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ACNE
BACKGROUND
Acne affects between 50-80% of teenagers and young adults. It is a disorder of the
pilosebaceous unit (hair follicle and associated oil gland). Factors that contribute to acne
formation include increased sebum (a substance made up of oil and wax that functions to
protect the skin), increased build-up of material in the hair follicle, increased levels of
Cutibacterium acnes (a bacteria that is commonly present on the skin in low numbers), and
inflammation. Clinically, there are three categories of acne including comedonal
(whiteheads and blackheads), inflammatory (red bumps), and nodular (large, painful
cysts).
Hormones signal oil glands in the skin to increase their production of sebum. A plug of
sebum and keratin (a protein that helps maintain the structure of the skin, hair, and nails)
forms and blocks the opening of the hair follicle creating whiteheads and blackheads. The
increased sebum supports increased concentrations of P. acnes. This leads to further
blockage of the hair follicle opening and to increased inflammation. Ultimately the hair
follicle can rupture, resulting in large, painful nodules. Insulin also contributes to the
formation of acne. Insulin and insulin-like growth factor act by directly increasing the
activity of the oil gland, as well as by indirectly increasing the levels of other hormones that
stimulate the oil gland including insulin-like growth factor and androgens.
Figure 1. Pathophysiology of Acne
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There are many factors to take into account when deciding on a treatment plan: the type of
acne, the severity of acne, whether there is scarring, what has been tried in the past, and
the psychological impact should all be assessed. In girls and women, information about
menstrual history (specifically regularity, duration, and quantity of bleeding) and signs of
hormonal abnormalities (excessive facial hair, insulin resistance) can also be helpful.
TREATMENT
SKIN CARE
The first step to managing acne is to adhere to gentle skin care practices. The skin should
be rinsed gently with warm water once or twice a day. Washcloths or other abrasive
materials should be avoided, and only gentle, nonsoap-based cleansers should be used.
Detergent-based soaps, toners, and astringents further dry and irritate the skin. While they
do remove oil and sebum from the surface of the skin, they do not alter sebum production
within the oil gland. Ultimately, overly dry skin signals the pilosebaceous units to make
more oil in order to adequately protect the skin. Moisturizers can help acne, but it is
important to make sure any moisturizers or cosmetics are not oil based and are labeled
noncomedogenic.
The impulse to pick and squeeze acne lesions is common and can be difficult to overcome.
These practices can lead to immediate gratification, but ultimately slow down the
disappearance of specific acne lesions. These practices also result in tissue injury, which
creates more inflammation and potential scarring that is very difficult, if not impossible, to
reverse.
FOOD & DRINK
Healthy dietary choices are important for overall health. Anti-inflammatory or
Mediterranean-style dietary approaches have been found to enhance many aspects of
health—especially in the setting of inflammatory diseases. Acne is an inflammatory
condition and will likely improve when dietary choices better align with foods that inhibit
rather than promote inflammation.[1] In particular, low glycemic index/low glycemic load
diets have been shown to improve acne in clinical trials.[2] More information about these
dietary approaches can be found in the “Food and Drink,” Whole Health overview.
Avoiding or limiting all forms of dairy may be beneficial. Dairy intake has been linked to
increased risk and severity of acne. This is likely in part due to stimulating increased levels
of insulin-like growth factor.[3] Limiting the intake of foods high in added hormones (such
as meat and dairy) may also be helpful since these foods may alter hormonal balances and
may lead to overstimulation of the oil gland.
There is also evidence that increasing plants in the diet can help treat acne. We know that
plants are full of prebiotics—compounds that are either indigestible or partially digestible
by humans, which can be metabolized by the microbiome in our guts. Basically, plants help
feed the gut microbiome and help keep it healthy. Maintaining a healthy balance of
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microbes in the gut is important for many areas of health including acne. Other mechanism
that have been proposed for benefits of diets rich in plants for patients with acne include
modulation of hormones, normalization of blood sugar and insulin sensitivity and anti-
inflammatory benefits.[4]
SUPPLEMENTS
Note: Please refer to the Passport to Whole Health, Chapter 15 on Dietary Supplements
for more information about how to determine whether or not a specific supplement is
appropriate for a given individual. Supplements are not regulated with the same
degree of oversight as medications, and it is important that clinicians keep this in mind.
Products vary greatly in terms of accuracy of labeling, presence of adulterants, and the
legitimacy of claims made by the manufacturer.
OMEGA-3 FATTY ACIDS
Omega-3 fatty acids have been shown to decrease the production of inflammatory
compounds and of the hormones important in acne formation.[5] Additionally, groups of
people who consume high amounts of omega-3 fatty acids have less acne than groups of
people who have lower levels of this nutrient. Ideally, omega-3 fatty acids should come
from foods such as fatty fish (salmon, mackerel, and sardines), flaxseeds, and walnuts.
When that is not possible, supplements can be helpful. The omega-3s in flax are not as
potent as those from fish oil; refer to the Whole Health overview “Food and Drink” for
details.
Dose:[6]
• 1tbsp of flax oil for every 100 lb daily
• 1-2 tbsp of ground flaxseeds daily
• 1-2 gm of fish oil capsules twice daily
BREWER’S YEAST
Brewer’s yeast (Saccharomyces cerevisiae) is commonly used to treat acne in Eastern
Europe. It has a high concentration of chromium picolinate, which has been shown to
improve glucose tolerance and insulin sensitivity (thereby reducing insulin and insulin-like
proteins in the blood stream). One study looked at brewer’s yeast supplementation in
people with acne and found significant improvement in 80% of those taking the
supplement.[7] It is generally quite safe, but due to high levels of tyramine, it can cause
headaches in people sensitive to this compound and can cause higher blood pressures in
people who are also taking monoamine oxidase inhibitors. Brewer’s yeast may also worsen
Crohn’s disease.[8] Oral antifungal medications may decrease the effectiveness of the
yeast.
• Dose:[7] 2 gm of dried brewer’s yeast three times a day
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PROBIOTIC
Both Lactobacillus and Bifidobacterium are lactic acid producing bacteria found in high
numbers in the human gut. There have been a few small studies that have found probiotics
(particularly strains of Lactobacillus and Bifidobacterium) to be helpful in the treatment of
acne.[9-11]
• Dose: No clear dosing has been established for acne. Consider a product that
contains both Lactobacillus and Bifidobacterium strains and at least 10 billion
colony forming units (CFUs).
VITAMINS AND MINERALS
Studies have found that vitamin A, vitamin E, and/or zinc are decreased in patients with
acne.
Zinc. Zinc is a cofactor in many reactions important in maintaining skin health and immune
function. It has anti-inflammatory properties as well as inhibitory effects on C. acnes. Many
studies show that supplementation can improve acne. It is likely that the formulation of
zinc is important, and it appears that effervescent preparations of zinc, zinc picolonate, and
methionine-bound zinc are more bioactive than other formulations such as zinc gluconate.
• Dose:[12] 30 mg elemental zinc a day*
*At doses higher than 30 mg a day, zinc can induce a copper deficiency; 2 mg of copper
should be added for every additional 30 mg of elemental zinc.
Food sources: oysters, beef, poultry (dark meat), pork, beans, nuts
Vitamin A. Vitamin A modulates the immune system and decreases keratinization of the
hair follicle. However, studies looking at the effectiveness of preformed vitamin A
supplementation in acne have found that only very high doses effectively improve acne.
These doses were well above the upper limit of safety set by the Recommended Daily
Allowance (RDA), and most participants had significant side effects consistent with
hypervitaminosis A. Hypervitaminosis A is a set of symptoms caused by the intake of toxic
amounts of preformed vitamin A. Symptoms can include headaches, sore muscles, nausea,
dry skin and mucous membranes, fatigue, nausea, hair loss, liver damage, and severe
damage to a fetus when levels are high in pregnant women.
Because of the significant risks, it is reasonable to recommend conservative
supplementation to the levels set by the RDA, but higher doses should be avoided.
• Dose: RDA for women is 2,300 IU a day and for men is 3,000 IU a day
Food sources: liver, cod liver oil, fish oils, milk, eggs
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Vitamin E. This vitamin is a strong antioxidant. Although it has been found in lower
concentrations in patients with acne, the specific role vitamin E plays in the development of
acne is not clear. It is generally considered safe up to doses of 1,500 IU a day. At higher
doses, there is a risk of problems with blood clotting, which can lead to increased bleeding.
• Dose: RDA for people older than 14 years is 22.5 IU
Food sources: eggs, fortified cereals, fruit, leafy greens (spinach), meat, nuts and nut oils,
other oils, poultry, wheat germ, whole grains
NicAzel. NicAzel is a prescription dietary supplement that contains zinc and copper along
with some B vitamins and azelaic acid (a compound found in grains that is used topically as
a prescription formulation to treat acne). It is fairly new but does offer an alternative to
prescription antibiotics for the treatment of acne.[13]
TOPICAL BOTANICALS
TEA TREE OIL
Tea tree oil is an essential oil extracted from the Australian tea tree (Melaleuca alternifolia).
It has been shown to have antimicrobial effects against C. acnes and does appear effective
for mild to moderate acne. It can produce contact dermatitis in some people.
• Dose:[14] 5%-15% solution or gel applied once daily as spot or area treatment
GREEN TEA
Some of the compounds in green tea have antimicrobial and anti-inflammatory properties.
Additionally, it appears to decrease sebum production. Studies looking at its use in mild to
moderate acne are promising.
• Dose:[15] 2%-3% cream, lotion, or gel applied twice a day
TOPICAL OVER-THE-COUNTER MEDICATIONS
SULFUR
Sulfur helps by unclogging blocked pores (comedones) and blocking the growth of C. acnes.
It can cause irritation, and many formulations have an unpleasant odor.
• Dose:[16] 1%-10% available as a bar soap, liquid wash, cream, or ointment
BENZOYL PEROXIDE
Benzoyl peroxide has antibacterial properties against C. acnes and is useful in treating acne.
It can cause irritation—especially at higher concentrations—and will bleach fabric.
• Dose:[16] 2.5%-10% (cream, lotion, gel, or wash) applied once or twice a day
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SALICYLIC ACID
Salicylic acid can be useful in treating acne by unclogging blocked pores (comedones). It
can cause irritation.
• Dose:[16] Creams, lotions, and washes in concentrations up to 2%. Higher
concentrations are available in prescription formulations or as chemical peels.
MIND-BODY
Acne is a condition that can carry a significant emotional and social burden. Many people
with acne have associated lower self-esteem, depression, and anxiety. Additionally, stress
can exacerbate flares. Mind-body approaches such as biofeedback, clinical hypnosis,
Guided Imagery, mindful awareness, and cognitive behavioral therapy can help minimize
depression and anxiety, and boost self-esteem.[17] Finally, picking at acne lesions can lead
to permanent scarring, and this behavior can be addressed through mind-body approaches
as well.
ACUPUNCTURE
There have been a few studies looking at acupuncture for treating acne. A review and
meta-analysis found that while the results have not been overwhelmingly positive, it does
appear that acupuncture may be as effective as pharmacological treatment for acne
vulgaris. While evidence does not support using acupuncture widely in acne patients, it
may be a good option for some patients who do not tolerate or respond to more traditional
approaches.[18]
PHARMACOLOGIC APPROACHES
There are many topical and oral medications that can be used successfully to treat acne.
This document is intended to focus on other therapeutic options within the realm of
integrative approaches to this common skin condition.
PREVENTION
• Take gentle care of your skin.
• Eat a plant-rich, low glycemic index/low glycemic load diet that contains foods rich
in omega-3 fatty acids (salmon, nuts, flax).
• Consider taking a probiotic that contains at least 10 billion CFU and is composed of a
mix of Lactobacilli and Bifidobacterium species.
• Avoid dairy and meat from animals treated with exogenous hormones.
• Consider taking an omega-3 supplement.
• Consider taking a good-quality multivitamin that contains appropriate doses of zinc,
vitamin A, and vitamin E.
• Learn about different approaches to stress management.
• Avoid picking or squeezing acne lesions.
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RESOURCE LINKS
• Food and Drink: https://www.va.gov/WHOLEHEALTHLIBRARY/self-care/food-
and-drink.asp
• Passport to Whole Health:
https://www.va.gov/WHOLEHEALTHLIBRARY/docs/Passport_to_WholeHealth_FY
2020_508.pdf
AUTHOR(S)
“Acne” was written by Apple Bodemer, MD (2014, updated 2020).
This Whole Health tool was made possible through a collaborative effort between the
University of Wisconsin Integrative Health Program, VA Office of Patient Centered Care and
Cultural Transformation, and Pacific Institute for Research and Evaluation.
REFERENCES
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improves symptoms in acne vulgaris patients: a randomized controlled trial. Am J
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2 Ismail NH, Manaf ZA, Azizan NZ. High glycemic load diet, milk and ice cream
consumption are related to acne vulgaris in Malaysian young adults: a case control
study. BMC Dermatol. 2012;12:13.
3 Melnik BC, Schmitz G. Role of insulin, insulin-like growth factor-1, hyperglycaemic
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6 Integrative Medicine. 2nd ed. Philadelphia, PA: Elsevier Saunders; 2007.
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12 Dreno B, Amblard P, Agache P, Sirot S, Litoux P. Low doses of zinc gluconate for
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