1. Perceptions about acne causation 2. Non-westernized vs modernized societies: differences in acne prevalence 3. Clinical evidence on Nutritional factors potentially impacting acne: a.Dairy products b.Hyperglycemic food c.Whey proteins d.Alcohol e.Tea f.Coffee g.Chocolate h.Salt 4. Potentially beneficial nutrients in acne 5. Management of acne through nutrition 6. Influence of environment on acne a.Medications b.Occupational factors c.Mechanical factors d.Pollutants e.UV radiation 7. Practical considerations

1. The link between
Diet, Environment & Acne

2. “It is important to look beyond the physical
scarring, for there is no disease that has
caused more insecurity and feelings of
inferiority than acne.”
J AmAcad Dermatol 1995;32:S26-30.

3. Lasts for
years and can cause
physical and
emotional scars
Most prevalent skin
condition
Affects 80% of
people between 12
and 18 years of age
A family factor is
frequently
associated
with acne severity
One of the main
reasons for
dermatologic
consultation
Physical and
psychological
morbidity in up to
90% of adults

4. Contents
1. Perceptions about acne causation
2. Non-westernized vs modernized
societies: differences in acne prevalence
3. Clinical evidence on Nutritional factors
potentially impacting acne:
I. Dairy products
II. Hyperglycemic food
III. Whey proteins
IV. Alcohol
V. Tea
VI. Coffee
VII. Chocolate
VIII. Salt
4. Potentially beneficial nutrients in acne
5. Management of acne through nutrition
6. Influence of environment on acne
I. Medications
II. Occupational factors
III. Mechanical factors
IV. Pollutants
V. UV radiation
7. Practical considerations

5. Overall knowledge about the causes,
natural course, and therapy was
very low, not only among patients
but also among final year medical
students and even among family
physicians and nurses.
Australas J Dermatol 2001;42: 98-101.
Patient EducCouns 2004;54:21-5.
Austral New Zealand J Pub Health 2002;26:108-15.

6. Acne is surrounded by

7. Perceptions about acne causation
• Studies have evaluated the knowledge, beliefs, and
perceptions about acne causation among patients & their
families
• No major differences were noted in the beliefs and
perceptions
The role of diet was uniformly noted among acne
patients from different societies and cultures

8. 62.3% high school
students
implicated diet as
a cause for their
acne1
Greece
Diet, poor skin
hygiene, and
infection were
implicated2
Canada
11% of teenagers
blamed greasy
food as the main
cause3
England
J Eur Acad DermatolVenereol 2007;21:806-10
JAm Acad Dermatol 2001;44:439-45.
Br J Dermatol 2001;145:274-9.

9. Role of food in acne is not surprising!
• Enormous increase in public awareness of the
cause-and-effect relationship between diet and
health
• Changed perceptions and attitudes of consumers
toward the image and importance of the daily diet
• Mountains of epidemiologic studies in the scientific,
pseudoscientific, and nonscientific literature are
confusing

10. “Let food be your medicine,
and let medicine be your food”
“Doctor, is it something I
ate?”

11. The role of diet in acne: IS THERE A SOLID
• Convincing trials are lacking
• No meta-analyses, randomized controlled clinical studies,
or well-designed scientific trials have followed evidence-
based guidelines
• An overview of currently available information is
presented in the following slides
Arch Dermatol 2001;137:345-6.

12. A difference in the prevalence of acne
between non-Westernized and fully
modernized societies has been noted, and
diet has been suspected to be the reason

13. Non-westernized v/s modernized societies:
differences in acne prevalence
• Studies by Schaefer & Bendiner
• Acne was absent in the Inuit (eskimo)
population when they were still & eating
in their traditional manner.
• The prevalence of acne became similar
to that in Western societies after their
acculturation.
NutrToday 1971;6: 8-16.
Hosp Pract 1974;9:156-89.

14. Surveys from Africa & Brazil
African villages report far less acne than is found in the
descendants of people in these areas who now live in the
United Kingdom or the United States
Of 9955 children aged 6 to 16 years from Purus valley in
Brazil, only 2.7% had acne vulgaris
Arch Dermatol 1968;98:577-86.
Br J Dermatol 1979;101:449-53.
Br J Dermatol 1968;80:758-61.

15. Prevalence of acne in 2 non-Westernized isolated populations
Kitavan Islanders of Papua
New Guinea
Ache hunter-gatherers of
Paraguay
• Diet of both communities includes mainly traditional foods
• Not a single case of acne of any grade was found in young adults of these tribes
• This is attributed to environmental factors, mainly local diets, which have a
substantially lower glycemic index than the Western diet
• An alternative explanation is that of genetic susceptibility to acne, especially given
that the people in these isolated regions live in close-knit and closed communities.
Arch Dermatol 2002;138:1584-90.

16. Nutritional factors potentially impacting acne
• A review published by Claudel et al.
identified nutrients potentially playing a
role in acne:
• Dairy products
• Hyperglycemic food
• Whey proteins
• Alcohol
• Tea
• Coffee
• Chocolate
• Salt

17. Acne and dairy products: Could milk cause acne?
• Milk contains placenta-derived progesterone and other
dihydrotestosterone (DHT) precursors
• These compounds are only a few enzymatic steps away from
DHT, the main acne stimulator
• Insulin like growth factor-1 (IGF-1) present in ordinary milk
stimulates the synthesis of androgens in the ovary, adrenals,
and testicles.
J Invest Dermatol 2002;119:992-1007.
Vitam Horm 1995;50:77-149.
Endocrinol Metab Clin North Am 1999;28:265-93.
J AmAcad Dermatol 2001;45:S95-S104.

18. Acne and dairy products: Could milk cause acne?
• Insulin itself and, even more so, IGF-1 have been
demonstrated to stimulate hair follicle growth and sebocyte
growth.
• IGF-1 may mediate some of the effects of comedogenic
factors, such as androgens, growth hormone, and
glucocorticoids
J Invest Dermatol 2002;119:992-1007.
Vitam Horm 1995;50:77-149.
Endocrinol Metab Clin North Am 1999;28:265-93.
J AmAcad Dermatol 2001;45:S95-S104.

19. Alternative hypothesis
• Iodine content of milk might also have an effect in
the development of acne
• Iodine intake could exacerbate acne
• The concentration of iodine in milk varies according
to the season and geographic location, but
significant levels of
J AmAcad Dermatol 2005;53:1102.
JAMA 1967;200:879-80.
Br J Nutr 2003;90:679-85
J Dairy Sci 1990;73:3421-7.

20. Alternative hypothesis
• Iodine were found in milk in different countries
• The observed association of dairy products with acne
might be secondary to the iodine content of the dairy
products ingested
• Whether iodine in any concentration causes true acne
is debatable.
J AmAcad Dermatol 2005;53:1102.
JAMA 1967;200:879-80.
Br J Nutr 2003;90:679-85
J Dairy Sci 1990;73:3421-7.

21. Milk was the most common food implicated in acne
flares in 1925 patients

23. So, can milk cause acne?
• Even though there are more and more elements
confirming the relationship between acne and dairy
products
• Association between dietary dairy intake and the
pathogenesis of acne is slim
• There is no consensus concerning the role of fat levels
in dairy products in the physiopathology of acne

24. Do Whey proteins have a role in ACNE?

27. Insulin
Growth
Factor
(IGF)-I
Tumour
Growth
Factor
(TGF)
Growth
factors in
whey
Insulin
Growth
Factor
(IGF)-II
Platelet
derived
growth
factor
(PDGF)
fibroblast
growth
factor
(FGF)-2
fibroblast
growth
factor
(FGF)-1
Potent inducers of glucose-
dependent insulinotropic
polypeptides stimulating insulin
secretion of pancreatic b-cells and
may be related to acne
JAmCollNutr2007;26:713s–723s.
NutrMetab(Lond)2011;8:41.

28. Can Hyperglycemic food lead to ACNE?

29. HYPERINSULINAEMIA
FREE INSULIN LIKE GROWTH FACTOR
(IGF-1)
MAY LEAD TO ACNE
STIMULATES GROWTH IN TISSUES
MITOGENIC ACTION
INSULIN LIKE GROWTH FACTOR
BINDING PROTEIN -3 (IGFBP-3)
Int J Obes Relat Metab Disord 1997; 21: 355–359.
J Clin Endocrinol Metab 1998; 83: 1467–1471.
J Clin Endocrinol Metab 1994; 79: 872–878.

32. The role of Alcohol
• Testosterone levels increased in men after both acute
and habitual alcohol consumption
• Testosterone is an important acne trigger and are
present in both men and women
• Some alcohol is secreted through the sweat, thus
possibly acting as a nutritive for Cutibacterium acnes
Alcoholism Clin Exp Res 2003; 27: 682–685.
BMJ Open 2014; 4: e005462.
Presse Med 2013; 42: 1487–1499
J Am Acad Dermatol 2000; 43: 1–16; quiz -8.

33. The role of Alcohol
• Alcohol may worsen acne by influencing the immune
system leading to an unbalanced skin microbiota
and to acne
• Chronic consumption of alcohol has been suggested
to increase cytokine release which may influence
acne
Br J Nutr 2007; 98(Suppl 1): S111–S115.
Alcohol Res: Curr Rev 2015; 37: 159–170.
Tissue Antigens 2010; 76: 411–415.

34. Tea, coffee, and chocolate
• To date, there is no clinical evidence that products
containing coffee or caffeine cause or worsen acne
• No data on potential relationship between the consumption
of tea and the onset or worsening of acne except one
epidemiological study
• Some evidence suggests that green tea polyphenols may be
beneficial in reducing sebum secretion and show some
antibacterial properties
Dermatol Pract Concept 2016; 6: 21–27.
Antioxidants (Basel, Switzerland) 2016; 6: 2.
J Drugs Dermatol 2015; 14: 574–578.

36. • Chocolate consumption group had a statistically significant increase in acne
lesions compared with the jellybean consumption group
• The increase in acne lesions was present across gender, age, frequency, and
severity classifications
• Chocolate flavonoid consumption modulates cytokine production, which may
account for these observations

37. These data should be considered with caution,
as chocolate was administered as a chocolate
bar also containing sugar and milk: both are
considered as potentially playing a role in acne

38. Salt (sodium chloride)
• Very few studies about the role of salt in acne are
available
• A clinical study showed that consumption of salty foods
was significantly higher among patients with acne
compared to acne-free subjects
• Advanced investigations still have to be performed to
determine the role of salt in acne.
SkinTherapy Lett 2010; 15: 1–2, 5.
Int J Dermatol 2009; 48: 339–347.
J Cosmet Dermatol 2016; 15: 145–149.

39. Clin Cosmet Investig Dermatol 2015; 8: 371–388.

40. Clin Cosmet Investig Dermatol 2015; 8: 371–388.

41. Clin Cosmet Investig Dermatol 2015; 8: 371–388.

42. Associated factors
• In addition to nutrients the following could
potentially impact acne:
• Uncontrolled food intake(nibbling, modern lifestyle
nutrition)
• Obesity
• Eating disorders

43. Potentially beneficial nutrients in acne
• Acne is rare in non-Westernized societies with higher ratios of
n-3 to n-6 polyunsaturated fatty acids (PUFA)
• Regular fish consumption and vegetable consumption have been
reported to reduce acne
• Populations in Papua New Guinea and Inuits, who have no milk or
cereal intake, do not develop acne
• Prevalence of acne increased in individuals who changed their
nutrition habits
Der Hautarzt 2013; 64: 252, 4-8, 60-2.
Lipids Health Dis 2012; 11: 165.
Der Hautarzt 2013; 64: 252, 4-8, 60-2.

44. Paleontological nutrition regimen reduces the risk
of acne
• A palaeontological nutrition regimen, consists of
• Fish
• Vegetables
• Fruits
• With a low glycaemic, lipid and trans-fatty acid load
• Suggested by Melnik and confirmed by Grossi et al. in
2016
J EurAcad DermatolVenereol 2016; 30: 96–100.
Der Hautarzt 2013; 64: 252, 4-8, 60-2.

45. Fish products
• Lower n-3 PUFA content of the Western diet is an
important dietary modulator of inflammatory mediators
Int J Dermatol 1977; 16: 488–492.
Clin Cosmet Investig Dermatol 2015; 8: 371–388.
Am J Clin Nutr 2000; 71(1 Suppl): 343s–348s.
Arch Dermatol 2003; 139: 941– 942; author reply 2-3.

46. Individuals with acne consumed significantly less fish
and more junk food than the control individuals
Consumption of fish was associated with a protective effect against
moderate-to-severe acne

47. Arch Dermatol 2003; 139: 668–670.
Inverse association between fish consumption and
acne severity
• Fish contains high levels of n-3 eicosapentaenoic acid
(EPA)
• EPA acts as a competitive inhibitor of arachidonic acid
(AA) conversion to inflammatory mediators
• Thereby, reducing inflammation in acne

48. Fish oil supplements may improve overall acne severity

49. Fish intake may impact or aggravate acne

50. Based on the available data, no
conclusion on the impact of fish
food on acne can be drawn

51. Role of Vegetables and fruits
• Plant-based approaches have been practiced in multiple
medical perspectives, including Chinese medicine &
Ayurveda
• Low intake of fruits or vegetables triggers acne, especially
in the female population
• Mediterranean diet, rich of vegetables and fruits and
unsaturated fatty acids, positively impacts acne
PLoS ONE 2009; 4: e4903.
J AmAcad Dermatol 2016; 75: 1134–1141.e1.
Scand J Public Health 2012; 40: 466–474.

53. Management of acne through nutrition
• Patients should be questioned about
• Daily Food Habits
• Potential Family Acne History
• Lifestyle Disorders
• Eating disorders
• BMI should be calculated
• patients may be advised to change their food habits

56. The effect of probiotics on immune
regulation, acne
• Probiotics have been shown to directly inhibit P. acnes through the
production of antibacterial proteins (Bowe et al., 2006)
• Streptococcus thermophiles, applied as a cream for 7 days, has been
shown to increase ceramide production both in vitro and in vivo (Di
Marzio et al., 1999, 2003, 2008)
• In an Italian study of 40 patients,the group receiving the probiotic
experienced improved clinical outcome and resolution of acneiform
lesions (Marchetti et al., 1987).

57. Conclusion: relationship between nutrition &
acne
• Recent research has identified certain potential triggers
such as
• Dairy products, mainly skimmed milk
• Hyperglycemic load
• Excessive intake of whey proteins
• Evidence is still mainly based on epidemiological studies,
questionnaires and basic or translational research,
reported through level B and C publications

58. Currently, no clinical data generated
through controlled level A clinical
trials allow the association between
nutrition and acne to be confirmed

60. Exposome
• Used for the first time by Wild in 2005
• Describes the sum of environmental exposures to
which an individual is subjected from conception to
death
• The definition of exposome varied over time and
was refined a number of times
Cancer Epidemiol Biomarkers Prev 2005; 14: 1847– 1850.

61. Definitions of exposome

62. Exposome & chronic diseases
• In 2016, the impact of exposome on chronic diseases was
estimated at almost 80%
• conversely, that of genomewide-associated diseases did
not exceed 20%
• Exposome-wide association studies may allow discovering
factors that, over time, cause complex chronic diseases.
PLoS ONE 2016; 11: e0154387.

63. Role of exposome in dermatology
• Not investigated until recently
• In 2017, Krutmann et al. studied the role of exposome in skin
ageing
• Skin ageing exposome fall into the following categories:
• Sun radiations: ultraviolet radiation, visible light and infrared
• Radiation
• Air pollution
• Tobacco smoke
• Nutrition;
• A number of less well-studied, miscellaneous factors
• Cosmetic products
J Dermatol Sci 2017; 85: 152–161.

64. External exposome factors impacting acne

65. Nutrition
• By far the most published acne exposome factor
• Adequately discussed in previous sections

66. Medications: Hormonal treatments
• Androgenic progestins have been identified to cause or
worsen acne:
• Desogestrel and 3-cetodesogestrel
• Levonorgestrel
• Lynestrenol
• Norgestrienone
• Norethisterone
• Norgestrel
• Gestodene
• Norgestimate
• Etonogestrel
Ann DermatolVenereol 2010; 137: 746–749; quiz 5,50-1.
J AmAcadDermatol 2013; 68: 1022–1029.

67. Medications: Hormonal treatments

68. Contraceptives beneficial in treatment of
acne
• Chlormadinone acetate
• Dienogest
• Drospirenone
• Norgestimate
• Cyproterone acetate present in combined hormonal antiacne
treatments has also been reported to be efficient in acne
Ann DermatolVenereol 2010; 137: 746–749; quiz 5,50-1.
J Am Acad Dermatol 2013; 68: 1022–1029.
J Drugs Dermatol 2016; 15: 670–674.
Cutis 2008; 82: 158.
NedTijdschrGeneeskd 2003; 147: 2137–2139.
Acta DermVenereol 1978; 58: 449–454.

69. Anabolic steroids
• Anabolic steroids trigger acne through targeting
androgen receptors on sebocytes and keratinocytes
J Sex Med 2014; 11: 222–229.
Int J Dermatol 2009; 48: 1044–1048; quiz 8.
Arch Dermatol 2012; 148: 1210–1212.
An Bras Dermatol 2016; 91: 706.

70. Other medical treatments
• Agents reported to cause acneiform eruptions:
• Corticosteroids
• Halogens
• Isoniazid
• Lithium
• Vitamin b12
• Immunosuppressants
• Anticancer agents
• Radiotherapy
Clin Exp Dermatol 1993; 18: 148–150.
Clin Dermatol 2017; 35: 156–162.
Derm Beruf Umwelt 1985; 33: 220–222.
Breast J 2014; 20: 650–652.
Cutan OculToxicol 2014; 33: 94–95.
Geburtshilfe Frauenheilkd 2014; 74: 845–851.
Dermatol Online J 2014; 20. pii: doj_21545.
Br J Radiol 2002; 75: 478–481.
Hautarzt 2000; 51: 187–191.
SciTransl Med 2015; 7: 293ra103.
Arch Dermatol 2002; 138: 129–131.

71. Occupational factors: Cosmetics
• Acne cosmetica was described for the first time by Kligman and Mills in 1972
• Characterized by small scattered comedones on the face with only very few
inflammatory lesions
• Acne flare-up triggers in cosmetics include
• Comedogenic Ingredients
• Essential Oils
• Too Greasy Or Oily Foundations
• Powder Make-up
• Aggressive Skin Cleansers
• Soaps with pH of 8.0.
ArchDermatol1972;106:843–850
CutanOculToxicol2007;26:287–292.
IndianJDermatol2014;59:442–444..
ArchDermatol1970;101:580–584.

72. Mechanical factors
• Mechanical factors that may trigger acne flare-up:
• Rubbing
• Scrubbing
• The Use Of Home Devices
• Medical Devices Such As Sonic Brushes
• Dermarollers or microneedling systems
Eur J Dermatol 2015; 25: 114–121.

73. Inflammatory lesions: Mechanical factors

74. Musician with folliculitis mechanica (fiddler’s neck)
Eur J Dermatol 2015; 25: 114–121.

75. Acne vulgaris on the sub-mammary left area caused
by friction with a brassiere
Eur J Dermatol 2015; 25: 114–121.

76. Exacerbation of acne on the face caused by
intensive pressure
Eur J Dermatol 2015; 25: 114–121.

77. Severe inflammatory acne caused by a combination
of a facial skin massage device and topical skin care products
Eur J Dermatol 2015; 25: 114–121.

78. Pollutants: Air pollutants
• Air pollutants increase oxidative stress inducing severe
alterations inlipids, DNA, and/or proteins in the human
skin
• This is more marked in acne patients as in this population
the skin lipid film on the surface of the stratum corneum
is altered through an increase in oxidized squalene and a
decrease in linoleic acid
Clin Cosmet Investig Dermatol 2017; 10: 199–204.
Int J Cosmet Sci 2015; 37: 357–365.

79. • Compared subjects in the Mexico area in highly polluted to less polluted
areas
• Skin quality changes with chronic exposure to ambient pollution were
studied
• Vitamin E and squalene levels, both signs of sebum oxidation, were
reduced
• Although this study did not measure clinical signs of acne, raised sebum
levels were observed

80. • Chinese study, conducted during 8 weeks on 64 acne patients
• Showed a relationship between exposure to environmental pollutants
and increased sebum levels
• Higher number of inflammatory and non-inflammatory acne lesions

81. Even though there is growing evidence that air
pollutants exert their harmful effects by means of
reactive oxygen species and inflammation, more
research is needed to better understand the link
between air pollution and acne

82. Industrial pollutants
• Acne has been frequently observed in industry workers
after prolonged exposure to certain organic molecules,
such as coal tar or crude oil
• Today, exposure to these molecules has become less
common
• Only sparse information about their impact on acne
etiology is available from the literature
Contact Dermatitis 1988; 18: 120–121.
Dermatology 2015; 231: 334–338.
Int J Dermatol 2015; 54: 868–879.

83. Chloracne
• Chronic type of acneiform eruption
• Induced by halogenated aromatic hydrocarbons
• Differential diagnosis with acne vulgaris
• Males are more commonly affected than females
Contact Dermatitis 1988; 18: 120–121.
Int J Dermatol 2015; 54: 868–879.
Dermatoendocrinology 2009; 1: 125–128.
Int J Epidemiol 1981; 10: 135–143.

84. Cigarette smoke
• Chemical Substances From Cigarette Smoke Increase:
• Transepidermal Water Loss
• Degeneration Of Connective Tissue In The Skin
• Upregulation of matrix metalloproteinases 1 and 3
• Leading to:
• Degradation of collagen and elastic fibres
• Impact on the natural skin barrier
Ann NY Acad Sci 2012; 1271: 75–81.
Surgery 1998; 123: 450–455.
Br J Dermatol 2007; 156: 85–91.

85. Acne tropicana, acne majorca or tropical acne
Climatic conditions
Intensive UVR
Humidity
HeatSeasonal variations
Climatic conditions
Cutis 1983; 31: 79–81.
Calif Med 1946; 65: 274–277.
Int J Dermatol 1996; 35: 116–117.

86. Role of Ultra violet radiation (UVR)
Release of antimicrobial peptides
Adaptive cellular immune response
suppressed
P. Acnes may
overcolonize
Skin microbiota may be altered
Innate immune system activated
Flares of acne
Front Microbiol 2016; 7: 1235.

87. Exposome factors to be checked at the
patient’s 1st visit

88. Practical consideration 1
• Prior to any prescription, identify potential negative
exposome factors, especially in patients with moderate-to-
severe acne
JEADV 2018, 32, 812–819

89. Practical consideration 2
• The identified negative exposome impact should be limited
as much as possible to allow the natural skin barrier and
its microbiota to recover
• Limitation of high glycaemic index food in predisposed
patients and food supplements containing weigh proteins,
decrease in smoking tobacco/cannabis, modifications of
contraceptives and skin care regimens might be suggested
JEADV 2018, 32, 812–819

90. Practical consideration 3
• The use of topical antibiotics in monotherapy is not
recommended.
• This is to avoid increase in antibacterial resistance and
modifications in the natural skin microbiome.
• Topical retinoids combined or not with benzoyl peroxide
should be prescribed to be applied in the evening according
to current guidelines to avoid irritation and damaging of
skin barrier
J EurAcad DermatolVenereol 2016; 30: 1261–1268.
J EurAcad DermatolVenereol 2016; 30: 1480–1490.
J AmAcad Dermatol 2016; 74: 945–973.e33.

91. Practical consideration 4
• Patients should be reminded to avoid harsh washing of
their skin (avoid scrubs or exfoliating devices)
• Cleansers with a pH of 5.5 should be favored over
traditional detergents (i.e. soaps)
• Optimal frequency of cleansing should be twice a day
Pediatr Dermatol 2006; 23: 421–427.

92. Practical consideration 5
• Moisturizers should be used in the morning to
restore/improve the natural skin barrier function in order
to reduce cutaneous pollutant penetration during the day
and to limit irritation, frequently observed with topical
retinoids, especially during the first few weeks of therapy
JEADV 2018, 32, 812–819

93. Practical consideration 6
• Patients should be advised to use non-comedogenic make-
up and to apply sun-protecting products with a sun-
protecting factor of at least 30
• Daily photoprotection is of importance as UV radiation may
increase the impacts of pollutant particles on the skin
Cutis 2005; 76(6 Suppl): 7– 12.

94. Conclusion
• Environmental factors including nutrition, medication
occupational factors, pollutants, climatic factors and
psychosocial and lifestyle factors may impact on the
course and severity of acne and on the treatment efficacy
• Exposome factors act on the natural skin barrier and on
the skin microbiota, resulting in increased sebum
production, hyperkeratinization, modification of the
microbiote, activation of the innate immunity thus
resulting in acne worsening
Identifying the negative exposome factors and thus
reducing their impact are mandatory for an adequate acne
management.