7 min|Dr. Maya Kuczma

Understanding the Root Cause of Acne

Wellness, Beauty, Skin Health

What is Acne?

At the root of all breakouts is a clogged pore. Within each pore is a sebaceous gland, a gland that secretes sebum, an oil that keeps the skin protected. If a pore is blocked - by excess oil, dead skin cells, and/or bacteria, a breakout can develop. Blocked pores can develop into a variety of acne lesions:
  • Closed Comedones: also known as whiteheads: a blocked pore, the contents of which are not exposed to the air.
  • Open Comedones: also known as blackheads: a blocked pore with an opening, allowing oxidation of the debris within the follicle.
  • Inflammatory Acne: red and inflamed blocked pores (papules), as well as red and inflamed blocked pores filled with purulent material (pustules); both papules and pustules begin as comedones.
  • Nodular Acne: large and tender blocked pores that remain intact deep beneath the surface of the skin.
  • Nodulocystic Acne: large and tender blocked pores that become inflamed, pus-filled lumps beneath the surface of the skin.
Additional changes in skin health can occur as a consequence of acne, such as post-inflammatory hyperpigmentation, skin pitting, and keloid scars.

Why Does Acne Occur?

Imbalances within the Microbiome

A loss of balance between various species of bacteria, known as dysbiosis, can lead to the development of acne. This imbalance can occur within the microbiome of the gut or skin and can manifest as a variety of skin symptoms, including breakouts. Dysbiosis can act as a trigger for the innate immune system, leading to a heightened inflammatory response within the skin. Although it was once believed that a hyperproliferation of Cutibacterium acnes (C. acnes) bacteria triggered breakouts, it has recently been suggested that a loss of diversity within C. acnes phylotypes plays a role in triggering acne via immune system activation and an increase in inflammatory cytokines. (1)

Additionally, gut microbiome imbalances, such as an increased ratio of Proteobacteria to Actinobacteria, as well as an increased ratio of Bacteroidetes to Firmicutes have been observed in individuals with acne. (2,3) These imbalances may be related to acne by way of increased intestinal permeability, leading to an increased release of inflammatory mediators into the bloodstream. Due to these connections, long term usage of antibiotics as a treatment for acne can further perpetuate an inflammatory cycle, while also creating antimicrobial resistance to antibiotics. (4)

Poor Gut Health

In addition to imbalances within the gut microbiome, food sensitivities, inflammatory foods, and insufficient breakdown of nutrients can all lead to damage of the gut lining known as increased intestinal permeability, or ‘leaky gut’. Impairment in the gut lining can lead to an alteration in the microbiome of the skin, as well as an increase in inflammation; both factors play a role in the pathogenesis of acne. (5) Additionally, insufficient breakdown of nutrients, due to a lack of stomach acid (hypochlorhydria), low bile output, and/or a lack of digestive enzymes (exocrine pancreatic insufficiency) can lead to deficiencies of the nutrients required to maintain a healthy skin barrier, appropriate immune response, and hormonal balance.

Dietary Factors

Vast differences in acne occurrences between Westernized and non-Westernized civilizations appear to be largely due to environmental differences. (6) Specifically, consistent intake of high-glycemic foods, characteristic of a Westernized diet, triggers an increase in insulin (hyperinsulinemia), which can trigger an increase in androgens, leading to an increase in sebum. Additionally, excess insulin release increases IGF-1, a hormone that triggers a rapid increase in skin cells (keratinocyte proliferation), an additional trigger for breakouts. (7) Dairy products, although thought to be relatively low on the glycemic index, paradoxically increases IGF-1, which may explain why dairy acts as an acneic trigger for some individuals. (8)

High glycemic foods → insulin & IGF-1 → androgens → sebum & keratinocyte proliferation

Reduced levels of linoleate, a component of the essential omega-3 fatty acid linoleic acid, in sebum can negatively affect the barrier of the skin. (9) A diet high in omega-6 fatty acids can lead to an imbalanced ratio of omega-6 to omega-3 fatty acids, leading to increased inflammation throughout the body - including the skin. (10) Elevated dietary intake of omega-6 fatty acids is typical within a Western diet, due to the high consumption of seed and vegetable oils (such as soybean oil, corn oil, canola oil, sunflower oil) and the low intake of sources of omega-3 fatty acids, such as coldwater fish, algae, shellfish, flax seeds, chia seeds, and walnuts.

Additionally, a Westernized diet typically includes heavily processed, nutrient-poor food products, rather than nutrient-dense whole foods; suboptimal nutrient levels, such as deficiencies in zinc, vitamin A, and vitamin E have been linked to severity and type of acne lesions. (11,12) Many nutrients are also required to support the liver and gallbladder, as well as hypothalamic-pituitary-adrenal (HPA) axis; inadequate intake can perpetuate imbalances within these organs.

Insufficient Liver Functioning

The liver is responsible for detoxification, as well as breakdown of hormones. A compromised liver, either due to overload of toxins, nutrient deficiencies, dehydration, or genetic abnormalities in detoxification pathways, can lead to a build-up of toxins and/or certain hormones, both of which can affect the health of our skin. Additionally, congestion within other organs of detoxification - such as the lymph, kidneys, and colon - can also lead to skin symptoms.

Genetics

Multiple studies have established a genetic susceptibility to acne formation. (13) Alterations in genes influencing inflammatory responses, the function of sebaceous glands, and androgen production all appear to act as risk variants for acne. (13,14) However, due to the wide variety of factors that play a role in acne, genetic-related susceptibility, while related to an increased tendency towards breakouts, does not guarantee acne will develop.

Irritation

Rupture, via picking or squeezing the skin, chemical peels, lasering, abrasive exfoliation, or alterations of the skin’s natural pH, can all damage the integrity and permeability of the stratum corneum - the outermost layer of the skin. (15) The stratum corneum provides an immunity barrier, antioxidant barrier, antimicrobial barrier, and photoprotection barrier; disruption in the stratum corneum can lead to microbial imbalances, inflammation, increased sebum production, and a build-up of dead skin cells.

Hormonal Triggers

Androgens, such as testosterone and DHT, stimulate sebum production and can cause enlarged sebaceous glands, known as sebaceous hyperplasia. (16) Estrogens help to decrease oil production on the skin, counteracting the effects of testosterone. Estrogen also stimulates synthesis of sex hormone binding globulin, which binds androgens, decreasing levels of testosterone and DHT. (17) A delicate balance is required between estrogen and testosterone to support skin health. (18)


Insulin, the hormone released in response to the intake of glucose, increases production of androgens, while inhibiting synthesis of sex hormone-binding globulin (SHBG); this results in an increase of bioavailable - or active - androgens. (7) Increased levels of insulin also increases IGF-1 and reduces IGFBP3; this shift leads to proliferation of skin cells (keratinocytes). (19) Insulin also stimulates the growth and maturation of sebaceous glands. (20) An elevation of insulin can be due to a high glycemic diet, lack of physical exercise, advanced age, pregnancy, or as a symptom of certain diseases, such as PCOS and diabetes.




Stress-induced release of stress hormones, such as cortisol, has been linked to increased inflammation within the skin, as well as decreased wound healing. (21,22) Additionally, stress-induced release of melanocyte-stimulating hormone stimulates sebum synthesis. (23) Lastly, stress-related increases in acne be due to substance P - a neurotransmitter released during times of stress that stimulates proliferation and differentiation of sebaceous glands. (24)

What is the Best Treatment for Acne?

The root cause of acne is often multifactorial; the optimal treatment plan takes all of these factors into account, in order to support the skin - inside and out. If imbalances are occurring within the body, even the most advanced - or priciest - topical skincare routine cannot eradicate acne on its own. Keep an eye on the blog for our next article on acne, where we will discuss the key components of both internal and external skincare.


Contact us today to book an appointment with a Naturopathic Doctor who can develop an individualized treatment plan that is appropriate for you.


REFERENCES

1. https://link.springer.com/article/10.1007/s40257-020-00531-1 2. https://pubmed.ncbi.nlm.nih.gov/30101990/ 
3. https://pubmed.ncbi.nlm.nih.gov/29756631/
4. https://pubmed.ncbi.nlm.nih.gov/20645527/
5. https://www.mdpi.com/2077-0383/8/7/987
6. https://pubmed.ncbi.nlm.nih.gov/12472346/
7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4565837/
8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4884775/
9. https://www.sciencedirect.com/science/article/pii/S0022202X1545763X
10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7037798/
11. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4135093/
12. https://pubmed.ncbi.nlm.nih.gov/23826827/
13. https://www.nature.com/articles/s41467-018-07459-5
14. https://bmcmedgenomics.biomedcentral.com/articles/10.1186/s12920-021-00953-8
15. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3175800/
16. https://pubmed.ncbi.nlm.nih.gov/1831118/
17. https://www.sciencedirect.com/science/article/pii/S2352647517300291
18. https://pubmed.ncbi.nlm.nih.gov/18786497/
19. https://pubmed.ncbi.nlm.nih.gov/18158933/
20. https://www.dovepress.com/hormonal-treatment-of-acne-vulgaris-an-update-peer-reviewed-fulltext-article-CCID
21. https://pubmed.ncbi.nlm.nih.gov/18704103/
22. https://jamanetwork.com/journals/jamadermatology/article-abstract/479409
23. https://escholarship.org/content/qt8949296f/qt8949296f_noSplash_746548ddbd3349eef6309d29a6c5a898.pdf?t=q98obx
24. https://pubmed.ncbi.nlm.nih.gov/18704103/