Acne and Your Microbiome - Naturopathic Perspectives

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Acne vulgaris is one of the most common, chronic skin conditions. Up to 80–90% of the population will experience some degree of acne.^[1] For a relatively benign condition, it can have a very serious impact on an individual’s mental health. Higher rates of anxiety and depression are seen in those with acne, regardless of its severity.^[2] Even once acne lesions have cleared, scarring and pigmentation changes that may remain can have a longlasting impact on one’s self-esteem and psychological wellbeing. For these reasons alone, finding effective solutions for acne is vital.

It has also long been suggested that digestive health may play a role in the development of acne.^[2] Decades ago, studies began looking into how the microbiome may be involved, and we are now uncovering more. With a better understanding of this connection, comes the hope for more effective treatments.

Understanding What Causes Acne

Acne lesions arise in the “pilosebaceous units” of our skin, which are hair follicles with an adjoining sebaceous gland. Sebaceous glands produce sebum, an oil, to help protect the skin. Pilosebaceous units are found most densely on our faces, chests, and upper backs, which is why these are the most common locations for acne to arise.^[3] The process which lead “pimples” to form starts with increased growth, known as hyperplasia, of the sebaceous glands in these hair follicles. This means an increase in oil production, which can trap dirt and other particles in the follicle as well as allow certain bacteria to flourish; this will then trigger our immune system. Activated immune cells will create inflammation to clear the bacteria or particles that are trapped, which is what leads to the redness and pain associated with acne.^[3]

The growth of the sebaceous glands can be triggered by a variety of hormones. The following are a few of the most wellknown ones which can act on these glands, causing them to make more oil:

• Androgens, which are a group of sex hormones (including testosterone);
• Insulin and insulin-like growth factor (IGF-1), which are released with high blood sugar levels; and
• Corticotropin-releasing hormone (CRH), which is released by our brains under stress.

Another important factor to note is the hydration of your skin. When we are dehydrated or use harsh cleansers that strip away our skin’s natural oils, our sebaceous glands will subsequently increase their production of oil.^[4]

Conventional Treatments

Conventional treatments are helpful in many cases, and include things like oral and topical antibiotics, isoretinoin (the drug “Accutane”) and other retinoids, and other topical antimicrobials such as benzoyl peroxide.^[3] Antibiotics, considered a firstline treatment for a long time, are becoming less effective with the emergence of antibiotic-resistance. Oral antibiotics can also disrupt our normal gut microbiome, which we now understand to have some role in acne development.^[2] All these conventional options can come along with other side effects and potential long-term implications, and do not address all the causal factors at play.^[5] This is why they may not be enough to see completely resolution and aren’t acceptable to most as effective, long-term solutions.

The Role of Your Microbiome

Your microbiota is made up of trillions of bacteria, fungi, yeasts, and other microorganisms living upon our skin and throughout our digestive tract. Normally, we provide these microbes with a nourishing place to live, and they benefit us in return, producing nutrients and important compounds to keep our digestive tracts healthy, metabolize hormones, help digest food, and more.^[6] The right balance of bacteria on your skin is important to ensure that pathogenic (harmful) and acne-causing bacteria cannot overgrow. The acidity level of your skin is important for maintaining this healthy balance and can easily be altered by what we put on our skin.[6] The normal diversity and balance of our gut bacteria can be altered by things like antibiotics, poor diet, stress, environmental toxins. and more.^[7]

Changes in this microbiota, both on the skin and in the gut, are now being linked to many common diseases.^[4] An imbalance in the skin microbiome can trigger immune cells, creating inflammation as they try to clear bacteria that shouldn’t be there.^[6] Thus, as inflammation is a component of how acne arises, this imbalance can be triggering or worsening acne. Changes in gut microbiota have been seen in those with acne.[8] One study has shown a decreased diversity in microbiota of those with acne, compared to those without.^[1] A decreased diversity has been linked with other inflammatory skin conditions such as psoriasis.^[7] This type of change in the microbiome reflects changes we typically observe in those eating a “Western-style” diet—one higher in sugars as well as saturated fats, and low in fibre.^[1] Therefore, following a poor diet may be worsening acne, through the negative effect it has on our microbiome’s diversity.^[8]

Psychological stressors, such as stress and anxiety, can also influence the microbiome in a way that can promote acne or exacerbate it.^[2] In addition to the corticotrophin releasing hormone (which can trigger the sebaceous glands) that is produced under stress, are brains are also signalling to and communicating with our guts through the vagus nerve. In order to help respond to stress, it is thought the brain’s signals cause the microbiota to increase production of certain neurotransmitters (chemical messengers). These neurotransmitters cause nearby cells to produce compounds which alter intestinal permeability. When intestinal permeability increases, more substances from our gut end up directly in our bloodstream (where they normally wouldn’t be able to get). This often activates immune cells, further increasing systemic inflammation.^[2]

Another point to consider is that low stomach acid is a common finding in those with acne.[2] Normally, stomach acid inhibits the growth of certain bacteria in our stomachs and small intestines. With lower acid, bacteria can migrate up the digestive tract from the colon. This creates an overgrowth of bacteria in the small intestine.^[2] An overgrowth can impair proper digestion and absorption of nutrients, many of which (such as zinc and omega-3 fatty acids) are important for skin health. An overgrowth of bacteria can also lead to the production of more “toxic” metabolites which may increase intestinal permeability, again increasing inflammation in the body.^[2]

Probiotics in the Treatment of Acne

Based on these connections between the microbiome and the development of acne, a few studies have looked at using probiotics as a treatment strategy. Probiotics are live bacterial strains, usually taken as an oral capsule with the hope that they will reach the intestines to rebalance the gut with a healthy, beneficial microbiota.^[5] One study used Lactobaccillus probiotics and reported an improvement in 80% of the participants. Unfortunately, the study didn’t include a control group for comparison.[2] Another study provided patients with Lactobacillus acidophilus and Bifidobacterium bifidum in combination with conventional antibiotic treatments, and found better clinical improvement and tolerance to antibiotic treatment compared to those who took antibiotics alone.[2] A more recent study utilized a Lactobacillus-fermented dairy beverage, which improved severity of acne over a twelve-week period.[9] Topical probiotics are also being investigated as a way to restore a normal skin microbiome, and showing promise as well.^[5]

The Importance of Diet

Although we have limited studies on how improving gut health may help treat acne, we know diet is incredibly important to support a healthy microbiome. Conveniently, eating in a way that supports a healthy and diverse microbiome will also help address inflammation and hormone balance, two of the better-known triggers for acne development. The following are some basic guidelines to help optimize digestive and microbiome health, in order to improve skin health:

• Eat a Diverse Amount of Fruits and Veggies. Not only will this provide you with lots of fibre but eating a wide range of plant foods also helps promote a diverse population of gut microbes. Colourful fruits and veggies are also a great source of antioxidants, nutrients, and antiinflammatory compounds which are important for healthy, clear skin.
• Eat More Probiotic and Prebiotic Foods. Probiotics are sources of live, beneficial bacteria, and prebiotics are a type of fibre that feed our beneficial bacteria. Dairy products like yogurt are often considered to be good sources of probiotics, but since dairy has been linked to worsening acne,[10] opt for things like kimchi, sauerkraut, coconut kefir, and kombucha instead. Good sources of prebiotics include onions, leeks, garlic, Jerusalem artichokes, chicory, and dandelion greens.

Something else to consider when eating for skin health is to ensure adequate fat intake. Fats are necessary for hormone production, can slow blood sugar absorption like fibre (to control insulin levels), and are a necessary component of healthy skin cells. Including lots of omega-3 fatty acids in your diet (primarily found in fish, other seafood, and algae) is also a great way to combat inflammation.[11] Other healthy sources of fat include raw olive oil, avocadoes, nuts, and seeds.

Comprehensive Treatment

As many factors are believed to be involved in acne, it will of course be important to also consider stress, immune health, liver health, skin-care products, and other hormonal issues as part of a comprehensive treatment. With regards to acne in adolescence, we are limited on how much we can influence the normal, drastic shifts in hormones taking place. However, diet is a great way to support teens gently, as their hormones balance out. Diet, in other cases, is a powerful way to address many of the major factors and triggers involved in acne. A healthy diet and optimal digestive health can really set a foundation for better skin health, which can then be built upon as needed with other herbs, supplements, as well as topical and other treatments.