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Journal of Drugs in Dermatology, July-August, 2004
Dr. Robins: We should say more about the influence of various factors on acne.
Dr. Shalita: We've already touched on stress, hormones, and genetics.
Dr. Robins: Let's review them in detail.
Dr. Berson: For starters, family history plays a part. If either or both of your parents have had acne, there is a good chance that you will get it. Hormones play a part in the initiation of acne at around the time of adolescence. Moreover, in women predisposed to acne, hormonal factors can definitely influence breakouts at around the time of their menstrual cycle. We can also see flares during perimenopause and menopause.
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Women's acne can either flare or improve markedly when they become pregnant, and can improve for many who take the birth control pill. Conversely, we often see women develop a bit more acne after they go off the birth control pill.
Dr. White: Usually the flares occur right before menses or with ovulation.
Dr. Robins: We haven't talked about medications and diet. There are a lot of fairy tales about diet.
Dr. Berson: When someone comes in with new onset acne, if it's a sudden development, there are certain medications that can cause eruptions.
Dr. Brand: Steroids, for example.
Dr. Robins: Which ones?
Dr. Brand: All steroids can exacerbate acne. You tend to see monomorphic inflammatory acne on the chest.
Dr. Berson: Some antidepressants can also cause eruptions, as can lithium.
Dr. Shupack: Even some of the newer nonsteroidal topical medicines can cause problems. I'd like to back up a second and talk about stress. We all agree that stress makes acne worse, but we went right into hormonal fluctuations without touching on it. Clearly, stress can affect hormonal status, but is that the primary, direct way in which it aggravates acne? I believe it also has an effect on one's immunologic/inflammatory responsiveness through neuroendocrine pathways. It works through that route, in addition to its effects on endogenous corticosteroids and the like.
Dr. White: It's multifactorial.
Dr. Shalita: But there's no ethical way to investigate that, unless perhaps you were to study the internal reactions of students before and during examinations--their physiologic responses under normal conditions and under conditions of high stress.
Dr. White: There was a study of college kids which found that their acne flared when they took exams.
Dr. Shupack: But the question is, were they having flares because of stress or did the stress make them wash less often to clean away their P. acnes?
Dr. Shalita: If you are talking about neuroendocrine transmission, you can measure certain factors in the blood.
Dr. White: I simplify it for patients it by saying how stress works and telling them that their adrenal gland, for example, is releasing adrenaline. I explain that along with the adrenaline, the gland releases androgenic hormones that can stimulate acne. I don't think it's that simple, but it's a way to explain things to patients.
Dr. Shalita: The hormones don't really work that fast.
Dr. White: Exactly. There's a lot more going on with stress that we just don't know about with certainty. When we talk about its impact on psoriasis and eczema and acne, there are all these pathways that we just don't understand yet.
Dr. Shalita: But there's a whole list of medications we do know about that affect acne. We mentioned lithium and steroids. There are also halogenated hydrocarbons.
As for diet, only a few things have been identified as possible causative factors, and they're questionable. Years ago there was a myth about chocolate and peanuts, as well as some other things. Chocolate was studied at the University of Pennsylvania, where they looked at what was then the $5.00 Hershey bar, the big pound bar. They gave it to patients who thought their acne was aggravated by chocolate, and they gave others carob, an imitation chocolate, as a control. No difference was found between the two.
The late Dr. Phil Anderson, of the University of Missouri, studied the effect of several dietary factors on acne. He looked at cheese, milk, and several other foods, and there was no aggravating factor. The only other conceivably related thing I've heard about is peanuts; a colleague told me that certain strains of peanuts have androgen in them. In addition, a study published in the Archives of Dermatology described a group of people who have no carbohydrates in their diet and don't get acne.
Back when Weight Watchers had just begun, it included a lot of salt-water fish in its recommended diet, and we saw people breaking out while they were on it. There was a lot of iodine in that diet, and there's been some debate as to whether or not the iodine actually induced acne. In any event, it's hard for anybody to be on a diet exclusively of shellfish because it's so expensive.
Dr. Shupack: Iodine sensitivity is known to manifest itself in many different ways. Some people have truly severe allergic reactions, but there are also in-between groups, such as a group that developed acrodynia. It's not too much of a jump to conceive of a subpopulation of people who have iodine sensitivity. If we've thought about dietary factors at all. I think we've all on rare occasions seen people whose acne seems to be aggravated by iodine. Interestingly, the foods that are high in iodine are the same ones we've often warned people about: shellfish, kelp, and certain mineral supplements. True iodine sensitivity may occur in only one of a thousand cases, but I think it's true in some.
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