Acne Vulgaris

Acne is an erythematous, irritating skin rash that primarily affects young adults, but can occur at all ages. It typically appears in the sebum-producing areas of the body including the face, chest, and back, and less often on the neck and upper arms. Most people that have experienced acne can attest to the negative effect that this condition can have upon the psyche, particularly in adolescents who are just becoming aware of their social image and physical appearance, but also in adults, who may feel burdened by what is generally thought of as a disease of teenagers. Chronic acne can have a negative impact upon self-esteem and self-confidence and can lead to withdrawal and even depression. Left untreated severe acne can lead to disfiguring scars, which can further compound the issue of self-image.

Acne is often associated with uncleanliness, particularly with the formation of “blackheads,” which may appear to be “dirt” trapped inside the pores. In actual fact however, excessive cleanliness and extraction of blackheads (especially with non-sterile implements) may worsen the condition by promoting disturbances in the delicate ecology that forms on the skin.

There are several factors that contribute synergistically to the development of acne. The primary mechanism is attributed to the abnormal flaking and hyperkeratinization of cells within a hair follicle leading to the formation of a plug, which can enlarge and even rupture the hair follicle. Once a ruptured hair follicle spills its contents of oil and debris into the skin it leads to swelling and localized inflammation. Commensal bacteria that live on the skin, and in particular a strain of bacteria called the Propionibacterium, secrete enzymes that dissolve the sebum. The formation of the plug is enhanced by the activity of the androgens, the secretion of which peaks during adolescence and promotes the enlargement of and increases the activity within the sebaceous glands, providing more nutrients for the bacteria. Although the androgens are secreted in much larger volumes in males, they are also present in females, although the effect is to some extent countered by the estrogens. Thus young women will often notice that their acne worsens premenstrually as the levels of estrogen drop off to promote menstruation. (Harper 2005; Berkow 1992)

There are two major types of acne lesions: noninflammatory and inflammatory. Noninflammatory acne lesions include blackheads (open comedones) and whiteheads (closed comedones). Although blackheads are often thought to contain dirt, in actual fact open comedones contain oxidized sebum, which has characteristic black color. In contrast, a closed comedone or whitehead is not exposed to oxygen and thus does not turn black, but appears a tiny, sometimes pinkish bump on the skin. When open and closed comedones manifest with papules and pustules this is referred to as papulopustular acne, which is a form of inflammatory acne. Papules are closed comedones that have become red, swollen, and inflamed (i.e. “blemishes”). Pustules are closed comedoness that have become inflamed and begin to rupture into the skin forming pustules heads of various sizes (i.e. “pimples,” “zits”). The severest form of acne is nodular acne, representing large, tender, swollen acne lesions, that have become intensely inflamed and rupture under the skin. If left untreated nodular acne can produce deep scarring. (Harper 2005; Berkow 1992)

Medical treatment

For mild to moderate acne most doctors will recommend simple hygienic measures including water, soap, and antiseptics such as benzoyl peroxide. More severe forms of acne are often treated both topically and systemically by antibiotics, retinoids, and in young women, birth control pills.

Holistic treatment

Holistic measures to control acne are somewhat different than conventional methods. In particular, greater attention is directed to maintaining the normal ecology of the skin, and thus measures such as soap and antiseptics are avoided because they tend to disturb this delicate ecology. Instead, measures are taken to limit sebum production by the using of agents that “tone” the skin, rather than strip oils away from the skin that encourages even greater sebum production. Among the best agents for this purpose is cold water, which can be applied in liberal volumes splashed over the face 5-6 times daily to promote local vasocontriction. This can be used in association with mild facial scrubs, once or twice daily, prepared with botanicals that combine a gentle astringent activity with a demulcent effect, toning the skin while relieving inflammation:

Exfoliation powder

Adzuki beans
Yellow Pond Lily root
Oat groats

Combine as equal parts, and grind to a moderately fine powder. Apply to moistened skin and scrub gently. Rinse face well with cool water and pat face dry with a clean towel.

Teenage acne represents a period of reproductive excess, and often, an accompanying burden upon the liver whose job it is to deactivate and eliminate these circulating hormones. While attempting to downregulate hormonal secretion is probably unwise, herbalists can support the deactivation of these hormones by enhancing liver catabolism. Used in conjunction with alteratives such as Burdock, Alfalfa, Gokshura, and Echinacea to pull toxins away from the skin, cholagogues such as Dandelion root, Barberry, Buplerum and Fringetree can be safely used along with gentle aperients such as Yellowdock, Cascara, and the Ayurvedic formula Triphala to promote the elimination of these compounds. Botanicals that have an amphoteric activity on neuroendocrinal function can also be helpful including Kelp and Eleuthero. In females botanicals that inhibit androgenization such as Saw Palmetto can be helpful, as well as progesterogenic botanicals such as Peony and Vitex along with weak estrogenic botanicals such as Dan Gui, Black Cohosh and Unicorn root to help regulate the menstrual cycle.

Although most medical doctors believe that there is no physiological connection between diet and acne, these assumptions are based on suspect data that is more than 30 years old. Recent research has demonstrated a link between a high glycemic diet and acne vulgaris (Cordain 2003). In a recent study examining the prevalence of acne vulgaris in non-industrialized societies of the Kitavan Islanders of Papua New Guinea and the Aché hunter-gatherers of Paraguay, Cordain et al found that the prevalence of acne in these societies is virtually non-existent, compared with a nearly universal incidence in the West, afflicting 79% to 95% of the adolescent population, and 40% to 54% of adults above the age of 25 (2003). In addition to being much higher in omega-3 fatty acids, the diets consumed by the Kitavans and Aché also include increased quantities of plant-derived antioxidant vitamins, minerals, and phytochemicals that support antioxidant pathways. Recent research demonstrates that omega-3 fatty acids can increase insulinlike growth factor binding protein in animals and decrease insulinlike growth factor-1 in healthy humans (Li et al 1999; Bhathena et al 1991). Thus a diet high in omega-3 fatty acids could be involved in the prevention of the hyperkeratinization of sebaceous follicles that leads to acne. Furthermore, the involvement of the proinflammatory leukotriene B-4 (LTB-4) in the pathogenesis of acne has been recently been described, and the administration of a novel LTB-4 blocker has been shown promote to a 70% reduction in inflammatory acne lesions (Zouboulis 2001). The antiinflammatory activities of omega-3 fatty acids, including the inhibition of LTB-4 is well known. Thus a diet rich in omega-3 fatty acids may have a synergistic effect with a diet that reduces the overall glycemic load.

Exposing the affected skin to the sun is frequently noted with an anecdotal improvement or abatement in acne, and there is a significant body of evidence to suggest its efficacy.  One possible mechanism  is that UVB light activates a porphyrin in acne-promoting bacteria, killing them by stimulating the release of singlet oxygen (Papageorgiou et al 2002).   In Ayurveda the sunlight and the skin have an intimate connection, as the surface of the skin is viewed much like the sun radiating light.  Sunlight helps to normalize  the bhrajaka pitta of the skin, particularly when combined with skin-nourishing fats that have antimicrobial properties such as coconut oil and shea butter.  The interest in the relationship between the sun and the skin has fostered new research that demonstrates a possible role for vitamin D3 in acne (Reichrath 2007).

Although it is a poorly researched area, many of the so-called “junk-foods” that are often consumed by adolescents can be seen to worsen acne, and promote the formation and retention of toxins in the blood that induce immunological responses and burden the liver. Such diets also place stress upon the neuroendocrinal system by depriving the body of essential nutrients. Dietary measures to control acne include an avoidance of all junk foods (e.g. chocolate, candy, soda pop), a reduction in refined carbohydrates (e.g. sugar, bread, pasta), fried foods (e.g. french fries), and excessively oily foods (e.g. cheese, pizza). In particular, dairy is particularly problematic, which, despite the fact that it has a low glycemic index, enhances insulin secretion, and in the study by Cordain et al, was notably absent from the Kitavans and Aché diets. As inferred from the above, the fatty acid content of the diet is particularly important, to prevent the hyperkeratinization and inflammation that is characteristic of the lesion of acne. Omega-3 fatty acids found in fish oils, grass-fed animal products and leafy green vegetables appear to play an important role in regulating proper sebum secretion and decreasing inflammation. Overall, foods that should be emphasized in the diet include fresh vegetables and fruits vegetables, high quality proteins and whole grains. Important supplements include vitamins A, B, C, E, magnesium, and zinc, to promote healing and support antioxidant mechanisms in the liver. To correct the underlying ecology of the gut live culture foods such as pickled vegetables, probiotics and prebiotics  can also be used, particularly in situations where antibiotics and/or oral contraceptives have been used to control the acne. In such cases attention should be directed to the possibility of secondary candidiasis, and the use of antifungal remedies such as Pau D’arco, Barberry, Neem and Echinacea.