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Acne is one of the most common disorders in the western world where it is estimated to affect 50-95% of teenagers. Acne is typically thought of as a disease of adolescence, but it can persist into later life, especially in women, causing significant mental health issues (R, R1, R2).

This article takes an in-depth look at the science surrounding acne, as well as the steps you can take to get rid of it.

Why Does Acne Form?

Increased Oil Production

Increased levels of oil (sebum) production leads to blocked pores. This increase in sebum can be caused by a range of mechanisms, such as increased testosterone production, increased CRH, increased IGF-1, and lack of Vitamin-D (R, R1).

Overgrowth of Bad Bacteria

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Blocked pores provide a perfect oxygen-free, fat-rich environment for P. acnes, the main acne-causing bacteria, to live (R).

Certain P. acnes bacteria might contain natural defense mechanisms that enable them to recognize attackers and destroy them before they infect the bacterial cell (R).

P. acnes might act like a biofilm within the hair follicle, thereby decreasing the efficacy of antimicrobial treatments (R).

Inflammation

It is not the blocked pore that causes the red, angry looking zit. This is caused by the body’s inflammatory response to the bacterial infection, which involves CD4+ lymphocytes, macrophages and a variety of pro-inflammatory cytokines (R).

Increased Skin Cells

Skin cells mature as they move from deep within the skin to the skin’s surface. This process is called keratinization.

People with acne have abnormal keratinization that can cause a build up of old cells which become black heads and white heads (R).

Who is at Risk for Acne?

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Genetics

A family history of acne dramatically increases the risk of having acne (R, R1).

There is a range of genes that have been attributed to acne, including SNPs in IL-1α, TNF-α, and CYP1A1 (R).

Twin studies have shown that genetic factors can play an important role for severe acne scarring (R).

Demographics

Acne is less common in rural areas (R).

An increase in some sex hormones, particularly testosterone, during puberty and pregnancy can increase oil production and cause acne (R).

Acne happens earlier in girls but is more common in mid-teen boys (R).

Black children have more blackheads/whiteheads than white children, most likely due to earlier onset of puberty (R).

Tropical acne can occur when visiting an unfamiliar, hot, humid climate (R).

Lifestyle

Severe acne gets worse with smoking (R, R1).

High stress lifestyles cause acne (R).

An unhealthy lifestyles (lack of exercise, circadian dysruption, etc..) can cause insulin resistance.  Insulin resistance and high DHEA levels (in PCOS) can cause acne (R, R1).

Diet

It has been noted that many non-westernized populations do not suffer from acne. This has led to the suggestion that acne is caused by the high glycemic diets of westerners’:

high insulin levels -> increased testosterone -> high IGF-1 -> altered retinoid signaling (R).

Dairy products, particularly milk, can worsen acne (R).

Other

Smothering the skin with greasy skin products, clothing or excess sweat may worsen existing acne (R).

Use of anabolic steroids can cause severe acne (R).

Conventional Treatments to Acne

Conventional acne treatments typically take four to eight weeks before results are seen, and usually involve reducing oil production, speeding up skin cell turnover, fighting bacterial infection or a combination of all three.

Benzoyl Peroxide (BP)

BP is an over-the-counter topical cream applied over the entire affected area.

BP works by reducing the growth of P. acnes bacteria, but does not carry the risk of antibiotic resistance (R).

BP used alone has been shown to be as effective as oral antibiotics.

BP is as effective as topical antibiotics (R).

BP exerts more anti-inflammatory effects than topical retinoids (discussed below) (R, R1).

2.5-5% BP is just as effective, but less irritating, than higher concentrations (R).

The efficacy of BP might be enhanced when combined with retinoids or antibiotics, but by so little that the extra effort and cost is probably not worth it (R, R1, R2, R3).

BP can often cause irritation, drying, and occasionally allergic reactions. These issues are usually temporary and BP has been shown to be relatively safe (R).

An extra safe way of using BP is short contact therapy which uses a foam wash that is only applied to the skin for five minutes (R).

Topical Retinoids

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Usually applied daily, these creams help expel blackheads and whiteheads and have anti-inflammatory effects (by decreasing cytokines and nitric oxide) (R).

Retinoid therapy is much more effective (more significant and faster improvements) when combined with topical antibiotics or benzoyl peroxide (R, R1, R2).

A large analysis of multiple acne studies found that adapalene 0.1% gel, a type of retinoid, is just as effective and less irritating than the common retinoid, tretinoin 0.025% gel (sold as Retin-A) (R).

Topical retinoids are a lot safer than oral isotretinoin discussed below, but I still consider them dangerous – especially seeing as women are told to take a contraceptive if using retinoids as to avoid birth defects.

Topical Antibiotics

One study found that the most effective topical antimicrobial treatment was a topical combination of benzoyl peroxide (5%) and Erythromycin (3%) (R).

Combining topical antibiotics with benzoyl peroxide helps prevent antibiotic resistance caused by topical antibiotic alone (RR1, R2, R3).

Clindamycin is widely prescribed as a topical antibiotic, typically at doeses of 75-150mg twice a day.

Topical antibiotics should not be used in combination with oral antibiotics as this increases the risk of developing antibiotic resistant bacteria (R).

Topical benzoyl peroxide and benzoyl peroxide/erythromycin combinations are just as effective as oral antibiotics, like tetracycline and minocycline, and less irritating than benzoyl peroxide alone (R).

Oral Antibiotics

While many doctors don’t follow this rule, oral antibiotics are meant to be a treatment for severe acne that has been unresponsive to topical treatments (R).

Antibiotics help reduce the inflammation of the lesions but do not clear acne completely (R).

There is no evidence that oral antibiotics are more effective than topical antibiotics (but topical won’t destroy your gut bacteria) (R).

Common antibiotics prescribed for acne include: tetracycline, doxycycline, minocycline & limecycline. There is no evidence that any particular antibiotic is most effective (R).

Tetracycline is the most commonly prescribed antibiotic for acne. The typical dose is 500mg twice a day continued until a significant decrease in acne lesions is seen (R).

It is conventionally recommended that courses of oral antibiotics do not exceed 6-8 weeks to prevent antibiotic resistance (R).

Higher doses of oral antibiotics do not appear to be any more effective than lower doses (R, R).

Tetracycline should not be given to pregnant women or children under 9 years of age as tooth discoloration in children is common.

The biggest danger of oral antibiotic use is damaged gut flora. A 2013 study found that during and after an antibiotic treatment the gut biome has a lower capacity to produce proteins, less ability to absorb iron or digest certain foods (R).

The study also demonstrated that bacteria that were in limited numbers at the start of the study grew to very large populations at the end of the study, signifying an overgrowth of opportunistic (likely bad) bacteria (R).

Oral Clindamycin therapy can cause a serious intestinal infection called pseudomembranous colitis caused by the bacteria, Clostridium difficile (R).

Antibiotics might damage mitochondria by increasing toxic reactive oxygen species and promoting protein imbalances. This might explain why people report feeling sluggish and rundown after a course of antibiotics (R, R1).

The health of your gut is very important. I think antibiotics should be reserved for emergencies or if all else fails and, definitely, should not be taken long term. If you have to take them, make sure you take a powerful probiotic along side them.

Oral Contraceptives (Women)

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COCs (combination oral contraceptives) that contain estrogen and a progestogen (synthetic progesterone) are given as an acne treatment because estrogen suppresses your oil glands and lowers androgens like DHEA which can cause acne (R).

Progestogen-only contraceptives can actually make acne worse (R).

Oral Isotretinoin (Accutane)

Since oral isotretinoin was first approved for acne use in 1982, over 20 million people have used it.

Isotretinoin is probably the most effective acne treatment available with relapse rates after treatment much lower than other medications.

While isotretinoin was originally put forward as a treatment only for the most severe cases of cystic acne, a number of trials have shown that low-dose treatment can be effective for moderate acne (R, R1, R2, R3)

Isotretinoin is justified on the basis that it will work quickly, prevent scarring and lead to a rapid improvement in the patients life (R).

However, Isotretinoin is alarmingly toxic. So much so that pharmacists must provide a warning brochure from the FDA, called a Medguide, to all patients prescribed Accutane.

Personally, I would not advocate anyone take it regardless of how bad their acne is.  I have some clients whose issues started or worsened after Accutane.

Isotretinoin might cause:

  • serious birth defects. Women have to sign an agreement saying they will take contraceptives and not get pregnant while on the drug (R).
  • hair loss (R).
  • extremely dry skin and mucous membranes (R).
  • increased risk of developing staph infections (R).
  • slowed wound healing (R).
  • dangerously high cholesterol (R).
  • intense muscle pain – especially in the back (R).
  • IBS (R).
  • ulcerative colitis (R).
  • depression and suicidal behavior. Although a 2007 paper did not find any evidence to support this anecdotal claim, there are a number of mechanisms by which isotretinoin might cause these issues (R).
  • serious damage to parts of the brain related to learning and memory (R, R1).
  • cell death in your oil glands (R, R1).

Alternative and Natural treatments For Acne

1) Sun/Light Therapy

Blue light has been shown to inactivate P. acnes bacteria. Daily self treatment using a blue light treatment for mild-to-moderate inflammatory acne reduced the number of acne lesions significantly (R).

Red light is less effective at inactivating P. acnes than blue light but penetrates much deeper (R, R1).

The combination of blue and red light works far better than either used alone. Broad-spectrum continuous-wave visible light therapy is used to harness the power of both blue and red light (R, R1).

Topical aminolevulinic acid, methylaminolevulinic acid, or other photosensitizing agents, applied before the laser treatment, improve the outcome of the treatment by decreasing oil gland activity (R).

Infrared light at 1450nm wavelength successfully helps treat acne, possibly by heating the oil gland and reducing its production of oil (R).

Therefore, sun and an infrared sauna can help acne.

2) Fish Oil For Acne

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Preliminary studies indicate that fish oil supplementation may improve acne (R).

In fact, one study found that 10 weeks of supplementation with 2000mg of EPA & DHA caused a 42% reduction in acne lesions (R1).

If you don’t eat a lot of seafood you should take a high quality omega-3 supplement:

3) Probiotics For Acne

A large number of the treatments already mentioned attempt to treat acne by killing the bacterias that scientists have decided cause acne.

While temporarily effective, these treatments do not recognize that the bacteria on our skin are just like any other community in the world in a delicate balance. No species will overgrow if the rest of the community is in balance.

I think one of the best techniques to deal with “bad bacteria” is to ensure that the rest of the bacterial community is thriving. This should help prevent unwanted overgrowths. You can do this with probiotics.

Topical Probiotics

Probiotics produce antibacterial proteins and bacteriocins that have been shown to directly inhibit P. acnes (R, R1).

Application of probiotic skin cream (Streptococcus thermophiles) was shown to improve the barrier function and antimicrobial properties of the skin (R, R1).

Certain probiotic bacterial strains might control the inflammatory response. For example, application of S. salivarius has been shown to lower the production of pro-inflammatory cytokine, IL-8 (R).

A 2009 study found that topical application of a probiotic lotion (containing Enterococcus fecalis)  for 8 weeks resulted in a 50% reduction in acne lesions (R).

A second study found a reduction in acne count, size and irritation with the application of Lactobacillus plantarum 5% extract (R).

Oral Probiotics

Some research has indicated that people with acne are more likely to have constipation, indicating an altered microbiome (R, R1).

Oral probiotics can improve acne via a number of mechanisms, including reduction of systemic inflammation and increasing nutrient absorption (R).

Giving the oral probiotic L. reuteri to stressed animals decreases inflammation in hair follicles where acne arises (R).

High IGF-1 levels can increase the risk of acne. Oral probiotics may decrease levels of IGF-1 (R, R1, R2).

One study found that 80% of patients given a probiotic mixture of L. acidophilus and L. bulgaricus saw a clinical improvement in their acne.

An Italian study found that patients given 250 mg of freeze-dried L. acidophilus and Bifidobacterium bifidum in addition to their standard treatment, saw greater improvements in their acne than standard treatment alone.

A recent study found that a combination of oral antibiotics and probiotics might be more effective at treating acne than either alone, and pose less of the risks, such as candida overgrowth (R).

Here are some great oral probiotics:

4) Heal Your Damaged Gut

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Alterations in gut function can cause leaky gut and lead to chronic inflammation – a key process in formation of acne (RR).

By healing the gut lining you can stop leaky gut and decrease systemic inflammation.

For healing the gut, I recommend following a lectin avoidance diet.

5) Diet For Acne

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It was found that non-westernized populations, like Kitivans of Papua New Guinea and the Ache hunter gatherers of Paraguay, do not suffer from acne. This led to the suggestion that acne is caused by a western diet rich in high glycemic carbs (R, R1).

An initial study on this theory proved that low glycemic diets improve acne (R).

People with acne should focus on low glycemic foods, as found in ancestral diets, in order to keep their androgens and IGF-1 levels as low as possible. They should avoid dairy products for the same reason (R, R1).

6) Reduce Stress Levels

High stress lifestyles can make acne worse (R).

As already mentioned, altered gut bacteria can cause acne. Acne sufferers should try to limit all types of stresses –  e.g. confinement, crowding, academic examination – because they reduce levels of healthy gut bacteria (R).

See here are a comprehensive list of ways you can lower your stress response.

7) Rosmary Oil

In one study, rosemary essential oil showed antibacterial properties that significantly decreased the size and number of P. acnes bacteria (R).

8) Resveratrol

Topical resveratrol is an effective treatment for acne. It inhibits P. acnes bacteria (through phytoalexin exhibiting activity) and acts as a potent anti-inflammatory (R).

9) Honey For Acne

Honey is often used in the alternative health community as a natural face wash.

Honey is antibacterial – probably because its enzymes produce hydrogen peroxide which inhibits bacteria (R).

Manuka honey is especially effective against bacteria because of its high sugar content (dehydrates bacteria) and low ph (R).

Honey helps wounds heal faster and provide a protective barrier against further infection (R).

Medicinal grade honeys have been shown to be very effective against antibiotic resistant bacteria (R).

The antibacterial properties of honey can vary significantly, depending on where it was harvested (R).

10) Eucalyptus

A number of components isolated from the eucalyptus plant have inhibitory effects on microorganisms that cause acne (R).

You could try applying eucalyptus essential oil diluted in a carrier oil.

11) Tea Tree Oil

An Australian trial found that tea tree oil significantly reduced all forms of acne but was less effective than 5% benzoyl peroxide in reducing inflammation. Both treatments worked equally well for non-inflammatory acne (R).

Tea tree oil treatment caused fewer of the negative side-effects (like itchy, dry, burning, red skin) that were associated with benzoyl peroxide (R).

12) Ocimum Oil & Aloe Vera

A Nigerian study showed that ocimum gratissimum (aka clove basil or wild basil) oil caused a greater reduction in acne lesions than 10% benzoyl peroxide (R).

While not that effective on it’s own, aloe vera gel significantly enhances the efficacy of Ocimum oil lotion. This combination was shown to be more effective than topical antibiotics (1% clindamycin) (R).

13) Zinc

Patients with acne usually have low levels of zinc (R).

Zinc levels in a patient’s blood correlate with the severity of their acne (R).

0.6 grams of oral zinc per day was found to improve mild to moderate acne (R).

Plant-based diets generally don’t get enough zinc. I use ~20mg daily. This is a good source:

14) Gugulipid (Guggul)

Orally administered Gugulipid, an extract of the Indian medicinal plant Commiphora Mukul, is just as effective as the oral antibiotic, tetracycline (R).

Avoid if allergic to guggul -Signs of allergy to guggul may include itching and shortness of breath. Also avoid if you are pregnant or have a history of thyroid disorders, eating or bleeding disorders (R).

15) Green Tea

Green tea may have anti-acne effects, since it contains flavonoids, which seem to be antiseptic, as well as tannins, which have natural astringent and anti-inflammatory properties (R).

Application of a 2% green tea lotion for six weeks was found to be effective at treating mild to moderate acne (R).

I find that green tea cleansers work well.

16) Berberine

Berberine is a bitter substance that lowers oil production and has anti-inflammatory effects (R).

In lab studies, Berberine inhibited the growth of Staphylococcus coagulase, P. acne and Candida species, indicating that it might be a useful treatment for acne (R).

See here for full benefits of berberine and where to buy.

17) Gluconolactone

A study on 150 patients using a topical 14% gluconolactone solution showed a decrease in inflamed acne lesions. This result was comparable with 5% benzoyl peroxide, but with far fewer negative side effects (R).

18) Cannabis Seed Oil

Cannabis seed oil of Cannabis sativus is helpful for the treatment of acne. It relieves pain and itchiness while strengthening the skin’s barrier function and makes it more resistant to infections (R).

19) Onion extract

Onion extract contains allium cepa and allium sativum, both of which are promising for the treatment of bacterial and fungal-associated infections, including acne (R).

Fortunately, onion extracts can also help lessen the appearance of scars (R).

20) Echinacea

The extract of Echinacea kills P. acnes bacteria (R).

Echinacea normalizes high levels of pro-inflammatory cytokines, such as IL-6 and IL-8 (R).

21) Curcumin

One study found that curcumin might be an effective way to inhibit P. acnes bacteria on the skin (R).

The study recommends using lauric acid (found in coconut oil) as a carrier. You could try coconut oil and curcumin powder for face masks.

See here for full info on benefits of curcumin and which types to buy for internal use.

22) Peptides

A number of antimicrobial peptides, such as frog-skin peptides peptides, have been found to decrease the activity of P. acnes (R, R1).

23) Acupuncture

Just 12 acupuncture sessions can significantly improve inflammatory acne (R).

One study found that acupuncture was very effective at enhancing skin recovery and was better at reducing the pro-inflammatory cytokine, IL-6, than oral isotretinoin (accutane) (R).

24) Purified Bee Venom (PBV)

Topical treatments containing PBV reduced the severity of acne ((R)).

One study found that PBV treatment decreased skin level of ATP by 57.5%, indicating a drop in bacterial activity (R).

25) Glycolic Acid

Glycolic acid has been shown to inhibit the growth of, and helps kill, the P. acnes bacteria (R).

All subjects of an asian study reported improvements in their acne with the use of glycolic acid application (15% daily and 35-50% every 4 weeks) (R).

Different types of acne take different lengths of time to respond to glycolic acid. One study using 70% glycolic acid peels showed that blackheads and whiteheads improved rapidly, moderate inflammatory acne took six peels to improve, and deep cystic acne required ten sessions (R).

Acid peels have the advantage of reducing post acne scarring (R).

70% GA peel performed every two weeks is more effective for atrophic acne scarring than 15% GA cream used daily (R).

26) Salicylic Acid

Application of 2% salicylic acid lotion, two times per day, was significantly better than placebo in treating mild to moderate acne (R).

One study demonstrated that a salicylic acid cleanser was more effective than 10% benzoyl peroxide and did not cause an initial worsening of the condition (R).

Salicylic acid might enhance the effectiveness of other topical therapies, like benzoyl peroxide.

27) Lauric acid

Lauric acid (C12) is a medium chain triglyceride found in coconut oil. It has antibacterial effects against P. acnes and might be a useful treatment option for acne sufferers (R).

28) Linoleic acid

Linoleic acid gel was found  to reduce the size of lesions in patients with blackheads/whiteheads (R).

One study claimed that application of linoleic acid gel resulted in a 75% reduction in inflammatory acne lesions (R).

29) Azalaic Acid

Azalaic acid is antimicrobial and reduces pore blockages (R).

15-20% Azalaic acid is less effective than benzoyl peroxide at reducing non0inflammatory acne but similarly effective for inflammatory acne (R, R1).

Azalaic acid has a better tolerability and safety profiles than benzoyl peroxide or retinoids. (R, R1)

30) Saw Palmetto

Saw palmetto (Serenoa repens) may improve acne by balancing male hormones. Although, to date, there has been little scientific research for the use of saw palmetto for acne treatment or prevention, there is a long tradition for using it for such purposes

Saw palmetto is not recommended during pregnancy or breastfeeding unless otherwise advised by a doctor.

31) Boswellia

Boswellia is an anti-inflammatory herb that has traditionally been used in acne therapy.  

32) Nicotinamide

Studies have shown that 750mg of nicotinamide, a form of the vitamin niacin, when combined with zinc, copper and folic acid, is an effective treatment for acne (R).

33) Maintain Your Natural Skin Barrier

People with acne often think that their skin condition is the result of lack of cleaning or “dirty” skin. They over-wash their skin and apply irritating topicals like the ones discussed above. This can worsen the condition by altering the skin’s natural barrier function, creating more inflammation and encouraging the formation of resistant bacteria (R).

Drying out the skin might also encourage the body to produce more oil leading to increased lesions (R).

Gentle cleansing or no cleansing at all may actually be more beneficial than conventional treatments (R).

34) Get Regular Sunlight Exposure

In a recent study, it was shown that inflammatory biomarkers found in skin cells, which are often raised in the case of acne, are lowered by treatment with Vitamin D (R).

The best source of Vitamin D is via synthesis in the skin induced by sun exposure. I recommend at least an hour of full body sun exposure per day (R).

35) Vitamin A

One study found that Vitamin A was highly effective at treating acne in doses of 300,000 IU for women and 400,000 to 500,000 IU units for men. At this dosage, toxicity was minimal and limited to skin and mucous membranes (R).  I wouldn’t recommend taking vitamin A at this dosage.

36) Sweat Regularly

When we sweat our skin produces a natural antibiotic called dermcidin, which can destroy tuberculosis germs and other dangerous bugs – possibly those involved in the formation of acne (R).

FDA Compliance

The information on this website has not been evaluated by the Food & Drug Administration or any other medical body. We do not aim to diagnose, treat, cure or prevent any illness or disease. Information is shared for educational purposes only. You must consult your doctor before acting on any content on this website, especially if you are pregnant, nursing, taking medication, or have a medical condition.

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2 COMMENTS

  • Serena

    Great Article as usual! Just a number of observations the causes of acne in women can be perplexing! However, after many years of being a cystic acne sufferer and despite improvements in lifestyle, nutrition and sleep, my acne only became worse! With the contraceptive pill it disappeared but a number of other negative reactions occurred including lethargy and depression. After a lot of research and trial and error, I went on to DIM (Estroblock) formulation and TestoQuench from Dr Joseph Collins and my cystic acne has disappeared. It may be worth your while looking into the fantastic work of Dr Joseph Collins and Dr Nick Delgados on the issues of hormonal imbalances. Please feel free to inbox me on [email protected] and I can send you the research into- I would also be very interested in learning from you and would be keen if I can pay for private training from you! Please let me know if that is a possibility and at what cost you might charge a 2 hour session of training- Very excited to discover your amazing website and work! Hopefully look forward to hearing from you!

    1. Joseph M. Cohen
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