Whey Out Approaches to Acne: Updates from the Field

There is evidence that some popular dietary supplement ingredients can exacerbate acne. Meanwhile, research is looking at a range of non-drug approaches to supporting acne clearance. Hilary Baldwin, MD spills the dirt (literally) on the latest developments with a focus on practical implications for your patients. Plus, Roman Bronfenbrener, MD advocates for greater dermoscopy use, and we get an agenda update for DERM2026!

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Transcript

Transcript is provided as a courtesy only and has not been edited for accuracy.

Welcome to the Dermalorian podcast from the Dermatology Education Foundation. When it comes to diet and fitness, Americans increasingly turn to supplements. There is no shortage of purportedly beneficial ingredients intended to help cut weight and build muscle. But what do we know about the quality of supplements and what effects they can have on the skin health of patients with acne?

DEF faculty member dermatologist Dr. Hilary Baldwin provides an update on supplements that may influence the course of acne. She also takes a look at some potential new directions in non-prescription acne management.

Dr. Hilary Baldwin:

So there are lots of different supplements for lots of different reasons, right? And the problem is that half of our patients are probably using supplements, but nobody's ever writing it on our intake form. That was my fault. My intake form says, "List your medications." Well, they don't think it's a medication, so they don't list it. So you have to ask about it specifically.

The Mayo Clinic showed us that. If you don't ask, about 30% report it. If you do ask, about 61% of patients report it. There's still people who don't tell you anything, that are sort of ashamed of what they're on or, I don't know, feel that it's not something that the doctor needs to know or the provider needs to know, but they don't write it down.

And then we have another problem, which is adulteration of supplements. And we're going to see in a second that the FDA found that most of those over-the-counter supplements for bodybuilding are adulterated.

So we've got a lot of issues to talk about. So the first thing that people take in abundance is B6 and B12. It can be taken orally or as an injectable, and high doses are associated with acne, especially in women, especially those injections. Everybody thinks they need this if they see it. They get these injections. They end up with monomorphic papules on the face, chest, and back, which do fortunately go away as soon as they discontinue. But it's something that you need to keep in mind.

Interestingly, most of these supplements produce a type of acne that looks very much like steroid acne, so monomorphic small papules. What about iodine? We've known for years that this can cause acne or exacerbate acne. And again, it looks very much like steroid acne, and people are taking a lot of this stuff. There's pills that are kelp seaweed supplements. There's salads and snacks. I used to buy these things in that 12 pack. My kids would consume the entire 12 pack in a day. So they were consuming a lot of iodine. No wonder they're both an isotretinoin.

So what about anabolic steroids? These are in our supplements. The FDA looked at 776 dietary supplements and found that 89% of those intended for muscle building had steroids in them. And it's not on the label most of the time. Although some of them brag about it and they call themselves almerall and androball and all sorts of combinations with the word andro in it and promise all sorts of things including an increase in muscle mass.

So it increases surface lipids, it increases C. acnes, and it causes bad acne, not the little kind of monomorphic stuff. Real bad acne, acne conglobata, acne fulminans. And in women can also cause alopecia and hirsutism. In men can cause baldness and fertility issues and impotency and other kinds of problems.

So this is a major big deal, and you're going to see this in your career. And some of the patients don't realize that they're taking steroids. You ask them specifically, because you see this acne that came on suddenly and you really think it's that, and you ask them about it, and they say no, they're not taking steroids because they don't even realize that they are.

The other thing I want to tell you, has anybody ever tried to take somebody off of this stuff or told them to stop taking this or stop taking whey protein? If they're bodybuilders, they are not happy. Getting them to come off of this stuff is very, very difficult.

So let's move on now to whey. So what is whey? Whey is this disgusting greenish yellow soup that's produced when you're trying to make cheese. So you take whole milk, you put acid in it, it curdles. Just like remember... anybody remember little Ms. Muffet who sat on her tuffet eating her curds and whey? Never knew what that was. That's what this is. They whey is that disgusting liquid that has a very pungent, nasty odor.

So they used to toss it out, but they put it into rivers and it caused algae blooms because of all the protein and the fact that it stopped oxygen from getting through and stopped light from getting through. So they banned the ability to put whey into rivers. So instead they decided, "You know what? Let's concentrate it and feed it to stupid humans."

So it's added as a filler often to low-fat dairy products. You know that milk? I think it's called Skim Plus. So it's skim milk, but they put a lot of whey in it. So now it's nice and white and it looks creamy and it gets mouth feel. That's what that is. It's a ton of whey that's in there, and they brag because they've increased the protein content of your milk, but it's actually a whole bunch of whey.

But the biggest use is for muscle building. So the question is, do our patients even need this stuff? The rationale is that the whole point in muscle building is to destroy muscle tissue, and then when it heals, you end up with a bigger muscle, bottom line. And if you take protein peri-workout, either before or after, nobody's sure which is best, it increases the speed with which the muscle returns back to normal.

So whey protein is a big source of this. It's rich in branched-chain amino acids. It does its job. That's not the problem. The problem is it's not clear if it's any better than any other source of protein. So you could use a hunk of chicken for the same outcome, but it's harder to throw a chunk of salmon into your gym bag than it is a protein bar. It's convenience.

But look at how much whey is in whey. If you take one scoop, which is usually about 25 grams, or one bar, which is usually 25 grams, it's the equivalent to the amount of whey you would drink if you had six to 12 liters of milk. So we know that we think that maybe dairy products could be associated with acne, but whey protein is dairy products on steroids on steroids on steroids. There's a lot of whey in here, and whey does all sorts of bad things.

Mostly it does exactly what we don't want to do with our Western diet problem with acne. The Western diet provides already an abundant amount of branched-chain amino acids. And then if you throw whey protein in on top of it, you're doing all sorts of problems. You're increasing insulin and IGF-1, which ordinarily would suppress the activity of FOXO1, which is a good thing for preventing acne, and it increases mTORC, which is a bad thing for acne. Increasing lipogenesis, for example, and comedogenesis, as well as inflammation.

So whey is a big problem and a big source of all of the Western diet problems that many of our patients have.

So what data is there behind that suggesting that whey actually causes acne? Well, we don't have anything big and juicy. We have a bunch of little stuff, but it all says the same thing. There's no conflicting data. There's no study that says, "Eat whey and your acne goes away." It's all stories about mostly males, because more males than females end up weight-building and taking whey, where acne occurs when they start, disappears when they stop, and inability for acne medications to work.

I've seen that personally. I had two patients on isotretinoin, just weren't getting any better. And finally, I had them stop their whey protein, kicking and screaming. I had one guy who was 17, his father had to ground him to make him stop taking his whey protein. And as soon as he stopped, the isotretinoin started to work.

So if you have a patient who's not responding, make sure they're not on a supplement of some sort.

Only one small study, 30 people, very poorly done, but they looked at amount of acne that they had at baseline, 30 days, and 60 days into the use of a supplement. They started out with about 60% of them having acne, ended up with everybody having acne, face and chest.

Speaker 1:

Next up, Dr. Baldwin addresses pro, pre, and postbiotics and other emerging approaches to acne management. But first, for this edition's Dermalorian clinical clip, Derm 2026 faculty member, Dr. Roman Bronfenbrener provides a reminder about the role of dermoscopy in the dermatology clinic.

Dr. Roman Bronfenbrener:

I will say that if you are not using your dermatoscope, there are lesions that you are missing in your clinic because you're not able to pick them up. Your clinical eye cannot get trained as well until you've understood the dermoscopy. Don't use dermoscopy to talk you out of biopsying lesions that you think are very suspicious clinically.

A dermatoscope is not useful for that. A dermatoscope is useful for finding lesions that you clinically might not be so suspicious about, and then recognize the dermoscopic features that would lead to a biopsy and an earlier diagnosis of a skin cancer. So make sure you're using your scopes.

Speaker 1:

That's some timely advice during Skin Cancer Awareness Month. Let's get back to Dr. Baldwin's update on acne.

Dr. Hilary Baldwin:

So now let's go on to pro, pre, and postbiotics. And when we're talking about this topically, now I'm not talking about oral probiotics, topically, we're talking about caring and feeding for our microbiome, and is that going to make our acne better?

So our menu for microbiome repair includes probiotics, and we all know what those are, active microorganisms, which we think, if we smear them on our face, will help to restore our microbiome. Prebiotics, which feed the probiotics, which feed the organisms that we think we want on the surface of our skin. And then postbiotics, which we don't talk about very often, but are actually way better than probiotics, in my opinion. They're probiotics that have been killed. So now we don't have to worry about bugs wandering around on our face. We don't have to worry about it going to places that we don't want it. We get all of the benefits of the probiotic with none of the problems that include refrigeration and preservation because you're trying to keep the little suckers alive. So postbiotics make a whole lot more sense.

So the problem is we don't know what a normal microbiome is. So let me ground you here. Four areas of the body: the antecubital fossa, the back, the nose, and the plantar heel. And then within each one of those groups is four people, HV1, 2, 3, and 4. So they swab four people in each one of those locations. There is very little consistency. The biggest organism, Propionibacterium, is probably P. acnes, right? So that's the most dominant in all four of those people, but look at how much variation there is.

So we don't really know, if you said, "Okay, I'm going to give you something. Here, smear it on your skin. It'll normalize your microbiome." Well, what the heck is a normal microbiome? This has taught us that a healthy microbiome is not specifically definable, so you can't grab something off the shelf and fix your microbiome. There's no recipe. Your microbiome is whatever the heck it is in a particular location, in a particular person, at a particular time as well.

So probiotics, most of the data that we have is for oral supplements, not for topicals. Topicals are a way bigger issue. Bacteria like water, and the skin is dry as all heck. So you've got very limited number of organisms that are capable of living there, and they also have to feed off of fat, which is not usually something that bacteria eat very often.

So the problem is that if you take a microorganism that looks as if it's going to be helpful, let's say from the soil, and you put in it, like Mother Dirt, remember? Sorry, no, I don't work for them. Mother Dirt, you take a hunk of soil and you basically smear it all over yourself. Those bacteria are not going to live very long. They're going to die because they like the rich soil with a lot of moisture in it. So the durability is going to be very low.

Normally we have our resident microflora that live on the surface of our skin, very happy. If we mess up the microbiome, it comes back. So if we do a chemical peel, laser resurfacing, we get rid of all those organisms, but then they come right back again because that's where they're supposed to be, and that's what we refer to as a normal healthy microbiome. But again, it's different for everybody.

The transient guys are the ones that land on your skin because you're in a different environment, because you shook hands with somebody that had syphilis, because you did something and you end up with MRSA on your skin, but it's temporary. It's going to go away unless, of course, it's a pathogen, in which case you've got a little bit of a problem. But all those transient guys, which are our topical probiotics, are going to go away in short order after it's applied to the skin. So at the very least, if a topical probiotic is effective, we're going to have to use it frequently in order to keep it up. It's not like it's going to replace our resident flora.

So when we're talking about C. acnes, because we're talking about acne, we remember that there's not just one type of C. acnes, right? We've got three different subtypes aptly named type one, two, and three. Type one is associated with acne. Type two is associated with health and is referred to as the subtype defendens, and brings up an obvious question. If we could figure out how to get rid of just one and keep all of our twos, wouldn't that be great?

Maybe we could eradicate acne. Maybe I have acne because I'm filled with one and I could get rid of it. Let's say we put on one of those pads that you strip off and it looks like top of a porcupine, right? If you take those things off and then rub type two into my skin, could we get rid of the type one in my follicle and make my acne go away?

It's an interesting thought. It's actually been taken for a spin. This guy, I'm going to use his name because he's an amazing, very intelligent man, his name is Thomas Hitchcock, and he's just absolutely brilliant. And what he realized was that if you did that and you smeared the bacteria on your skin, what's to stop that bacteria from migrating to your titanium knees, to your brain, right?

So he figured out how to put in a growth-arrest genetic switch. So these bacteria function normally, but when they die, they die. They don't multiply, they don't make new ones. Crazy good.

Anyway, they took a sample from a bunch of patients from a swab, grow it in an aerobic culture, take just the defendens type, just the type two, the good one, give it to 121 healthy women to smear on their face twice a day for eight weeks, and their skin looked better. And I said, "Thomas, what are you doing? Do it in acne. Why are we doing it in healthy skin?"

So just came out, 136 subjects, eight weeks, twice a day, 20 patients only evaluated, a pilot study. They looked at lesion counts in global assessment and found, yes, that lesion count was reduced at all time points compared to baseline, and it was well tolerated. So maybe we'll see this in the future. I'm kind of excited about it.

We have ammonia-oxidizing bacteria that was looked at in a phase two and phase three trial. It's Nitrosomonas from the soil again. Didn't work. No irritation, but unfortunately did not reduce acne. The guy, by the way, who owns this has said that he has not used soap, deodorant, or shampoo for 20 years. He just smears this stuff on. Kind of gross.

Anyway, what about bacteriophages? Wouldn't that be great? Bacteriophages are hugely abundant, and they're specific for a particular bacterium. So could we take bacteriophages that kill C. acnes and smear that on the skin?

They're obligate intracellular pathogens, and they land sort of like the lunar module, and then they squish their legs and poop their stuff into the bacterial cell, and there it takes over the machinery of the bacterial cell, commands all the machinery to do its own work to make new phages, and then produces a protein that causes lysis of the cell wall and boom, tons and tons of baby bacteria phages to infect other C. acnes organisms.

So it might be kind of cool. Phages are very abundant in the follicles, and they can kill C. acnes. Interestingly, in those of us who have acne, we have less bacteria phages than you guys that don't have acne. So it seems to be protective. It's also hugely abundant in people over the age of 55. And who sees people with acne over the age of 55, right? Maybe it's hormonal, maybe it's the bacteriophages.

So there was a study, very small. 103 patients were given phages or placebo or phage plus salicylic acid. And it's only for monograph purposes. As you know, if you're going over the counter, you can't make acne claims without a monographed substance in there. So they put in 1.5% salicylic acid.

And this is what they found. In the people who did respond, the percentage of C. acnes went way down. In the patients who did respond, their IgAs improved as their C. acnes went down. In the patients who responded, their C. acnes, about 75% at baseline, 43% after the treatment. So they have clinical improvement along with the reduction in the C. acnes, and this increased the diversity of the microflora on the skin, which is associated with skin health.

So this looks kind of promising. It's got a very low environmental impact, specific for C. acnes, and maybe we can make it specific for C. acnes just type one. It reduces biofilm formation, it costs hardly anything, and it's got very good safety.

On the other hand, we don't really know what we're doing just yet with it. What's the dose? What's the frequency? And phages can get resistant too. So although we're not using antibiotics, we may end up with phage resistance instead of antibiotic resistance.

Could combination therapy therefore work? What if we used the strip, yanked out all of my type one, and then picked just my type two, put it into a cream, took bacteriophages just against type one, put both of those in a cream, and had me smear it on my acne-prone skin? Maybe that's our future.

Speaker 1:

Maybe Derm 2026 is your future. Whether you've registered yet or are still making plans, be sure to check out the full agenda now available online at dermnppa.org/derm2026. The education kicks off at 1:00 PM Pacific Time on Wednesday, July 22nd, and continues through Saturday, July 25th.

Check out evening educational programs as well as multiple networking opportunities, including ample time to visit with industry colleagues in the exhibit hall. Spaces are filling up, so register soon to be part of Derm 2026. We hope to see you there.

Thanks for joining us for this edition of the Dermalorian podcast. The Dermalorian podcast is produced for the DEF by Physician Resources. Find us wherever you listen to podcasts.