Diet and Acne Management  

Despite the range of available pharmacologic therapies for acne, many patients continue to experience lesions, underscoring the need for additional acne management strategies. Patients often report suspected associations between acne flares and various foods or dietary patterns, and a growing body of research has explored the potential role of diet-based interventions in this patient population.¹ Although the evidence regarding these associations is largely inconclusive, certain dietary factors have been implicated in the development of acne.

“Several studies, including randomized controlled trials, have supported a link between a high-glycemic index diet and acne,” John Barbieri, MD, MBA, instructor in dermatology at Harvard Medical School and director of the Advanced Acne Therapeutics Clinic at Brigham and Women’s Hospital in Boston, told us in an interview.

The glycemic index (GI) is a measure of how rapidly a particular food will increase blood glucose levels relative to other foods containing the same amount of carbohydrates, and the glycemic load (GL) accounts for the quantity of carbohydrates and rate of carbohydrate absorption associated with specific foods.^2,3 Foods with a high GI index typically include processed, high-carbohydrate, low-fiber foods such as desserts, white bread, and white rice. Low-GI or low-GL diets are low in carbohydrates and processed foods such as those with refined grains and added sugar.²

Some findings have shown greater intake of high-GI/GL foods among individuals with acne, and low-GI/GL diets have been linked to improved outcomes in this population.² In 2 earlier randomized controlled trials (RCTs), low-GL diets were associated with reductions in total lesion counts, insulin-like growth factor-1 (IGF-1) levels, and insulin sensitivity compared to a high-GL or high-carbohydrate diet.^4,5

A more recent RCT found significant reductions in the number of acne lesions, the size of sebaceous glands, and inflammation levels in patients with mild to moderate acne assigned to a low-GL diet for 10 weeks compared with a control diet.² In addition, a 2-week RCT published in 2018 in the Journal of the Academy of Nutrition and Dietetics observed significant reductions in IGF-1 concentrations in patients assigned to a low-GI/GL diet (preintervention=267.3±85.6 mg/mL vs postintervention=244.5±78.7 ng/mL; P =.049) compared with a usual diet.⁶

“It is thought that factors such as IGF-1 and insulin induce increased activity of keratinocytes and the sebaceous gland, which can result in increased acne activity,” according to Dr Barbieri. However, a 2015 Cochrane review concluded that the evidence supporting the role of LGLD in acne management is weak, overall.⁷

“In addition to findings regarding low-GI diets, there are some potential associations between dairy as well as whey protein intake and acne,” Barbieri noted. A 2019 meta-analysis of 14 observational studies revealed positive associations between acne occurrence and total milk intake (OR, 1.48; 95% CI, 1.31-1.66) and intake of low-fat milk (OR, 1.25; 95% CI, 1.10-1.43) and skim milk (OR, 1.82; 95% CI, 1.34-2.47), while no significant link was found between yogurt/cheese consumption and acne.⁸

A small case series reported in 2012 focused on 5 male teenaged patients who developed acne after taking whey protein supplements. Whey protein comprises roughly 20% of the naturally occurring protein in cow’s milk, and it is often isolated and processed for use in protein powder supplements. While standard oral and topical acne therapies led to a poor response in these patients, they experienced rapid and complete resolution of acne upon discontinuation of the whey supplement.^7,2

“Whey protein concentrate has a high proportion of leucine (14 g/100 g of protein), which is a known activator of mTORC1,” wrote Baldwin and Tan in a paper published in 2021 in the American Journal of Dermatology.² This may help to explain the potential effects of the supplement on acne development.

A cross-sectional study described in 2020 in JAMA Dermatology examined associations between dietary patterns and acne based on self-reported data from 24,452 adults (75% women).⁹ After adjustment for potential confounding variables, the results demonstrated significant links between current acne and intake of fatty and sugary products (adjusted odds ratio [aOR], 1.54; 95% CI, 1.09-2.16), sugary beverages (aOR, 1.18; 95% CI, 1.01-1.38), and milk (aOR, 1.12; 95% CI, 1.00-1.25). Current acne was also associated with an overall dietary pattern characterized by high intake of fatty and sugary products (aOR, 1.13; 95% CI, 1.05-1.18).

 “Much of the current data is based on nutritional epidemiology studies that cannot assess causality,” Dr Barbieri explained. “There is a need for clinical trials to understand whether making specific dietary changes results in a meaningful influence on the presence and severity of acne.” Further research is needed to elucidate the role of food types and dietary patterns in acne pathogenesis and treatment, he believes.

Presently, the strength of the available evidence precludes conclusive dietary advice regarding acne management in clinical practice. Ultimately, diet-based interventions may serve as adjunctive rather than primary strategies in the treatment of acne, Dr Barbieri stated in an editorial published in 2020 in JAMA Dermatology.¹⁰

“Since most dietary effects on acne are modest at best, I generally do not encourage patients to make any major dietary changes as a treatment strategy for their acne,” he said in our interview. “However, given the low risk and potential health benefits of a low-glycemic load diet, I think a low-glycemic load diet can be a reasonable suggestion as part of a comprehensive acne management plan.”

References

1. Nguyen QG, Markus R, Katta R. Diet and acne: an exploratory survey study of patient beliefs. Dermatol Pract Concept. 2016;6(2):21-27. doi:10.5826/dpc.0602a05

2. Baldwin H, Tan J. Effects of diet on acne and its response to treatment. Am J Clin Dermatol. 2021;22(1):55-65. doi:10.1007/s40257-020-00542-y

3. Katta R, Desai SP. Diet and dermatology: the role of dietary intervention in skin disease. J Clin Aesthet Dermatol. 2014;7(7):46-51.

4. Smith RN, Mann NJ, Braue A, Mäkeläinen H, Varigos GA. The effect of a high-protein, low glycemic-load diet versus a conventional, high glycemic-load diet on biochemical parameters associated with acne vulgaris: a randomized, investigator-masked, controlled trial. J Am Acad Dermatol. 2007;57(2):247-256. doi:10.1016/j.jaad.2007.01.046

5. Smith RN, Mann NJ, Braue A, Mäkeläinen H, Varigos GA. A low-glycemic-load diet improves symptoms in acne vulgaris patients: a randomized controlled trial. Am J Clin Nutr. 2007;86(1):107-15. doi:10.1093/ajcn/86.1.107

6. Burris J, Shikany JM, Rietkerk W, Woolf K. A low glycemic index and glycemic load diet decreases insulin-like growth factor-1 among adults with moderate and severe acne: A short-duration, 2-week randomized controlled trial. J Acad Nutr Diet. 2018;118(10):1874-1885. doi:10.1016/j.jand.2018.02.009

7. Barbieri JS, Spaccarelli N, Margolis DJ, James WD. Approaches to limit systemic antibiotic use in acne: Systemic alternatives, emerging topical therapies, dietary modification, and laser and light-based treatments. J Am Acad Dermatol. 2019;80(2):538-549. doi:10.1016/j.jaad.2018.09.055

8. Aghasi M, Golzarand M, Shab-Bidar S, Aminianfar A, Omidian M, Taheri F. Dairy intake and acne development: A meta-analysis of observational studies. Clin Nutr. 2019;38(3):1067-1075. doi:10.1016/j.clnu.2018.04.015

9. Penso L, Touvier M, Deschasaux M, et al. Association between adult acne and dietary behaviors: Findings from the NutriNet-Santé Prospective Cohort Study. JAMA Dermatol. 2020;156(8):854-862. doi:10.1001/jamadermatol.2020.160

10. Barbieri JS. Diet and acne-Challenges of translating nutritional epidemiologic research into clinical practice. JAMA Dermatol. 2020;156(8):841-843. doi:10.1001/jamadermatol.2020.1601