Did you know that acne impacts up to 85% of people between the ages of 12 and 15 years of age and some, like us in the office enjoy the occasional/often breakout in our 30’s… yay! While acne looks easily recognizable on the outside, it is actually multifactorial pathogenesis on the inside with multiple roots that cause some of the major ones we will cover below.

First let’s cover what acne is, acne also known as Acne Vulgaris is the most common of the inflammatory conditions affecting the sebaceous glands that produce sebum, a waxy constituent that resides in our pores and is released to lubricate the skin and hair in mammals and humans as such. This inflammation of the sebaceous gland creates inflamed skin elevations filled with puss or you have the blackheads and whiteheads too.

Acne affects the skin, but it more often has a cascading effect on the emotional wellbeing of the person who has to deal with it especially when they believe they have tried everything to find the cause, and we know now more than ever its more than just skin deep.

Types of Acne

- Acne Vulgaris - the main form of acne concerning adolescents and young adults.
- Acne Rosacea.
- Acne Cosmetica.
- Acne Fulminans.
- Acne Mechanica.

What Causes Acne?

Gut Health

Start at square one and branch out from there, square one is always the gut, it’s something we always put at the top of the list and work backward from there. Research is beginning to see that the acne-prone bacteria they believed to only reside in the sebaceous glands “Cutibacterium acnes” may actually originate in the gut in an ever-exciting Endeavor to link the gut -brain-skin axis. {1}
Reviewal of the hypothesis that it was a skin condition rather than a gut condition came after testing was conducted on acne dominant individuals and individuals without acne having an almost identical composition of C. Acnes present in the same areas as one another, leading to the question, what signifies the difference between the composition of acne in some and none in others if the resident levels of this bacteria are basically the same in both.

Diet and Intolerance

Foods and other factors can contribute to both a dysbiosis environment of the flora as well as an inflammatory response from foods that may signal this. For a long time carbohydrates were to blame initially based on blood sugar being linked to acne although blood sugars in those with clear skin and those with acne were almost identical, it was later found however that a low carbohydrate diet did improve secondary invasion with due respect it coming from Staphylococcus and controlling that population this way.

Acne and Dairy

Here is where the incrimination weighs in with dairy, this stems from the insulin signaling that can come from dairy; acne belongs to a family of mTORC1 diseases and to simplify this; it is a branch off from ‘mTOR’ which is a growth signaling process that cascades after insulin-like growth factor-1 elevate from stimulation and milk contributes to both of these pathways when ingested. Casual consumption, even just 1 glass of milk per day appears to increase the likelihood of acne production.

Observation of hunter-gatherer tribes who live under strict paleolithic conditions with no intake of milk/dairy products and higher glycemic food influence showed no prevalence of acne in their subject group studied [3,4].

In Conclusion on Diet

Review of the western/diet higher in hyperglycaemic inducing foods and drink appears to have a direct correlation with an increase in IGF1 and mTOR1c in the development of Acne Vulgaris. The increase is seen from these factors and their activation of SREBP, which is the master transcription factor of what is known as lipogenesis (formation of fat). Leucine, found in dairy-based proteins stimulates mTORc1-SREBP and then this is converted by our sebocytes into fatty acids and sterols for sebaceous lipid synthesis; interestingly, higher mTORc1 increases our androgen hormones.

From here we have a perfect recipe for signaling to sebaceous follicles in the dermis and as a result… acne [5]. If you were on the edge of ditching dairy… just saying.

Acne and our Environment

In recent years there is some research emerging regarding environmental pollutants and its exacerbation effects on skin concerns and in particular acne. There have been some established links between airborne pollutants and skin complaints such as:

- Particulate Matter.
- Volatile Organic Matter.
- Ozone/O3.
- Nitrogen Dioxide /NO2.
- Sulfur Dioxide/SO2.

Recently, for example, NO2 has been found to cause pigment spotting formation on the cheeks of both Asian and Caucasian women [6,7].

While the exact mechanism and direct links are yet to be confirmed, a very strong hypothesis from dermatologists and scientists is that there is a cascading pattern at play here. Squalene which is produced by the sebaceous glands in the torso and face of humans is prone to oxidation from ozone exposure, long exposure to ultraviolet rays, and tobacco smoke. This leads to the squalene by-product of squalene peroxide.

When pores are clogged with too much sebum or blocked with foreign particles it reduces the oxygen available to the pore and the P. Acnes thrives in an anaerobic environment, so they prosper when oxygen is deprived. From here keratinocytes go into overdrive, their job is preserving and protect against microbial, viral, fungal, and parasitic invasion – they signal an inflammatory mediating response to contain and handle the invasion initiating a pro-inflammatory response and purge or pustule.

The Body's Barrier

The body’s natural barrier response to this where possible is to mediate the oxidative issue to implement anti-oxidant to offset it with Vitamin E. This is often seen where many recommend vitamin E oil to the skin in an attempt to offer some relief to our health squalene and as a barrier between us and the outside world.

Genetics

Is it possible to be genetically predisposed to acne? There have been several studies done on twins, some up to 400 sets of twins, where both had acne to see if they could trace back any relevance to a genetic expression that may have been passed on hereditarily… unfortunately, the studies are not in-depth enough at this stage to pinpoint exactly where the ‘acne’ dominant genes lie in our bloodlines, however, some have been narrowed down for further investigation as links.

Polymorphisms of innate immunity-related genes – there is a heavy weighing look on pathogen recognition receptors and among them specifically, Toll-Like Receptors. During puberty, as sebum in the facial area is increased, pathogen recognition receptors play an important role in keratinocytes and initiating gene expression changes to regulate immune events. There is a polymorphism called Arg753Gln they have singled out in a central-eastern European study population, however continuous studies conducted on this led to different conclusions so doesn’t hold the highest credibility [8].

Could it be Aminos?

There are some studies done also on the glycine and arginine ratios possibly effecting inflammatory status as a cascade effect, androgen polymorphisms – however, in the past when we have talked often about genetics, though you may carry these genes and subsequent polymorphisms, it does not always mean they are expressed. There are ways, and in particular, this study revealed that even after the multifaceted look on genetics and genetic expression; it was broken down into environmental determinants. Linking it to a homeostasis imbalance subjected by our modern lifestyles. These environmental effects can lead to enhanced sensitivity to external stimuli and as such increase the likelihood of developing the chronic inflammatory disease and this can affect the expression and function of key genes [9].

Hormones

Finishing on the big question… is it my hormones? Yes, but not always in the way you think.

Let’s have a look at one of the biggest perpetrators, PCOS. Poly Cystic Ovarian Syndrome, presenting with symptoms such as:
- Hirsutism.
- Acne.
- Alopecia.
- Insulin resistance.
- Anovulation.
- Dyslipidaemia.
- Hyperandrogenism.

A hormonal profile like that matching PCOS is a recipe for Acne as both androgens are high and insulin resistance is occurring. High levels of insulin in the bloodstream decrease sex hormone-binding globulin and as a result allow higher instances of free androgens to be present – high androgens allow for the production of more sebum, this creates a profile of blocked pores and anaerobic environment where P.Acnes can thrive, create the signaling like we mentioned, instilling an inflammatory storm and purge AKA. Acne. [10]

Higher Androgens works in the same regard in both males and females. It’s the presence of a PCOS Profile in women that tends to increase this form of acne well into adult years.
Working to correct insulin sensitivity is a great start for women with PCOS aiming to balance their aggravated skin.

Where do you start if there are so many variables?

If ever there is a place to start on your health journey – start with the gut, what is your diet like, is it one of an inflammatory nature? One higher in quick insulin spiking foods, are you covering your micronutrients and macronutrients.
Then, look at your hormones – having your blood androgen profiles done is a great place to start or opting for a full organic acid test/dutch test to see where the triggers may be lying here.

The other place to look at is the environment and stress! Stress drives up cortisol, cortisol’s response is to keep glucose in the blood for prioritizing quick movements and as such will make cells less sensitive to insulin and storage of energy as it needs it now. Reducing stress so you are not in a chronic state of high cortisol, will help your body balance your insulin, the cascading effects that insulin resistance can have and be a crucial element to putting you on the right track of happier, healthier skin as well as a happier and healthier you.

Acne is not a skin-deep issue like it was once believed to be.

References:
1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6678709/
2. https://www.jacionline.org/article/S0021-8707(40)90389-6/pdf
3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6115795/
4. Acne Vulgaris: A Disease of Western Civilization Loren Cordain 1, Staffan Lindeberg, Magdalena Hurtado, Kim Hill, S Boyd Eaton, Jennie Brand-Miller
5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3408989/
6. Airborne particle exposure and extrinsic skin aging.Vierkötter A, Schikowski T, Ranft U, Sugiri D, Matsui M, Krämer U, Krutmann JJ Invest Dermatol. 2010 Dec; 130(12):2719-26.
7. Traffic-Related Air Pollution Contributes to Development of Facial Lentigines: Further Epidemiological Evidence from Caucasians and Asians. Hüls A, Vierkötter A, Gao W, Krämer U, Yang Y, Ding A, Stolz S, Matsui M, Kan H, Wang S, Jin L, Krutmann J, Schikowski TJ Invest Dermatol. 2016 May; 136(5):1053-1056.
8. Koreck A, Kis K, Szegedi K, Paunescu V, Cioaca R, Olariu R, et al. TLR2 and TLR4 polymorphisms are not associated with acne vulgaris. Dermatology (Basel) 2006;213:267–9.
9. Melnik B. Milk consumption: aggravating factor of acne and promoter of chronic diseases of Western societies. J Dtsch Dermatol Ges 2009;7:364 –70.
10. Hormonal Treatment of Acne in Women Tobechi L. Ebede, MD,a Emily L. Arch, MD,b and Diane Berson MD. J Clin Aesthet Dermatol. 2009 Dec; 2(12): 16–22.