traditions in Food, Farming and the Healing Arts, the quarterly journal of the Weston A. Price Foundation, Fall 2021🖨️ Print post