What Else Causes Acne?

Previous posts have implicated Western Civilization and face-washing with soap in the etiology of acne. What else might be involved? A reader writes:

My girlfriend suffered from acne for years. She went to a dermatologist, tried every fancy soap and skin cleansing system, but nothing worked. She was also a Diet Coke fanatic. Every morning while she was getting ready for work, like a coffee drinker, she’d have one. It was her daily jolt of caffeine.

When I read about your diet modification, part of which included giving up soda, and your subsequent acne disappearance [I found that Diet Pepsi caused acne], I of course told her about it. “No, it has nothing to do with my diet, it’s hormones and bacteria.” She was not about to give up her beloved Diet Coke! How else could she function in the morning? In the meantime, she would periodically get upset at what she called the “open sores” on her face.

About 9 months ago, she decided to go on a detox diet — not with the aim of treating her acne, but just to lose a couple pounds. It required her to eliminate as many artificial chemicals and preservatives from her diet as possible. Out went the Diet Coke. Within days, her skin cleared up. She hasn’t had a major breakout since.

Yet more evidence that acne is due to lifestyle factors and can be completely cured by lifestyle changes, often dietary. There should be a list somewhere, ordered from most to least likely, of lifestyle causes of acne. If you have acne you just go down the list eliminating each one in turn until you find the culprit.

Acne Self-Experimentation: Why It’s Promising

This article reports that there was no acne whatsoever among the Kitava Islanders in Papua New Guinea and the Ache hunter-gatherers in Paraguay. Here is the abstract:

BACKGROUND: In westernized societies, acne vulgaris is a nearly universal skin disease afflicting 79% to 95% of the adolescent population. In men and women older than 25 years, 40% to 54% have some degree of facial acne, and clinical facial acne persists into middle age in 12% of women and 3% of men. Epidemiological evidence suggests that acne incidence rates are considerably lower in nonwesternized societies. Herein we report the prevalence of acne in 2 nonwesternized populations: the Kitavan Islanders of Papua New Guinea and the Aché hunter-gatherers of Paraguay. Additionally, we analyze how elements in nonwesternized environments may influence the development of acne. OBSERVATIONS: Of 1200 Kitavan subjects examined (including 300 aged 15-25 years), no case of acne (grade 1 with multiple comedones or grades 2-4) was observed. Of 115 Aché subjects examined (including 15 aged 15-25 years) over 843 days, no case of active acne (grades 1-4) was observed. CONCLUSIONS: The astonishing difference in acne incidence rates between nonwesternized and fully modernized societies cannot be solely attributed to genetic differences among populations but likely results from differing environmental factors. Identification of these factors may be useful in the treatment of acne in Western populations.

This implies that acne isn’t inevitable. It’s almost surely caused by something environmental — perhaps diet, perhaps something else (such as washing your face with soap). That’s why self-experimentation about acne is promising: By changing your environment in various ways, you may be able to figure out what’s causing your acne.

Acne Gone Thanks to Self-Experimentation

A year ago I told students at my friend’s Mohamed Ibrahim‘s school that a student of Allen Neuringer’s had gone on a camping trip and found that her acne went away. At first she thought it was the sunshine; but then, by self-experimentation, she discovered that the crucial change was that she had stopped using soap to wash her face.

Now Mohamed writes:

I told my classes about your friend who went camping without her face products only to discover that the face products were contributing to her acne, and that from that point on she only washed her face with water. It turns out that two of my students wash their faces with water! And their skin looks great! I started “washing” my face with water about a month ago, and [now] my face is acne free and soft as a pair of brand new UGG boots. [He had had acne for years.] The only additional thing I do is wipe my face with a napkin throughout the day to remove any excess oil.

So one cause of acne is using soap to wash your face.

Acne really matters. And it’s common. It now turns out that it has a pathetically easy solution, in at least some cases. Dermatologists don’t know this. Apparently hardly anyone knows it. Somehow the entire healthcare establishment, to whom we entrust our health in many ways, missed this. Dennis Mangan’s discovery that niacin can cure restless-leg syndrome is another example of a pathetically easy solution missed by experts. Likewise, the Shangri-La Diet is very different than anything an obesity expert has ever proposed.

What else has been missed?

More Imagine a med student in a dermatology class. The student raises his hand and asks a question. “I read in a blog that acne goes away if you stop using soap. What do you think about that?” What would the instructor say — after telling the student not to believe everything he reads on the Web?

The American Health Paradox: What Causes It? (continued)

Atul Gawande might be the best medical writer ever. He is the best medical writer at The New Yorker, at least, and the best one I’ve ever read. He consistently writes clearly, thoughtfully, and originally about the big issues in medicine. That is why his recent article about health care costs (my comment here) and his graduation speech at the Univesity of Chicago are so telling. And not in a good way, I’m afraid.

The graduation speech starts off with an excellent story:

The program, however, had itself become starved—of money. It couldn’t afford the usual approach. The Sternins had to find different solutions with the resources at hand.

So this is what they decided to do. They went to villages in trouble and got the villagers to help them identify who among them had the best-nourished children—who among them had demonstrated what Jerry Sternin termed a “positive deviance” from the norm. The villagers then visited those mothers at home to see exactly what they were doing.

Just that was revolutionary. The villagers discovered that there were well-nourished children among them, despite the poverty, and that those children’s mothers were breaking with the locally accepted wisdom in all sorts of ways—feeding their children even when they had diarrhea; giving them several small feedings each day rather than one or two big ones; adding sweet-potato greens to the children’s rice despite its being considered a low-class food. The ideas spread and took hold. The program measured the results and posted them in the villages for all to see. In two years, malnutrition dropped sixty-five to eighty-five per cent in every village the Sternins had been to. Their program proved in fact more effective than outside experts were.

Bill Gates, Jeffrey Sachs, are you listening?  Gawande goes on to say that to improve medicine, there needs to be the same sort of study of “positive deviants”. Here is his first example:

I recently heard from one such positive deviant. He is a physician here in Chicago. He’d invested in an imaging center with his colleagues. But they found they were losing money. They had a meeting about what to do just a few weeks ago. The answer, they realized, was to order more imaging for their patients—to push the indications where they could. When he realized what he was being drawn to do by the structure he was in, he pulled out. He lost money. He angered his partners. But it was the right thing to do.

No kidding. The contrast between mothers who figure out creative iconoclastic new ways to feed children on tiny amounts of money and a doctor who merely refuses to be a scumbag could hardly be greater. But Gawande uses the same term (“positive deviant”) for both! This is the depth to which a writer and thinker of Gawande’s stature has to descend, given the straitjacket of how he thinks about medicine. Gawande thinks that doctors will improve medicine. He’s wrong. Just as farmers didn’t invent tractors — nor any of the big improvements in farming — neither will doctors be responsible for any big improvements in American health. The big improvements will come from outside. I’m sure they will involve both (a) advances in prevention and (b) patients taking charge of their care.

When these innovations happen, where will doctors be? Helping spread them or defending the status quo? That’s what Gawande should be writing about. One big advance in patients taking charge was home blood glucose testing. It came from an engineer named Richard Bernstein. Best thing for diabetics since the discovery of insulin. Doctors opposed it. When I invented the Shangri-La Diet, and lost 30 pounds, my doctor didn’t ask how I lost all that weight. Not one question. Like all doctors, he had many fat patients; the notion that I, a mere patient, could know something that would help his other patients didn’t cross his mind. When I was a grad student I did acne experiments on myself that revealed that antibiotics (hugely prescribed for acne) didn’t work. My dermatologist appeared irritated that I had figured this out. That’s a little glimpse of how doctors may react to outside innovation involving patients taking charge. Of course doctors, like dentists, cannot do good prevention research.

If Gawande took the first story he told to heart, he might realize it is saying that the improvements to health care won’t come from doctors, just as the improvements to the health of those village children didn’t come from experts. As I said earlier, doing my best to channel Jane Jacobs, a reasonable health care policy would empower those who benefit from change. That’s what the village nutrition program did. It empowered mothers who were innovating.

Antibiotics Associated with Later Infection

A 2005 study by David Margolis, a dermatology professor at Penn, and others, found that acne patients given long-term antibiotic treatment, which often lasts more than 6 months, were more than twice as likely to have an upper respiratory tract infection during the year after treatment began than acne patients not given antibiotics.

Does this correlation reflect causality? Two additional analyses suggest it does:

1. Perhaps acne patients who get antibiotics are more likely to see a doctor than those who don’t. However, a study of patients diagnosed with high blood pressure, which also requires relatively frequent doctor visits, had the same risk of upper respiratory tract infections as acne patients not given antibiotics.

2. A later study found that the contacts of acne patients (such as their family) are more likely to have upper respiratory tract infections if the acne patient has such an infection — as you’d expect from contagion. But it makes no difference to these contacts if the acne patient was given antibiotics or not. This means that acne patients given antibiotics do not live in more infection-prone surroundings than acne patients not given antibiotics.

Bottom line: Support for the idea that the bacteria in our body help us stay healthy.

A Second Opinion: You’ve Been Poisoned by Your Doctor

In a wonderful profile of master diagnostician Dr. Thomas Bolte, this especially pleased me:

Many of the patients Bolte sees are victims of iatrogenic, or doctor-caused, illness. Simply put, they have been misdiagnosed, overmedicated to the point of sickness, or given treatment inappropriate to their conditions. On occasion, this has led to shouting matches with more conventional docs, like the dermatologist colleague who burst into Bolte’s office one day and harangued him—in front of another patient—for telling the mom of an acne-ridden teen to stop feeding her child so much junk food. There’s no evidence that diet has anything to do with acne, the dermatologist shouted. Bolte begged to differ and cited the literature. “The pharmaceutical industry has trained even doctors to believe that there’s a pharmaceutical answer to everything,” he says, shrugging.

A large fraction of Bolte’s patients have been poisoned. They get better when the poison is stopped. The mother of a friend of mine was near death — so near that her children decided to put her in a hospice. By mistake her six or seven medicines were stopped. And she recovered! Her medicines were what had been killing her.

The technical term for such horrors is drug interaction.

Thanks to Dave Lull.

Diet and Acne (continued)

I’ve blogged several times about environmental causes of acne, especially diet. Cynthia Graber, a science journalist, wrote a whole article about diet and acne, a link that dermatologists deny much more strongly than the evidence warranted. Why do they act so sure? I asked Graber. Because, low on the medical totem pole, they want to appear more scientific, she said. Genetics and drugs — that’s science. Diet — that isn’t science.

Here is more data on the subject, from two widely-different sources. The first is a comment on Dennis Mangan’s blog:

I had some acne when I was a teen. I was considered a very “pretty” teenager, but was painfully shy whenever my face “broke out”. I remember going to a dermatologist who put me on a sulfur cream and antibiotics for it. He emphasized over and over that diet “had absolutely nothing” to do with it, and that I should eat whatever I wanted and that “only by eating huge amounts of fish” could I actually aggravate it.

I still had some breakouts even until my twenties every so often. Because I was basically bodybuilding as a “hobby”, I switched to diet colas and started eating a great deal of tuna and canned chicken around this time. Guess what? The acne completely went away at about 21 and didn’t come back until about 26. At 26 I had some hard bumps under my chin like boils. The dermatologist said they were folliculitis and told me to make sure my razors were dry and my sink was super clean. But I noted that I had drifted back to a fast food diet and was drinking regular colas again–and kind of power-lifting a couple of days a week but not hitting it hard.

I got back into it at the gym, and wanted a six-pack again. I went back to diet cola and started dieting again. The result? The acne completely went away. This time I made a connection.

I have sworn up and down to some of my friends that I think our diets might lead to acne when we’re teens. One of my pals, Myron, took his kids (both teens) off cokes and instant soups and started cooking for them and making them drink orange juice and apple juice and tea. Their faces completely cleared up (they were 14 and 16) in about two months. No trips to the doctor, no anti-bacterial soaps, nothing. Just diet. They have had lovely clear skin ever since.

I have another friend at work whose teenage daughter “got off” colas and he started cooking for her (single parent). Her face cleared up. He mentioned it. She was a pretty girl but used to break out fairly badly. According to him, she’s on top of the world now that her skin is cleared up and is confident (and she should be because she really is a cutie).

I read a little bit about the study doctors cite about acne and diet. They fed a big chocolate bar to one group and fed another a CANDY bar that didn’t contain chocolate to another group. Since both groups had acne at the same levels, they declared that diet had nothing to do with acne. WHAT HOGWASH!!!!! If they were both drinking sodas, both eating tons of refined white flour, white pasta, and both eating a big candy bar (so what if one was toffee and one was chocolate) every day, they still were eating a “western diet”.

Anyway, I’ve read about the severe uptick in acne in newly “Westernized” populations. I’ve read about the rate of prostate difficulties of Asian-Americans versus rural Asians. Diets do INDEED affect much more about ourselves than we’d like to admit. I can guarantee you, because I’ve seen it on my own face and have friends who I trust who have seen it on the faces of their children, that diet does indeed influence acne and that high glycemic index foods and colas and sugars certainly worsen it at the least.

The thing that REALLY got me thinking this was a few years ago, I saw a couple of very Indian-looking Mexican teenagers. They didn’t look like they had a drop of European blood in them. They had BAD acne on their cheeks. Hell, I thought those people never broke out, yet there they were at a convenience store buying two colas and potato chips–looking like Oxy poster-children.

The second source is Arbor Clinical Nutrition Updates, an excellent Australian publication aimed at nutrition professionals. The latest update, which I cannot link to, is about acne and diet. From its conclusions:

For many years the conventional wisdom dispensed by physicians on the relationship between diet and acne vulgaris has been that there is none. In a recent study, the fact that nearly a half of a group of final year medical students believed that diet was an important factor in acne was held to be an unfortunate misconception “likely to perpetuate misinformation in the community.”

The “expert view” from doctors is in stark contrast to what their patients think. Many studies have shown that the average person is under the distinct impression that diet can indeed affect acne, particularly fatty foods and chocolate.

A careful look into this question reveals something rather fascinating — that although medical textbooks used to strongly support the idea of “acne diets”, in the last 50 years this has completely reversed. Yet experts’ current confidence that there is nothing to the diet-acne story is itself based on almost no evidence.

The update describes two studies. One found that a low-glycemic-index diet reduced acne. The other found that, in teenage boys, greater milk consumption was associated with slightly more acne.

More Maybe Graber was too kind. Confidence that diet had nothing to do with acne allowed dermatologists to prescribe dangerous and expensive drugs. I wish I could be sure no payola was involved, but — given a horrifying story in today’s NY Times about several psychiatrists’ total and dishonest disregard of conflict-of-interest rules — I can’t. From the article:

From 2000 through 2006, Dr. [Charles] Nemeroff [of Emory University] earned more than $960,000 from GlaxoSmithKline but listed earnings of less than $35,000 for the period on his university disclosure forms, according to Congressional documents. Sarah Alspach, a GlaxoSmithKline spokeswoman, stated in an e-mail message that “Dr. Nemeroff is a recognized world leader in the field of psychiatry.”

What does that say about psychiatry?

Shannon Brownlee on the subject. A blog on the subject. A letter from Senator Charles Grassley to James Wagner, the president of Emory, describing Nemeroff’s behavior and asking for more information.

If Weston Price Had Been a Dermatologist

This review article — comparing several commonly-prescribed treatments for acne — ends up close to what I figured out as a graduate student via self-experimentation: that benzoyl peroxide works much better than antibiotics.

I like to think that in 100 years people will look back on current treatments for acne (and a hundred other things) as medieval, like leeches. If Weston Price had been a dermatologist, we would now have evidence, I’m sure, that certain traditional lifestyles produce very low rates of acne. Examination of those lifestyles would provide good clues about what aspects of our way of life cause acne. That would be a good starting point for experiments to zero in on what matters. Once we knew the environmental causes of acne, such as caffeine or soap, they could simply be avoided; no need for powerful dangerous expensive medicines. At the moment, however, determination of what aspects of modern life cause acne isn’t even close to being studied. You might think it is better to study safe cheap cures than dangerous expensive ones but you’d be wrong. At least now.

More Acne Self-Experimentation

This post from the self-experimentation forums deserves to be reprinted in full:

After being plagued with acne for years, I took a job which caused me to work in remote bush camps for short periods in the far north. My acne would invariably disappear within a few days of exposure to this. When I returned to the city, the acne would return with a vengeance. Did not know why.

My theory: Soap residue left after washing my face with hardwater was the true acne culprit. Washing my face with ultrasoft lake water in bush camps leaves little or no soap residue, so no acne. Soap residue stimulates excessive skin oil secretions which leads to increased acne. A rich diet aggravates the problem by feeding the oil secretions.

My self-experiment
: I experimented with different types of soap and different concentrations of soap in hard and soft water.

: Soft and slightly soapy water only (a very mild soap) produced the least amount of acne. Never apply soap lather directly to your face! If you have only hard water to work with, then no soap at all is the best choice by far. Compensate for the lack of soap with hotter water.

Added benefit: Washing your face with no soap causes acne lesions to heal much faster – a couple of days compared to a week or more with soap.

Great work!

The same technique applied to cold sores.

More about Acne (continued)

When I was a teenager, my dermatologist gave me a long list of foods that might cause acne. It wasn’t any help at the time but later, when my acne was better, it helped me realize that drinking Diet Pepsi caused me to get acne 2 or 3 days later because “cola drinks” was on the list.

Now I learn from Tucker Max that it was probably the caffeine that did it:

I had bad acne in high school. I cut all caffeine out of my diet–cola, chocolate, etc–and about 90% of the acne went away. I got the rest with Accutane.

Very useful information. The list my dermatologist gave me was too long and too homogenous. “The acne caffeine link is well-known to dermatologists,” Tucker added. Except those who claim acne has nothing to do with diet.

More about Acne

The highlight of my recent trip to New York was a talk I gave at Landmark High School, a public high school near Columbus Circle. The students paid close attention. Afterwards, a student named John Cortez told me what he’d figured out about what causes his acne. His skin was clear so I had to believe he knew what he was talking about.

He has three rules: 1. Eat less greasy food. 2. Work out hard. 3. Wash face extremely well, especially after working out. The last rule is surprising because one of Allen Neuringer’s students found that acne got better when she stopped washing her face. John explained his reasoning like this:

When I was little I got something because of the lack of hand washing. Nothing serious — it went away — but it caused me to become sort of a neat freak. When i started to get pimples I thought it was because i didn’t wash my face well. When i started to wash my face better, my acne stopped getting worse. One day i got lazy and from there on I stopped washing. Then I noticed that I was almost covered with pimples. When I got in a gym I realized that when i sweat and as soon as possible, washed my face got less pimples and prevented those nasty huge acne.

Amount JC figured out about acne while in high school: A lot. Amount SR figured about acne while in high school: Zero.

Addendum. Another unexpected aftereffect of my talk was that Shangri-La Diet forum traffic went way up. That evening, at one point there were 307 people simultaneously reading the forums, a new record. The average daily maximum during the days just before was about 150. There were about 50 people at my talk. Go figure.

Diet and Acne

Two years ago I guest-blogged at the Freakonomics blog about diet and acne. I wrote that the claim of dermatologists that there is no link between diet and acne was absurd, not only because I had seen for myself such a link but also because it was an impossibly broad generalization.

In an article in the Boston Globe, Cynthia Graber, a science journalist, describes quite a bit of evidence that yes, diet affects acne. The research on which the no-link claim was based tested only two foods (chocolate and sugar)! From which committees of dermatologists generalized to all foods.

SO WHY HAVE DOCTORS been taught for so long that there’s no link? The anti-diet hypothesis . . . arose solely from two studies from the late 1960s and early 1970s. . . . One compares real chocolate bars with fake ones and was conducted at the University of Pennsylvania School of Medicine with funding from the Chocolate Manufacturers Association. . . . The other study examines sugar in the diet of a small group.

It’s like that scene in the Wizard of Oz where the Great Oz is revealed to be an ordinary man behind a curtain. All those knowledgeable-sounding claims by dermatologists, based on nothing more than this.

Conventional research on the subject is difficult, both because of funding problems — drug companies won’t fund such research; and dairy farmers won’t fund experiments to find out if dairy causes acne — and because it’s clear that many different foods are involved. On the other hand, determining the effect of Food X or Y on your own acne is easy. I wonder why someone doesn’t build a website to gather information from such self-experiments. If I had superpowers, I would.

More about diet and acne.