Acne, Vitamins and Diet, Oh My!

Ever wondered why acne persists well into adulthood despite maintaining a diligent skincare routine? Join host Dr. Shannon C. Trotter on "Derm-It Trotter! Don't Swear About Skin Care." as she speaks with Dr. John Barbieri, a board-certified dermatologist, to debunk prevalent myths about acne. Discover why acne is less about poor hygiene and more about genetics, affecting teenagers and adults alike. 
Are you curious about how diet impacts your skin? Dr. Barbieri offers evidence-based insights into dietary factors influencing acne. Learn how cutting down on sugar and high-glycemic foods might help while considering the potential pitfalls of whey protein, dairy, and even chocolate. We explore effective treatment strategies and get practical tips on managing acne, from maintaining a simple skincare routine to the cautious use of natural products. Your journey to clearer skin starts here!

Transcript

Acne

Speaker 1 0:00

Welcome to Dermot Trotter Don't Swear About Skin Care where host Dr Shannon C Trotter, a board-certified dermatologist, sits down with fellow dermatologists and skincare experts to separate fact from fiction and simplify skincare. Let's get started.

Speaker 2 0:18

Well, welcome to the Dermot Trotter podcast. I'm Shannon Trotter, board-certified dermatologist, here to talk with you today, with a colleague of mine, dr John Barbieri. Dr John Barbieri is currently a board certified dermatologist and assistant professor at Harvard Medical School. He is also the director of the Advanced Acne Therapeutics Clinic at Brigham and Women's Hospital and he's co-chair of the American Academy of Dermatology's Acne Guidelines. And, of course, I'm bringing him in today to talk about everyone's favorite topic. We've all probably struggled at some point in life, but nonetheless then acne. So welcome to you, dr Barbieri.

Speaker 3 0:56

Thank you for having me.

Speaker 2 0:58

Of course, of course. I think one of the things you know with acne is that you know you get this jealousy streak because you look at people that seem to have this most beautiful porcelain skin. They've never had to deal with a pimple in their life and then you have others that seem to have struggled with it their entire life. And then myself kind of timely for the talk I had a couple of breakouts here even before we got started. It's like I knew you were coming today. So how do you explain to your patients you know who gets acne and who doesn't?

Speaker 3 1:25

The first thing, I think, is understanding really that who has acne overall. It's not just why, but like what percentage of people have acne. So, if we look at teenagers, about 85% of people have some degree of acne at some point in their life. Almost everybody has it, and we often think of acne as a disease of adolescence, something that goes away as we get older, but when you really look at the data, that's not the case. Many people are struggling with acne and we just don't realize it. So about 50% of women and about 30% of men will have acne in their 20s. About 35% of women and 20% of men will even have acne in their 30s and longer. So many individuals will have acne that either continues into adulthood or starts in adulthood, and that's an important thing to keep in mind. If you're having acne in adulthood, you're not alone. Many other people are dealing with this too.

Speaker 3 2:11

Now the second part of this who gets acne? Most of it, unfortunately, is genetics. We sometimes stigmatize acne as something that's like you're not washing your face well enough, you're not clean, you're eating the wrong things. Most of what causes acne is really genetics things we can't control, and so whether or not someone has acne, much of that is just their innate kind of what they got from their parents. There's nothing they can do about it, and our goal is to try to help manage it. Now I think we're going to talk later on about some environmental factors, some things we do like diet, like other things that happen in our world that can contribute to acne. Those do matter, but much of it is really just about genetics.

Speaker 2 2:47

So just another thing we can blame our parents for is what you're telling me Exactly. Well, I think that's one thing you know to, really. You know people can relate to. You know, not that you want to blame it on genes, but unfortunately it does predispose us to get acne. You know, a lot of us, you know, will run to the pharmacy to treat acne, and probably one of the most common things we might pick up off the shelf is something with benzoyl peroxide in it. But you know, lately benzoyl peroxide has really taken a hit, and so I'd like to talk a little bit more about that. What are your thoughts on, kind of why? You know there's all this hype around benzoyl peroxide and maybe it's not such a great treatment choice.

Speaker 3 3:20

So this, I think, stems from this Valisher report, which was released in March of this year, where this company went. They're a testing lab company, so they have some important potential conflicts of interest. They went and they took a bunch of benzoyl peroxide products off the shelf and they exposed them to high temperatures for prolonged periods of time and demonstrated that when you do this you can get these levels of benzene in the products and benzene is a carcinogen. We don't want that around us. So they're saying, hey, we should be worried about using benzoyl peroxide. There's a few caveats here. So first, we've actually known that benzoyl peroxide can do this thermal degradation. It can break down to benzene at high temperatures for decades. This isn't actually a new thing, but I think Ballester's media approach has made it something that's come up a lot.

Speaker 3 4:05

If we store benzoyl peroxide appropriately, if you look at the benzoyl peroxide products they got off the shelf or when they've done studies at lower temperatures and, to be frank, they haven't been that transparent about their data at lower temperatures. But the little bit of data they have shared are generally much less concerning than these data at high temperatures. So that's the first thing here is that we don't actually know that much about how much benzene is in benzoyl peroxide products when stored appropriately. These voucher data are storing things incredibly inappropriately, something that would actually be difficult to even accomplish if you tried to do it as a person. So that's the first thing. There is some uncertainty about it. But if we just think logically about this, benzoyl peroxide benzene is not actually absorbed through the scan, so the risk of benzene being on your scan is negligible. But it the scan, so the risk of benzene being on your scan is negligible. But it can go into the air. It's a molecule that can evaporate, it's volatile, so we could breathe it in and in that way that might be dangerous to us. However, if we just think about a benzoyl peroxide product, let's imagine one that's actually worse than 85% of what Valachert tested at baseline. That would have such a small amount of actually benzene on an absolute level with a typical use that it's likely much less than you get just being a person in the world. Sadly, there's benzene around us If you use a gas stove, if you go to a gas station, if you eat food. There's benzene in all of these things and the relative risk of the benzene from a benzoyl peroxide is probably negligible compared to these risks in our lives.

Speaker 3 5:23

In addition, there have been some studies that have looked at do people use benzoyl peroxide at high risk of cancer, and so far none of them have suggested increased risk. That's what we care about is does using benzoyl peroxide expose me to a carcinogen? Could it increase my risk for cancer? And all the data we have suggests no.

Speaker 3 5:39

So I do think this balance report's important to take seriously. We definitely want to store things appropriately, and I think this has some ramifications for now we have so much mail order stuff Like if you live in Texas and it's 100 degrees out and you mail something to your house and it sits on your porch for a week while you're on vacation. That might not be great, and so I do think we want to be thoughtful about how we ship things, how we procure, how we get these benzoyl peroxide products and how we store them, and be thoughtful about temperature and not keeping them for 10 years or putting them at really high temperatures, but outside of storing them appropriately. I think if we're doing that, the risk is likely negligible and I think we're going to see more and more reassuring data over time about this topic.

Speaker 2 6:17

So it sounds like it's okay, you know, for patients if they're sitting there at the pharmacy or they're at the store and debating to pick up a new acne medication, it would be okay to look at potentially doing that and using benzoyl peroxide. It wouldn't be something that you would really recommend against at this point.

Speaker 3 6:34

Yeah, I think at this point, if someone's interested in using benzoyl peroxide, I think it's completely reasonable to do so, especially if it's stored appropriately. I think that's the key thing there. And then if people are concerned because there is some uncertainty we're still waiting to hear what the FDA is going to say about this citizen's petition from Ballisher In the setting of uncertainty, I think it's reasonable for those who are more concerned to think about other options. And the challenge here is there's no substitute for benzoyl peroxide. Like if you told me you couldn't use Trenol and a topical randroid, I'd say, hey, let's just use Adapalene, but there is no alternative to benzoyl peroxide. So it does make it more challenging to treat acne if we don't have that option.

Speaker 2 7:07

Really good point. You know, also, when they're at the pharmacy, you know they might be picking up that acne treatment and then, as they're checking out, you know a lot of us might be eyeing that chocolate bar or something that we want to pick up as a nice sweet snack which kind of leads into. You know I've always had friends complain. You know if I eat chocolate I'm going to break out, and you know I used to always think back in the day is that really something that happens? Before getting into field of dermatology and now looking at diet a little bit more closer, what do you think about? You know the impact of diet and its role in dermatology, and what do you recommend to your patients?

Speaker 3 7:43

Diet definitely has an influence in acne, but it's often not something that's going to go from like I have severe acne to, I'm fear. I think people often are looking for a reason. Getting back to that first question, like why do I have acne? And people can spend a lot of time trying to be like if I just cut out gluten, if I just eat less dairy, I'm going to be better, and usually that's not the case. But diet doesn't matter. One of the most important dietary factors with acne is sugar, is high glycemic diet, and there are actually trials where they randomize people to have a lower sugar diet or a higher sugar diet that show that eating a lower sugar diet, a lower glycemic index diet, can help improve acne. So to me, we know sugar is not good for health in general. So a very basic recommendation from anyone who's having acne is to try to reduce sugary food consumption sodas, processed foods, those kinds of things that might have high glycemic loads because doing that is shown in clinical trials to improve acne and it's also not good for us in general. So even if you didn't have acne, that might be a good thing to do. So to me that's a very good starting point for those who are looking at how could my diet influence my acne. Another thing that I think is important to keep an eye out to especially for people who are really interested in working out or things like that is whey protein. So whey protein can activate this signaling pathway, igf-1, that can turn on the oil glands in our skin and can contribute to acne, and so occasionally there are people who are just consuming a lot of whey as part of their exercise routine or their nutritional approach, and reducing that whey or switching to other protein sources can sometimes have quite a dramatic impact on acne. People are consuming large quantities of that. So that's kind of the next thing I look for. So sugar and whey are kind of the starting points, because those, I do think can make a big difference.

Speaker 3 9:21

After that we get into things that have less evidence that might matter for some people but might not matter for everyone, and these are a bit more controversial. So dairy would probably be the next one that comes up. There are some studies that suggest people who consume more dairy are more likely to have acne. These aren't trials, so they're not as strong in evidence as the data I was talking about for sugar. There may be just people who eat more dairy do other things that contribute to acne. It has nothing to do with the dairy, but there is some evidence linking dairy to acne and so I think people who want to try to reduce dairy consumption to see if that helps their acne it's reasonable.

Speaker 3 9:53

Anytime people are doing nutritional things I always say it's important to think about, like are you being healthy? So dairy is an important source of calcium and protein, other things. So we want to make sure that we're not eliminating important nutrients from our diet and we're thinking about other sources of those. But I do think that's another one to consider.

Speaker 3 10:08

And then chocolate is one of these other kind of interesting controversial ones. There's actually a small study, as kind of cool, where they had people take a chocolate bar or an equivalent amount of sugar and jelly beans, so trying to control for that sugar factor we were talking about earlier, and the people who ate the chocolate bar actually did get more acne than the people who were given the jelly beans. So there probably is some association between chocolate and acne. It's probably relatively mild. Most of us probably aren't eating that much chocolate to the point where it's going to matter. I mean, some people really like chocolate, but even my mom, who loves eating chocolate, probably isn't eating that much chocolate every day. So it's something to consider, but I think again it's something if you completely eliminate chocolate from your diet, your climate can go from having moderate to acne and not, but it's another thing that may have a small effect.

Speaker 2 10:53

Oh, that's bad news. I didn't want to hear that. So you're okay to pick up that. You know benzoyl peroxide, but the chocolate may be not so good. So my friend was right. I'm going to have to tell her that that that's going to be a hard pill to swallow, but I think the diet.

Speaker 3 11:06

things are mild, like if you love chocolate or ice cream like you don't need to stop eating those things. I think there are other ways you can help manage your acne, too. Certainly, if you want to do that, that's great, but I always feel bad when people are torturing themselves on these diet things that might not actually even get them as much benefit as they hope.

Speaker 2 11:21

Well, and at least you didn't mention wine, so that's a good thing. So you know, also at the pharmacy we've got other options, you know, to treat acne, and I think a lot of people are tempted now to walk down that aisle, especially with supplements being such a big business. Here in the United States, you know people are looking for more natural approaches to healthcare in general, and I think, too, you know the thought of, you know, certain vitamins or supplements. Could they actually help to treat acne, whether it's a primary treatment or something, as you know, adjunctively you just add in to kind of get the results that you want? Well, what are your thoughts on the use of vitamins and treatment of acne?

Speaker 3 11:57

I definitely think that other nutritional and supplement approaches can have a role in the treatment of acne. The first thing here I just want to state is when we're taking these things, often because they're maybe from a natural source, we assume that equals safe, and that's really not true. There's plenty of things that naturally occur that are quite dangerous, that are poisons, and I really view them the same way I view any kind of medicine. There's not any inherent reason that a medicine which has been studied for safety and effectiveness is any more or lower risk than a supplement. I think there's this assumption that supplements are safe, but I really think we have to be cautious about that.

Speaker 3 12:31

A classic issue in acne is there will be these supplements and they're often not transparent about it that contain very high high levels of vitamin A, and vitamin A is basically the same way that Accutane, isotrinoin, works to treat acne, and I all the time see people who they want to avoid isotrinoin. They're concerned about the risks and side effects of it, which is completely reasonable, and then they're on these high dose vitamin A supplements and basically what they're doing maybe not even thinking of realizing it is they're basically taking low dose Accutane, they're trying to avoid it and they're taking a supplement that's basically doing that and has a lot of the same risks as isotretinoin. So I do think the first thing is, with these supplements especially that aren't named like there's something like Acnutane or something like that look at the label and if it's got a really high dose of vitamin A, think twice about that, because that could be kind of like taking low-dose isotretinoin and that might have some important risks and side effects and it can certainly help. But you want to be thoughtful, know what you're doing and getting into. There are a number of other supplements that have some evidence from randomized control trials really rigorous studies that support they can work. And the first two that I often suggest to people are vitamin D, especially in people who are vitamin D deficient. There's plenty of us right now who have low vitamin D for a variety of reasons, and there's a study where they looked at people and one they found that those who have worse acne tend to have lower vitamin D. That's just association right, not a trial. But then they took the people with low vitamin D and they randomized them to supplementation of vitamin D or not, and those who got vitamin D supplementation had improvements in their acne. So that to me is a simple recommendation, especially for those who are low vitamin D.

Speaker 3 14:03

The other one is vitamin B5. There's some randomized control trials that support that vitamin B5 can be helpful in acne. Now the doses in these studies were quite high. They were about 2,000 milligrams two grams a day and that's quite a high dose of vitamin B5. It is a water soluble vitamin. What that means is that it's not going to accumulate in your body. You'll just pee it out if you have too much of it. And when we look at it it seems to be safe at these doses. But that would be the other one. It has maybe a little bit more uncertainty to it because it is a high dose as opposed to just a regular dose of vitamin D. So that's something to think about. But it appears to be safe and it does appear to help with acne. So vitamin D, vitamin B5, those are usually my first two things.

Speaker 3 14:43

I suggest that people who are thinking about supplements and the nutraceuticals for acne. The next one would be zinc. Zinc has a number of trials that support that it can help for acne. The idea here is that it can reduce oil production in the skin. The challenge with zinc is that it can cause stomach upset for people, especially the doses that we need for acne, so many people can't really tolerate taking it, but it is something that can help for acne, especially in those who don't get stomach upset from it. So those would be like the maybe three strong evidence groups.

Effective Acne Treatment Recommendations

Speaker 3 15:11

The next one that may be helpful are probiotics. We know that there's an action between gut health and skin health, and there are several trials that suggest that a variety of different probiotics can be helpful for acne. The challenge here is there's lots of probiotics out there. I bet lots of companies have studied them to see if they help for acne, and probably they only publish the trials where it works, not the ones where it doesn't work, and so there may be some of what we call publication bias, where the data we see is only a small snapshot, just a piece of what exists out there. We're missing all the studies where it doesn't work.

Speaker 3 15:40

But I think again, a very low risk kind of treatment probiotic and it may be helpful for acne. So those would be kind of my main suggestions of things. I think of high quality evidence that they can be helpful for acne and kind of that diet and nutraceutical side of things. There's certainly other things that may be helpful and from my standpoint, if you find something that works for you, that's great. There's a lot of stuff that we just haven't studied and they may be really helpful for acting. We just don't have that data yet, so I never tell people that I don't think something can work, but I do think it's important to be thoughtful, that view these kind of like you're taking a medicine to some degree, just that's a really good point because I think that is a trend in medicine.

Speaker 2 16:25

We're all looking for safer, more natural or clean methods are often used, obviously, in the world of skincare, but at the same point, like you mentioned, the regulation may not be there. Natural doesn't always equate to being safe, so you do have to take that with a grain of salt and really look at where there's data. So I think you did a great job summarizing that to give people really some tips on what they could look at where there's some data and, like you said, there may not be data and other things, so it's hard to discount them. But also you want to be careful too, because they're not necessarily always safe, especially in the quantities people want to take, maybe to achieve their goals.

Speaker 3 16:59

And sometimes the absence of data of harm doesn't equal safety. So you know, example of this for me is bakuchiol, which is sometimes you just like the non-retinoid retinoid or like the pregnancy safe retinoid. And if you look at what happens with bakuchiol, which is this natural product that people use to treat acne, it certainly works for acne, which is great, but when you look at the pathways it activates, like molecularly in the skin, they're very similar to retinoids and so while it's not technically a retinoid, it on a molecular level does similar things, and so for me, if someone was pregnant, I wouldn't encourage them to take acucial because we just don't know it's safety in pregnancy and if it's activating similar pathways to retinoids, it might have similar risks to retinols and retinoids. So this is one of those examples where I think people view the absence of data at harm and something being natural equaling that something is safe, and that's not necessarily inherently true and I think we have to be careful about that.

Speaker 2 17:54

Very important point. So, as we kind of wrap up our conversation today, I know we've hit on, you know, a lot of interesting topics surrounding acne. Well, what are your tips that you would offer, you know, for patients to really be successful in, you know, doing an acne regimen? Obviously they can be complex, but are there just tips that you offer to say, hey, this is the way to be successful? Acne is, you know, a marathon, not necessarily a race, for most of us. What do you recommend for your patients?

Speaker 3 18:18

So one of the first things is is, unfortunately, patients so even our best acne treatments really take about eight to 12 weeks to start to see benefits from them. So sometimes we can get into these things where we do something for two weeks or four weeks and we feel like things are slightly worse or slightly better and we just start switching around treatments really rapidly and never give anything a chance to work. I mean acne. I think all of us who've had it know there's good days and bad days and you can really get caught up and like, oh my God, I started treatment and now I'm having a bad day it must be the treatment's not working and just give up really quickly. So I think patience and giving things time to work is important.

Speaker 3 18:50

Having a kind of logical and multimodal and by that I mean something that addresses the different factors that contribute to acne is important.

Speaker 3 18:58

Sometimes, especially in the social media era, see people who are using a bunch of products that are all great in their own right but make no sense as a treatment strategy, like they're using a retinol and a retinoid and something else in the same path and they're just overlapping and getting no more benefit, more side effects.

Speaker 3 19:16

So thinking about combining things that do different stuff using a retinol or retinoid to help the skin turn over and reduce inflammation, help keep the pores from being clogged up. Using something with antimicrobial properties like benzoyl peroxide or topical antibiotics to help kill acne bacteria. Using things that can address the hormones that cause acne in everybody, whether you're a 12-year-old boy or a 35-year-old woman, your acne is hormonal and there are a number of treatments, there are prescription things and even some over-the-counter things that can help address some of those factors that contribute to acne. So, making a regimen of things that complement each other, trying to keep things relatively simple I think sometimes we can go overboard and doing 10,000 toners and different types of things really trying to focus on what are the key ingredients and why am I using this, and having maybe three or four things that complement each other is really the key thing there.

Speaker 2 20:04

Excellent, I think those are all great points. Well, I really those are all great points. Well, I really want to thank you today for coming on and speaking with us regarding, you know, a topic that seems so simple but yet it's quite complex and, I think, for you know, patients that are frustrated about what's out there and what to do. You've really highlighted some of the more you know controversial things that are going on or surrounding acne and really given us great insights and how we can actually treat this a lot better. So, thank you so much for coming on the podcast. We really enjoyed talking with you today.

Speaker 3 20:32

It was a pleasure. Thank you for having me.

Speaker 1 20:34

Thanks for listening to Dermot Trotter. For more about skincare, visit DermotTrottercom. Don't forget to subscribe, leave a review and share this podcast with anyone who needs a little skincare sanity. Until next time, stay skin smart.