Data support acne dietary triggers

Information from recent publications provides dermatologists with some helpful strategies for acne management, says Jonette Keri, MD, PhD., associate professor of dermatology and cutaneous surgery, University of Miami Miller School of Medicine, Miami, Fla., and chief, dermatology service, Miami VA Hospital.

Speaking at the 14^th Annual South Beach Symposium (Miami Beach, Fla., February 2016), she highlighted new findings on dietary modifications that can influence acne and discussed protocols for managing severe acne.

Dietary triggers

Acne patients often wonder whether their skin condition is affected by what they eat. Insight on this issue is provided by findings of a recent Cochrane review on complementary therapies for acne vulgaris and a second review article focusing on dietary impact on acne metabolomics, follicular inflammation, and comedogenesis.^1,2 The conclusions of both studies indicate that a low-glycemic load diet is something worth considering.

The Cochrane review considered two studies comparing low-glycemic load and high-glycemic load diets, of which one found a benefit of the low-glycemic low diet for reducing inflammatory lesion and total skin lesion counts.¹ Authors of the review article cited results of several placebo- and case-controlled studies showing a high glycemic load diet can cause or aggravate acne as well as epidemiologic data linking dietary features to acne prevalence.² They stated the mechanism involves the effect of carbohydrates on the bioactivity of free serum insulin growth factor 1 (IGF-1) and free serum androgens.

“Now, if I see an overweight teenager with acne or an overweight adult woman with adult onset acne, I tell them there is evidence that foods causing a ‘blood sugar rush’ may worsen acne and suggest they consider avoiding these hyperglycemic carbohydrates,” Dr. Keri says.

Information from a few papers appearing in the last several years also supports the idea that whey protein may be the fraction of dairy products promoting acne formation.^3-5 Two of the publications each described five males who developed acne shortly after starting whey protein supplementation.^3,4 Investigators in Brazil following 30 patients over a period of 60 days found progressive increases in lesion counts after the study participants started protein-calorie supplementation; whey protein supplement was used by 22 of the study participants.⁵ The purported underlying mechanism for the acnegenic effect of whey protein also involves effects on IGF-1 signaling.

“Supplementation with whey protein is a popular practice for bodybuilding, and when I see a patient who looks like he or she is trying to bulk up, it is a red flag to me to discuss whey protein supplementation,” Dr. Keri says.

NEXT: Controlling severe acne

Controlling severe acne

In patients who appear to be bodybuilders and who present with acne fulminans, consideration should be given to the possibility of anabolic steroid abuse, Dr Keri says.

Aside from counseling patients to stop ingesting these illicit substances, treatment for the acne fulminans should be initiated using systemic corticosteroids followed by isotretinoin. However, a successful response depends on a regimen that provides a sufficiently long course of therapy using an adequate corticosteroid dose and waiting to initiate the isotretinoin until the acne is under control, Dr. Keri says.

The protocol she recommends begins with oral prednisone 0.5 to 1 mg/kg/d and adds isotretinoin 10 to 20 mg/d after about one month. Treatment should continue for two to five months to avoid recurrence.

“Isotretinoin can exacerbate acne fulminans, but when used in combination with prednisone, it can help control the condition and prevent recurrence. The prednisone can get the acne under control rapidly, but it is important to use a high enough dose,” Dr. Keri says.

As another pearl for managing acne fulminans, she notes that use of a potent topical corticosteroid mixed with urea 20% to 40% during the first seven to 10 days of systemic therapy will help control explosive crusting.

Whereas isotretinoin is used in a low dose regimen in the management of acne fulminans, Dr. Keri says that, over time she has evolved to using a higher cumulative dose of isotretinoin (≥220 mg/kg) when treating patients for severe nodular-cystic acne. This shift in practice is based on evidence that the higher cumulative dose reduces the frequency of relapse.

Initial evidence of this benefit derives from several retrospective analyses, but more recently, it was investigated in a prospective observational intervention study.⁶ The latter research analyzed outcomes from 116 patients who completed a 12-month follow-up survey. With patients stratified by cumulative dosing levels, relapse rates were 47.4% for patients who had received a cumulative dose <220 mg/kg, and 26.9% for those whose cumulative dose was ≥220 mg/kg. The only significant difference in adverse events between the two groups was a higher rate of retinoid dermatitis for the high-dose versus low-dose treatment group (53.8% vs. 31.6%).

Disclosure: Dr. Keri is a consultant for Hoffmann-LaRoche.

References

1. Cao H, et al. Complementary therapies for acne vulgaris. Cochrane Database Syst Rev. 2015 Jan 19;1:CD009436.

2. Melnik BC. Linking diet to acne metabolomics, inflammation, and comedogenesis: an update. Clin Cosmet Investig Dermatol. 2015;8:371-88.

3. Simonart T. Acne and whey protein supplementation among bodybuilders. Dermatology. 2012;225(3):256-8.

4. Silverberg NB. Whey protein precipitating moderate to severe acne flares in 5 teenaged athletes. CUTIS. 2012;90(2):70-2/.

5. de Carvalho Pontes T, et al.  Incidence of acne vulgaris in young adult users of protein-calorie supplements in the city of João Pessoa-PB. An Bras Dermatol. 2013;88(6):907-12.