Acne Vulgaris is the most common dermatologic condition in the United States, affecting more than 17 million people of all ages. 80-90% of adolescents have had acne.7 Teenage acne often begins around the ages of 10 to 13, when teenagers are going through puberty. Some teenage girls get acne at a younger age than boys, but boys often have much more severe acne than girls 2 Teenagers often get blackheads, whiteheads, and inflammatory lesions, often centered around the T-zone (forehead, nose, and chin). However, acne can also affect anywhere on the face and trunk in teens.
Some people, especially women, have adult-onset acne that begins in her 20s and 30s. According to Dubrow and Adderly, more than 50% of adults over the age of 25 experience acne breakouts (2003, p. 23). Often there are less blackheads and whiteheads than teenage acne and there may be mild breakouts of inflammatory lesions on the lower cheek, chin, and around the mouth. For adult onset acne in women, the acne often occurs two to seven days before the woman’s menstrual cycle, when estrogen levels fall and progesterone levels rise and produce excess sebum.2
Acne often occurs in the first trimester of pregnancy, when estrogen and progesterone levels are rising; it often clears up in the second and third trimester. After the birth however, acne can return due to hormonal changes. It is also a symptom in some endocrine disorders, such as polycystic ovary syndrome.
Since acne affects people from all socio-economic levels, there is not a huge health disparity in the incidence of acne. However, there is a health disparity over the treatment of acne. While many acne medications such as benzoyl peroxide and salicylic acid are available over-the-counter, medications for chronic acne such as Retin-A and Isotretinoin are only available with a prescription. Even in Canada, where there is universal health care, Haider, Mamdani, Shaw, Alter, and Shear found that those people who have a lower socioeconomic status were less likely to visit a dermatologist for a consultation, even with a referral from their general practitioner (2006, p. 331).
Many researchers have concluded that acne is due mainly to genetic predisposition and hormonal influences. The role of diet and acne is currently being debated. Some researchers think that genetic factors do not explain the whole situation and there is an environmental influence on gene expression.
Adult onset acne in women is not well understood. Although most women do not have elevated androgens, they seem to have an increased response to androgens. Estrogen is often used to treat acne because it has the opposite effect than androgens (estrogenic effect). Adult-onset acne may also be related to the consumption of hormones and drugs in foods and medications. 2
Katsambas and Dessinioti noted that “…the prevalence of acne is lower in rural, non-industrialized societies than in modern Western population… it has been suggested that the absence of acne reported in non-Westernized societies is attributable to local diets, which have a lower glycemic index than a Western diet” (2008, p. 91). They speculate that adolescents are “hyperinsulinemic” due to a high-glycemic diet. Another consideration is that many non-Western societies do not consume milk, and milk has been associated with acne due to the hormones in it (Ibid.). In a meta-analysis conducted by Spencer, Ferdowsian, and Barnard, a high-glycemic diet and dairy consumption are associated with increased acne. They concluded, “population-based studies have suggested that, as diets Westernize, acne prevalence increases” (2009, p. 344). Observational reports noted that residents in Kenya, Zambia, and the Bantu in South Africa have far less acne than the descendants from these countries that currently live in the United States or United Kingdom (Davidovici & Wolf, 2010, p. 13). Another report observed that only 2.7% of the 9,955 schoolchildren in rural Brazil had acne (Ibid.).
Stress is another factor with acne. The more stress a person has, the more cortisol the person produces, and the “fight or flight” response is initiated. According to Perricone, elevated cortisol levels bring about a rise in blood sugar, which causes a cellular inflammatory response (2003, p. 31). Stress can also increase androgen production (Logan and Treloar, 2007, p. 149). A specific neuropeptide, which is a chemical released by nerve endings on the skin, called Substance P is implicated in making sebaceous glands more active. When someone is stressed, Substance P is released from the skin nerves and causes an inflammatory response with the production of cytokines, which can promote free-radical production and ensuing oxidative stress (Perricone, 2003, p. 31-3, Logan and Treloar, 2007, p. 151).
Some doctors think that acne is a systemic inflammatory disorder. Perricone noted, "scientists have been puzzled for years because there are so many factors that influence the onset and course of acne, they know hormonal effects are important; that bacteria play a role. Genetics and other precipitating agents contribute to acne. Now they mystery is solved because whether it is endocrine, psychological, excess oil in the skin, the final common pathway of initiation and progression is inflammation (2003, p. 34)."
From a Functional Medicine perspective, acne is caused by:
Digestive, absorptive, and microbiological imbalances. The high-glycemic Western diet and milk consumption has been associated with acne as discussed above.
Detoxification and biotransformational imbalances. One concept in natural medicine is that skin imbalances are due to non-optimal detoxification. According to Yarnell and Abascal, “…if the liver and its detoxification and excretory functions are not functioning optimally, the body will attempt to compensate by eliminating toxic compounds through other routes in the body, including the skin” (2006, p. 303). Pitchford also noted “even though the vitality of the skin is related to the lungs, eruptions surface because of faulty blood cleansing by the kidneys and liver. These two organs purify the blood, and when they are overburdened toxins in the blood are excreted through the skin” (2002, p. 441).
Hormonal and neurotransmitter imbalances. Androgens have certainly been implicated in the production of acne. And the fluctuations of estrogen and progesterone often are implicated in adult women getting acne before their period.
- Dubrow, T.J., & Adderly, B.D. (2003). The Acne Cure: The Revolutionary Nonprescription Treatment Plan that Cures Even the Most Severe Acne and Shows Dramatic Results in as Little as 24 Hours. USA: Rodale.
- Goodheart, H.P. (2006). Acne for Dummies. Indianapolis: Wiley Publishing.
- Haider, A., Mamdani, M., Shaw, J.C., Alter, D.A., & Shear, N.H. (2006). Socioeconomic status influences care of patients with acne in Ontario, Canada. Journal of the American Academy of Dermatology, 54(2):331-5.
- Katsambas, A., & Dessinioti, C. (2008). New and emerging treatments in dermatology: acne. Dermatologic Therapy, 21, 86-95.
- Logan, A.C., & Treloar, V. (2007). The Clear Skin Diet. Nashville: Cumberland House Publishing.
- Perricone, N. (2003). The Acne Prescription. New York: HarperCollins.
- Pitchford, P. (2002). Healing with Whole Foods. Berkeley: North Atlantic Books.
- Spencer, E.H., Ferdowsian, H.R., & Barnard, N.D. (2009). Diet and acne: a review of the evidence. International journal of dermatology, 48(4), 339-47.