What causes it?

According to the National Institute of Health, acne is an inflammatory disorder of the skin. In healthy skin, the sebaceous (oil) glands make sebum that empties onto the skin surface through the pore, which is an opening in the follicle. Keratinocytes, a type of skin cell, line the follicle.  Normally as the body sheds skin cells, the keratinocytes rise to the surface of the skin. When someone has acne, the hair, sebum, and keratinocytes stick together inside the pore. This prevents the keratinocytes from shedding and keeps the sebum from reaching the surface of the skin. The mixture of oil and cells allows bacteria that normally live on the skin to grow in the plugged follicles and cause inflammation—swelling, redness, heat, and pain. When the wall of the plugged follicle breaks down, it spills the bacteria, skin cells, and sebum into nearby skin, creating lesions or pimples.

Concerning the cause of inflammation that leads to acne, it can vary for everyone. Some known causes, per the NIH, are:

• Excess or high production of oil in the pore.
• Buildup of dead skin cells in the pore.
• Growth of bacteria in the pore.
• Hormones. An increase in androgens, which are male sex hormones, may lead to acne. These increase in both boys and girls normally during puberty and cause the sebaceous glands to enlarge and make more sebum. Hormonal changes related to pregnancy can also cause acne. 
• Family history. Researchers believe that you may be more likely to get acne if your parents had acne.
• Medications. Certain medications, such as medications that contain hormones, corticosteroids, and lithium, can cause acne.
• Age. People of all ages can get acne, but it is more common in teens.

Additionally, the following factors may also contribute to inflammation:

• Diet. Some studies show that eating certain foods may make acne worse especially in relation to the gut flora.
• Stress + Mental Health.
• Pressure from sports helmets, tight clothes, or backpacks.
• Environmental irritants, such as pollution and high humidity.
• Skin Microbiome (see more below).
• Squeezing or picking at blemishes.
• Scrubbing your skin too hard.¹

Concerning the skin, it is important to understand the role the skin microbiota has in the body. “The term microbiome (microbiota) describes the entirety of microorganisms present in a given habitat. The skin is the most external organ of our body and is inhabited by bacteria, viruses, fungi, and mites. Most of the microorganisms that inhabit the skin are harmless to the skin and live in symbiosis with skin cells.”³

Human skin, which covers an area of 2 m² in adults, is the body’s largest organ and provides the first line of defense against external agents. The skin functions as both a physical and immunological barrier, performing a wide range of innate and adaptive immune functions. Resident skin microbes stabilize the host’s barrier by fighting off pathogens, interacting with immune cells in the skin, and modifying host immunity. Therefore, the skin microbiota is as an essential part of human health, and dysbiosis is thought to cause or aggravate skin diseases.

Environmental factors such as the use of soaps, cosmetics, antibiotics, occupation, temperature, humidity, and UV exposure also influence microbial colonization. 

Potential Role of the Microbiome in Acne: A Comprehensive Review

What are the symptoms?

Acne causes several types of lesions, or pimples. Enlarged or plugged hair follicles as referred to as comedones. Types of acne include:

• Whiteheads: Plugged hair follicles that stay beneath the skin and produce a white bump.
• Blackheads: Plugged follicles that reach the surface of the skin and open up. They look black on the skin surface because the air discolors the sebum, not because they are dirty.
• Papules: Inflamed lesions that usually appear as small, pink bumps on the skin and can be tender to the touch.
• Pustules or pimples: Papules topped by white or yellow pus-filled lesions that may be red at the base.
• Nodules: Large, painful solid lesions that are lodged deep within the skin.
• Severe nodular acne (sometimes called cystic acne): Deep, painful, pus-filled lesions.¹

In addition to the physical manifestations of acne, there are potential psychological symptoms especially for those that suffer from severe acne.

Severe forms of acne can cause disfiguration and scarring, resulting in low self-esteem, difficulties in social interaction, and psychological distress.

Potential Role of the Microbiome in Acne: A Comprehensive Review

Prevention

If you are prone to acne, the following recommendations from the NIH may help you in taking care of your skin.

• Clean your skin gently. Use a mild cleanser in the morning, in the evening, and after heavy exercise. Try to avoid using strong soaps, astringents, or rough scrub pads. Rinse your skin with lukewarm water.
• Shampoo your hair regularly, especially if you have oily hair.
• Avoid rubbing and touching skin lesions. Squeezing or picking blemishes can cause scars or dark blotches to develop.
• Shave carefully. Make sure the blade is sharp, and soften the hair with soap and water before applying shaving cream. Shave gently and only when necessary to reduce the risk of nicking blemishes.
• Use non-toxic sunscreen when needed to avoid sunburn and suntan. Many of the medicines used to treat acne can make you more prone to sunburn.
• Choose cosmetics carefully. Choose products labeled noncomedogenic, which means they do not clog pores. In some people, however, even these products may make acne worse.

For product recommendations, scroll to the bottom of this webpage.

Diagnosis

Per the NIH, healthcare providers such as dermatologists, family doctors, internists, or pediatricians will ask the following questions to diagnose acne:

• Ask about your family history, and, for girls or women, ask about their menstrual cycles.
• Ask you about your symptoms, including how long you have had acne.
• Ask what medications you are currently taking or recently stopped.
• Examine your skin to help determine the type of acne lesion.
• Order lab work to determine if another condition or medical disorder is causing the acne.

Treatment

There are many treatment options for acne. Here are some factors and treatments to research:

Nutrition

Even though many .gov sources state diet is not connected to acne inflammation, growing evidence shows there is a connection between gut and skin health. Let’s discuss.

The skin and gut, both heavily vascularized and richly innervated organs with critical neuroendocrine and immune functions, are somewhat similar. Interestingly, mounting evidence suggests that the two organs have a bidirectional connection, and many studies link intestinal health to skin homeostasis and allostasis.

In addition, evidence suggests that the gut flora can affect the skin more directly, by transporting the gut microbiota to the skin. When the intestinal barrier is disrupted, gut microbiota and their metabolites quickly enter the bloodstream, accumulate in the skin, and disturb the skin equilibrium.

In recent years, the role of environmental factors, especially the Western diet, has been raised in acne pathogenesis. The Western diet includes dairy products, refined carbohydrates, chocolate, and saturated fat, which may aggravate acne by activating nutrient-derived metabolic signals. Evidence also indicates that the intestinal flora associated with the Western diet contribute to inflammatory skin diseases. For instance, high-fat diets reduce the level of gut flora and increase the concentration of lipopolysaccharides, causing systemic inflammation by impairing colonic epithelial integrity and barrier function, decreasing mucus layer thickness, and increasing the secretion of pro-inflammatory cytokines.

In a study by Deng et al., acne patients exhibited lower gut microbiota diversity and a higher ratio of Bacteroidetes to Firmicutes, which is an enterotype of the Western diet. In addition, Yan et al. found a decrease in Lactobacillus, Bifidobacterium, Butyricicoccus, Coprobacillus, and Allobaculum in acne patients compared with controls, which provides a new understanding of the link between acne and the alteration of gut flora. Lactobacillus and Bifidobacterium are common probiotic species that balance the intestinal microbiota by fermenting unabsorbed oligosaccharides in the upper gut. They also strengthen the intestinal barrier by decreasing permeability and enhancing the epithelial resistance of the gut. In addition, Bifidobacterium and Lactobacillus encourage the production of CD4+Foxp3+T cells (regulatory T cells), and regulatory dendritic cells, suppressing T helper cell and B cell response and cytokine production. Butyricicoccus generates butyrate, which provides energy to cells and prevents mucosal barrier damage and inflammation.

Probiotics are living microorganisms that are beneficial to the host’s health. Upon ingestion, they provide a protective shield across the intestinal mucosa. The most commonly used and therefore, the best studied probiotic strains to date are Lactobacillus and Bifidobacterium. The official definition of prebiotics is a non-digestible food component that benefits the host by stimulating the growth or activity of bacterial species present in the colon. Although oral probiotics/prebiotics have been used in the past to prevent and treat bowel disease, evidence suggests that by adjusting the composition of the microbial community, probiotics induce immune reactions that expand beyond the gut to act on the skin.

Until recently, diet and psychological stress were thought to have little relevance to the pathophysiology of acne. However, with the understanding that the brain–gut–skin axis exists, it is now clear that intestinal microbes have significant effects on acne. As understanding of the microbiome in healthy skin and the pathophysiology of acne continues to develop, new therapeutic targets are arising. Novel systemic and topical interventions that influence the microbiota (i.e., probiotics, prebiotics), custom tailored to each patient according to their unique microbial ‘fingerprint’, are worthy of intense research.

Potential Role of the Microbiome in Acne: A Comprehensive Review

In basic terms, researchers state that, “An increasing number of studies indicate that the health of the intestines is related to the health of the skin”³

The Western diet disturbs the balance between beneficial and pathogenic microorganisms, which contributes to inflammation, including inflammatory skin diseases. Stress also disturbs eubiosis, and bacteria Lactobacillus and Bifidobacterium are particularly sensitive to its effects. In stressful situations, microorganisms can produce neurotransmitters that are inflammatory for the body.

Microbiome and Probiotics in Acne Vulgaris—A Narrative Review

So what does all that mean? It means there are several things you can adjust with your diet that may positively influence your skin (and heal your acne). Here are some things to research deeper:

• Anti-Inflammatory Diet According to the U.S. Department of Veterans Affairs, “over 60% of all chronic disease could be prevented if people ate a healthy diet.” An anti-inflammatory diet seeks to increase the foods that help calm inflammatory responses and decrease the foods that cause inflammation. An excellent resource for an anti-inflammatory diet is Dr. Ashley Turner.
• Hair Mineral Analysis This can be done through your healthcare provider and may help identify any supplementation needs in your diet. Additionally, a hair mineral analysis can identify absorption issues like dealing with an abundance of heavy metals. If you struggle with hormones, another fantastic resource that offers hair mineral analysis training is Master Your Minerals with Amanda Montalvo.
• Food Sensitivity Test To quickly narrow foods that may cause inflammation, a food sensitivity test may be helpful. This also can be done through your healthcare provider. However, there are at-home testing options like this one.
• Elimination Diet An alternative to a food sensitivity test is to conduct an elimination diet to observe any changes in your acne based on foods you eliminate from your diet for an extended period of time. Here is a general guideline, however there are many other ways to conduct an elimination diet to fit your lifestyle.
• Oral Probiotics As discussed above, probiotics may help treat acne. Scroll to the bottom of this webpage for recommendations.

Pharmaceutical medications

Per the NIH, here are some of the over-the-counter or prescription medications your healthcare provider may recommend. Be sure to read the manufacturer insert for any recommended medical products.

• Topical Medications
  • Over-the-counter products, such as benzoyl peroxide, which kills bacteria and may decrease the production of sebum.
  • Antibiotics, which are usually used with other topical medications.
  • Retinoids, which come from vitamin A and can help treat lesions and reduce inflammation. They can also help prevent the formation of acne and help with scarring.
  • Salicylic acid, which helps break down blackheads and whiteheads and also helps reduce the shedding of cells lining the hair follicles.
  • Sulfur, which helps break down blackheads and whiteheads.
• Oral Medications
  • Antibiotics, which help slow or stop the growth of bacteria and reduce inflammation. Doctors usually prescribe antibiotics for moderate to severe acne, such as severe nodular acne (also called cystic acne).
  • Isotretinoin, an oral retinoid, which works through the blood stream to help treat acne and open up the pore.  This allows other medications, such as antibiotics, to enter the follicles and treat the acne. Similar to topical retinoids, taking the medication by mouth can also help prevent the formation of acne and help with scarring.
  • Hormone therapy, used primarily in women, which helps stop the effects of androgens on the sebaceous gland.
  • Corticosteroids, which help lower inflammation in severe acne, including severe nodular acne. 

If you are unsure which manufacturer insert to research, ask your healthcare provider for the trade name. For example, the following antibiotics are commonly recommended for acne:

• Macrolides
  • Erythromycin
  • Roxithromycin
  • Clarithromycin
  • Azithromycin
• Clindamycin (lincosamide)
• Tetracyclines
  • Doxycycline
  • Tetracycline
  • Minocycline²

Note: the inserts linked above may be just one form of the antibiotic. Be sure to confirm the recommended route of administration and antibiotic trade name with your healthcare provider. If you need help reading the insert, click here for a free training course.

What about antibiotic resistance?

C. acnes resistance to antibiotics has increased over the years and become a worldwide problem in acne patients, with higher rates of resistance being reported for clindamycin (lincosamide) (36–90%) and erythromycin (macrolide) (21–98%) than for tetracyclines (4–16%).

Potential Role of the Microbiome in Acne: A Comprehensive Review

Concerning acne scar treatment, healthcare providers may recommend the following:

• Laser and other light therapies. However, researchers are still studying the best types of light and the amount needed to treat acne.
• Injecting corticosteroids directly into affected areas of your skin.
• Superficial chemical peels that a doctor recommends and applies to the area.
• Filling acne scars with a substance to improve their appearance.
• Treating acne scars with tiny needles to help induce healing. 
• Surgical procedures to help treat and repair scarring.¹

Frequent facials

Facials might seem like an indulgence, however for those that struggle with severe acne, it can help immensely. Here are some of the benefits of frequent facials:

• Exfoliation Help unclog your pores and remove dead skin cells.
• Deep Cleansing Remove impurities and excess oil from the skin.
• Extraction Remove existing blemishes carefully without damaging the skin to prevent scarring.
• Light therapy Reduce inflammation and kill bacteria that can cause acne.

Be picky when finding a skin professional for your facial. Osmosis-trained skincare professionals are highly recommended.

Stress management

According to a study conducted in 2019, acne “has close connections with the gastrointestinal tract, and many argue that the gut microbiota could be involved in the pathogenic process of acne. The emotions of stress (e.g., depression and anxiety), for instance, have been hypothesized to aggravate acne by altering the gut microbiota and increasing intestinal permeability, potentially contributing to skin inflammation.”

Furthermore, “the connection between acne and gastrointestinal dysfunction can originate in the brain. Supporting this hypothesis is the stress-induced aggravation of acne. Experimental animal and human studies have shown that stress impairs the normal gut microflora, most notably Lactobacillus and Bifidobacterium species. Psychological stressors cause intestinal microbes to produce neurotransmitters (i.e., acetylcholine, serotonin, norepinephrine) that cross the intestinal mucosa to enter the blood stream, resulting in systemic inflammation.”

Some ways to reduce stress include: yoga/stretching, mindfulness/breathing exercising, journaling, and finding an enjoyable hobby.

Homeopathy

As discussed above, acne is an inflammatory disorder of the skin. The source of inflammation may differ for each person, therefore be sure to work with an experienced homeopath before utilizing homeopathy for acne.

Herbal topical products

Based on a scientific review titled “Medicinal Plants for the Treatment of Acne Vulgaris,” products with the following plants may help prevent and treat acne:

• Matricaria recutita (chamomile)
• Calendula officinalis (calendula)
• Triticum aestivum (wheat grass)
• Hamamelis virginiana (witch hazel)
• Aloe vera
• Camellia sinensis (green tea)
• Achyranthes aspera (chaff flower)
• Rosmarinus officinalis (rosemary oil)
• Melaleuca alternifolia (tea tree)
• Eucalyptus globulus, E. viminalis and E. maculata

¹ National Institute of Health

² Potential Role of the Microbiome in Acne

³ Microbiome and Probiotics in Acne Vulgaris—A Narrative Review

Products to Research

Topical Products

Rowe Casa Organics Anti-Blemish Face Wash

$18.40 with discount | For your first Rowe Casa Organics order, use discount code “JUSTTHEINSERTS” for 20% off.

Clean and purify your skin with the anti-inflammatory and antimicrobial properties of tea tree oil. The cooling effects of peppermint will leave your face feeling fresh and restored. Ideal for combatting hormonal breakouts and oil-prone skin.

Rowe Casa Organics Anti-Blemish Spot Relief

$18.40 with discount | For your first Rowe Casa Organics order, use discount code “JUSTTHEINSERTS” for 20% off.

This soothing blend of witch hazel and rose water combined with the power of frankincense, lavender, tea tree, and more make these drops both powerful and effective for combating breakouts and blemishes.

TO USE: Apply 2–3 swipes to blemishes daily and gently massage.

Probiotics

Just Ingredients Probiotic Complex “JUSTTHEINSERTS10” for 10% off

3-In-1 Pre, Pro & Postbiotic Complex

• Prebiotics: Food for the good microorganisms. Non-digestible fibers and compounds found in certain foods that provide nourishment for beneficial gut bacteria, helping them thrive and promote a healthy gut microbiome.
• Probiotics: Live beneficial microorganisms, often referred to as “good bacteria,” that grow in the gut tract. When consumed in adequate amounts, they can have positive effects on the balance of the gut microbiota and overall digestive health.
• Postbiotics: nutrient byproducts of prebiotic and probiotic bacteria fermentation that offer health benefits. These compounds include short-chain fatty acids, peptides, and other molecules that can influence the gut environment and support well-being.

Ingredients: Organic Elderberry Powder, Inulin (Chicory Root, Agave Leaf and Stem), Probiotic Blend 5 Billion CFU (Bacillus clausii SC 109, Bacillus subtillis HU58, Bacillus coagulans SC208, Bacillus magaterium, Bacillus licheniformis), Kombucha Powder*, Ginger Extract, Citric Acid (Cassava Root), Lemon Extract, Stevia Leaf*, Monk Fruit*

Also available in Lemon Ginger.

Kuma Glow Biome Clear Skin Probiotic

Glow Biome contains 6-clinically validated probiotics strains + prebiotics that support the gut skin connection. It is nutritionist-formulated and contains clinically validated ingredients including Lactobacillus plantarum Lp-115, Lacticaseibacillus rhamnosus SP1, Lacticaseibacillus rhamnosus GG, Bifidobacterium animalis ssp. lactis BLC1, Lacticaseibacillus paracasei Lpc-37, and Lactobacillus acidophilus La-14.

Glow Biome is made in an NSF-Certified facility and third party tested for purity and potency. It is free of GMOs, soy, dairy, egg, corn, wheat, gluten, fish/shellfish, peanuts/nuts/tree nuts, artificial colors or preservatives, or any flavors or sweeteners.

Helpful Resources

Anti-Inflammatory + Elimination Diet Book

The book is a cookbook and lifestyle guide for helping those with chronic illness, leaky gut, or autoimmune diseases. While the book is written for those struggling with chronic illness, it is also for anyone who desires to pursue vibrant wellness. The elimination diet removes foods that are known to drive inflammation and symptoms as well as a careful reintroduction period to rule out food reactions. This plan is designed to remove potentially problematic foods in order to decrease inflammation in the body, rebalance the gut flora, soothe the gut lining, regulate blood sugar, modulate the immune system, resolve nutrient deficiencies, and bring overall healing to the body.

Food Sensitivity Test

The test measures IgG antibody reactivity to 96 different foods from a small blood sample. You can then use your results to help guide a two-part elimination diet to pinpoint the foods you’re sensitive to. (Note: food sensitivities are different than food allergies and intolerances. This is not an allergy test.) Test not available in the following states: New York, Rhode Island, New Jersey. Test Taker Ages 18+