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Anthony J. Mancini, MD, FAAP†

ABSTRACT failed to demonstrate important differences in diet
between subjects with and without acne. Recent
Acne is the most common dermatologic condi- research suggests that some dairy products may
tion encountered in clinical practice, affecting increase acne risk during adolescence.
nearly all adolescents and young adults to some (Adv Stud Med. 2008;8(4):100-105)
degree. The pathophysiology of acne is complex.
Increased sebum production by sebaceous glands
and abnormal desquamation of hair follicles
occur in response to increasing androgen levels
with the onset of puberty. Obstruction of follicles
causes follicular distention, which is often accom-
panied by the proliferation of the bacteria
Propionibacterium acnes and the activation of an
inflammatory response. Although the diagnosis of
acne is usually straightforward, some conditions
are occasionally confused with acne, including
periorificial dermatitis, keratosis pilaris, angiofi- cne vulgaris is the most common skin
bromas, bacterial folliculitis, and demodex folli-
culitis. In addition to physical discomfort, acne is
associated with considerable psychological dis-
tress, limitation of activities, and increased risk of
depression and suicide. The relationship between
acne and diet is controversial. Some studies have
demonstrated that diets that are high in minimally
A condition that is treated by physicians,
accounting for more than 14 million
office visits per year. Acne typically
appears for the first time during early
adolescence, and is present to some degree in approxi-
mately 85% of individuals between the ages of 15 and
17 years.1 The first acne lesions often appear before the
processed plant or animal foods or low in highly
processed carbohydrates are associated with emergence of secondary sexual characteristics, and are
lower rates of acne, although other studies have one of the earliest signs of impending puberty. Acne
presents several significant challenges, including a com-
plex etiology, concerns about antibiotic resistance, and
the potential for scarring. The effects of acne are not
limited to the skin—acne lesions among adolescents
*Based on proceedings from a satellite symposium held and young adults generally occur at a time of height-
during the American Academy of Pediatrics Annual Meeting ened emotional sensitivity, and may contribute to sig-
on October 28, 2007, in San Francisco, California.

Head, Division of Pediatric Dermatology, Children’s
nificant psychological distress, depression, and even
Memorial Hospital, Associate Professor of Pediatrics and increased risk of suicide.
Dermatology, Northwestern University’s Feinberg School of
Address correspondence to: Anthony J. Mancini, MD,
FAAP, Head, Division of Pediatric Dermatology, Children’s
Memorial Hospital, Box 107, 2300 Children’s Plaza, The pathophysiology of acne is a multifactorial
Chicago, IL 60614. E-mail: process that begins with the obstruction of the piloseba-

100 Vol. 8, No. 4 ■ March 2008

epithelial deeper lesions that often involve more than 1 follicle and cells. especially in patients comedone. which consists of the hair follicle. which are often accompa- licle. and abnormal keratinization of the follicle lesions may result in the formation of cysts. microscopic (a closed comedone or whitehead). Types of Acne Lesions Reprinted with permission from http://www. and other inflam- wax and sterol esters. Figures 2 and 3. Periorificial dermatitis is a common by many patients to be caused by dirt. a gram- and sebaceous gland. neck. triglycerides. Comedonal acne is shown in Figure 2. Previously referred to as perioral dermatitis. The micro. A comedone of color. Figure 1. and bacteria into the sur- of sebum—a waxy substance containing a mixture of rounding dermis.5 open comedone or blackhead). done) below the skin surface (Figure 1). become colonized by Propionibacterium acnes. causing the for. peptides. or an opening that is only The diagnosis of acne is usually straightforward. and back. Inflammatory acne is illustrated in Figure 3.1 mation of a keratin plug and follicle it actually reflects acneiform disorder in children and young adults that is the oxidation of compacted epithelial cells and sebaceous generally thought to represent a pediatric form of acne lipid. Finally. postin- Enlargement of the keratin plug and continued flammatory dyspigmentation or hyperpigmentation swelling of the follicle result in the formation of a visible often occur following acne healing. in the formation of pustules.4 Sebum secretion is accompanied formation. Larger inflammatory one another. Johns Hopkins Advanced Studies in Medicine ■ 101 . The accumulation of sebum.2 Acne lesions are therefore concen. hair shaft. As inflammatory and noninflammatory acne. and matory mediators released during this process stimulate potentially inflammation-inducing free fatty acids—by a localized inflammatory response. PROCEEDINGS ceous unit. resulting in Typical clinical presentations of acne are depicted in the formation of a microscopic lesion (the microcome. are associated with a high likelihood of scarring.2 described in more detail later in this monograph. positive anaerobe that is part of the normal skin flora. although some conditions may occasionally be con- Although the dark coloration of the blackhead is believed fused with acne. including open and closed comedones on the patient’s comedone is the earliest acne lesion. increased adhesion of follicular epithelial cells to nied by overlying comedonal acne. cellular components. CD4 T lymphocytes and neutrophils). which is the basic acne lesion. and is common to chin. resulting in papule the sebaceous glands. beginning at approximately 8 to 9 years of age.1. scarring is a common complication of may have a widely dilated opening to the skin surface (an acne that may be prevented by early treatment.niams. upper arms.nih.3 Usually immune cells (eg. cholesterol. includ. A more intense inflammatory response results by increased production of squamous cells lining the fol. Nodules are inner surface. increased which disrupt the follicular wall and cause the dispersal production of adrenal androgens stimulates the secretion of lipids. The proliferation of P acnes stimulates the infiltration of ing the face. Cytokines.2 trated in areas of greatest sebaceous gland density. chest.1 Inflammatory acne occurs when the follicles rosacea. and keratin obstructs the follicle.

Figure 2. that are usually distrib- uted near the eyes. These lesions tend to occur sporadically during childhood. an autosomal dominant multiple hamartoma syndrome. Figure 3. and should be regarded as a skin type rather than a disorder. Mancini. Inflammatory Acne pressed patients. depression. is characterized by hyperkeratotic papules associated with hair follicles. generally appear earlier than acne (typically at approximately 4–6 years of age). a common disorder in pediatric dermatology practice. Demodex folliculitis is also sometimes encountered in individuals with immunosuppression. presenting as clusters of white papules with a total absence of inflam- mation. pityrosporum is often associated with truncal papules in immunosup. acne often caus- es significant anxiety. Keratosis pilaris is very difficult to treat.11 This disorder may be distinguished from acne by the absence of facial lesions and by a pos- itive potassium hydroxide (KOH) test result. MD. and dorsal thighs.6.8 This condition is especially likely to be confused with acne when it is inflammato- ry. Bacterial fol- liculitis may cause erythematous papules and pustules that are rarely mistaken for acne. FAAP. Images courtesy of Anthony J. and mouth.7 Keratosis pilaris. 4 ■ March 2008 . No. For example. frustration. The presence of demodex mites may be confirmed by a skin surface biopsy. times confused with acne. Adolescents are in a period of life that is characterized by pronounced emotional volatility.12 Finally. 8. 102 Vol. presenting as a persistent acne-like eruption on the face that does not respond to acne therapy. Comedonal Acne typically without comedones. Angiofibromas (formerly referred to as adenoma sebaceum) are encountered in the setting of tuberous sclerosis. As a result. Treatment with topical permethrin or sulfa-based antibiotics is usually effective for these patients. milia is unlikely to be confused with acne. MD. They may rarely be syndrome associated. These lesions typical- ly involve the buttocks and posterior thighs of diaper- wearing children. and Images courtesy of Anthony J. although they may also appear in other locations.9 These papules may resemble acne. FAAP. typically involving the cheeks. although the characteristic white papules on a background of nonin- flamed skin may resemble closed comedones. nose. but are typically translucent (resembling molloscum). and they are often especially sensitive to the effects of acne or other conditions that adversely affect their physical appearance.10. outer arms. and are not accompanied by comedones. especially at sites of abrasional trauma. are located in the midfacial region. The emotional impact of acne is often very difficult for patients to tolerate. Mancini. PROCEEDINGS this condition is characterized by papules and pustules. Other forms of folliculitis are some.

org/pm/science/ processed plant or animal foods and very low amounts of _docs/ClinicalResearch_Acne%20Vulgaris. study to evaluate the effect of a low–glycemic-load diet forcement whenever possible. The authors identi- New Guinea. reviewed the clinical evidence supporting Guinea and the Ache hunter-gatherers of Paraguay. Subjects avoid antibiotic resistance. PROCEEDINGS anger. pathogenic factors as possible. these individuals also tend to expect insulin resistance that are more commonly encoun- improvement very quickly. Of 115 is more effective than either individual treatment alone. researchers have noted that acne is nearly absent in Specific Web Site of Supporting Evidence from regions where the diet consists primarily of minimally Approved Source: http://www.17 In particular.19 Diet-related hyperinsulinemia may also Education about the time required for acne therapy to contribute to acne by stimulating androgen produc- work is especially important for these patients. It has been sug- exhibit depression or suicidal ideation. ological. For example. Patients who require topical antibiotic therapy should a significant contributor to acne. THE RELATIONSHIP BETWEEN ACNE AND DIET and 45% from carbohydrates with low glycemic index values. and that intensive scrubbing of the skin EVIDENCE-BASED PRACTICE RECOMMENDATION can cure acne. Many people think that acne is caused by dirt. Topical antibiotics although many acne experts have argued that diet is not alone may increase the risk of antibiotic resistance. and academic attainment. and immunological mechanisms.15 In addition to the to exhibit low serum insulin concentrations and high emotional difficulties associated with acne in adoles. subjects in Paraguay. acne therapy typically employs a age. or fried foods. Individuals with moderate-to-severe acne are also at Test subjects from New Guinea have been shown increased risk of unemployment. acne is multifactorial and includes hormonal.20 Smith et al recently conducted a randomized panied by regular follow-up visits with positive rein. in contrast to hyperinsulinemia and cent patients. dating. sweets. Subjects in the control group consumed a diet There are several common misconceptions about the causes or treatment of acne. 30% from fats. and that combination therapy 300 subjects between the ages of 15 and 25 years. As described in the on acne in male subjects between 15 and 25 years of article by Dr Hebert. a mitogen ipating in sports. Combination therapy should be used to target as many including chocolate. However. tered in association with westernized high-carbohy- tient with and poorly adherent to acne therapy.20 A total of 43 subjects were randomly assigned to combination of treatments to reduce acne lesions and 1 of 2 dietary treatment groups for 12 weeks. including inate antibiotic resistance.pdf. convened by the American Academy of westernized populations—Kitavan islanders of New Dermatology. no cases of acne were identified over Johns Hopkins Advanced Studies in Medicine ■ 103 . that may stimulate follicle growth. insulin sensitivity. Strength of Evidence: A group of experts in the man- Cordain et al examined the prevalence of acne in 2 non. microbi- tion. vigorous scrubbing or abrasive cleansers do not improve acne.18 In various acne management strategies.aad. soda. and may actually worsen I. tion of insulin-like growth factor-1 (IGF-1). agement of acne. versial. Management. Acne is often attributed to several dietary causes. in 1 group consumed a low–glycemic-index diet con- sisting of 25% energy from protein. western-style high-carbohydrate foods that yield very high glycemic loads when ingested. partic. accom. initially suggested by the observation that the prevalence of acne is relatively low in some nonwesternized societies. Name of AAFP-Approved Source: American Academy and that acne becomes more common when previously of Dermatology: Guidelines of Care for Acne Vulgaris isolated societies adopt westernized diets. drate diets. and they are often impa.13 Approximately 7% of patients with acne a follow-up period of more than 2 years.14 Impairments gested that increasing glycemic load modulates acne risk in functional ability have been observed in several set.16 The relationship between acne and diet is contro. be treated with benzoyl peroxide in combination with A relationship between acne and glycemic load was erythromycin or clindamycin. by altering serum insulin concentration and the produc- tings. including socializing with friends. dermatologic examination revealed no fied several reports demonstrating that combinations of benzoyl peroxide and a topical antibiotic reduce or elim- cases of acne among a total of 1200 subjects. Practice Recommendation: The pathogenesis of it by traumatizing the skin and exacerbating inflamma. tion.

glycemic index. The panel therefore conclud- ed that restriction of foods or food classes is not recom- Reprinted with permission from Smith et al.57:247-256. insulin. in the free androgen index and an increase in IGF. a long-term. including instant breakfast drink. Physician-diagnosed acne was not significantly associated with patient-reported intake of other foods that have been associated with EVIDENCE-BASED PRACTICE RECOMMENDATION II. sherbet. After 12 weeks. subjects in the no significant differences in several metabolic factors low–glycemic-index diet group exhibited a greater between individuals with or without acne vulgaris. other studies have found line diets. mended for patients with acne.20 104 Vol. and the second questionnaire asked the subjects whether they had a lifetime history of physician-diagnosed acne. Name of AAFP-Approved Source: American Academy of Dermatology: Guidelines of Care for Acne Vulgaris Management. n = 20) at fications with one another. and cottage cheese. 4 ■ March 2008 . cream cheese. reduction from baseline than the control subjects for including serum glucose. J Am Acad Dermatol. or both inflammatory lesion counts and total lesion self-reported dietary glycemic _docs/ClinicalResearch_Acne%20Vulgaris.20 However. n = 23) and the control group (dashed line. Acne was also significantly associated with more fre- quent consumption of several other dairy products. Strength of Evidence: The American Academy of Mean (±SEM) percentage changes from baseline in inflammatory acne Dermatology expert panel noted that few studies have lesion counts and in total acne lesion counts in the low–glycemic-load directly compared the effects of different dietary modi- group (solid line.aad. Specific Web Site of Supporting Evidence from Approved Source: http://www. 8.17 counts (Figure 4). PROCEEDINGS high in carbohydrate-dense foods similar to their base. 2007. binding protein. but only among women who had regularly consumed skim milk. ongoing prospective study that is examining associations among several lifestyle factors and illnesses among women who were between the ages of 25 and 42 years when the study began in 1989. with failed to demonstrate associations between acne and baseline counts as the covariate.21 These investigators ret- rospectively evaluated data from 2 questionnaires that Figure 4. Practice Recommendation: Routine dietary modi- fication or the avoidance of particular foods are not rec- ommended for patients with acne. A history of physician-diag- nosed acne was significantly associated with self-reported high-school milk intake. particular dietary factors. Effects of a Low–Glycemic-Load Diet were provided by more than 47 000 women. and that some studies have each visit.20 in addition to reduction data from the Nurses’ Health Study II. The dietary intervention was also The relationship between acne and the consumption associated with reduced circulating insulin and of dairy products and other foods was examined using improved insulin resistance. Repeated-measures analysis of variance was performed by incor- porating the absolute data (log transformed) from each follow-up visit. One ques- on Acne Vulgaris tionnaire asked the participants about their diet during their high school years. No.

2006. Low serum insulin in traditional Pacific Islanders—the Kitava Study.31:618-626.57:819-823. They also hypothesized and psychological sequelae. insulin-like acne and foods. For the past 2 decades. Gupta MA. Laude TA. Acne and unemployment. 2005. Eliasson M. con- 1. Spiegelman D. considerable patient distress. Dermatol Clin. 710. pizza. such as chocolate or other sweets. alterations to 15. Therapy for acne vulgaris. Eichenfield LF. and bacterial 16.18:206-209. exert a protective effect against acne. bioavailability of some of the hormonal components of 7. Dermatol Ther. they noted that whole milk contains Semin Cutan Med Surg. Barham KL. Pediatr Rev. J Dermatol.htm. spective recall of diet and acne diagnosis. Am Fam Physician. Fried RG. Hurtado M. The clini- CONCLUSIONS cal importance of demodex folliculorum presenting with non- specific facial signs and symptoms. Careccia RE. Periorificial dermatitis in children and adolescents. 11. that differences in processing between whole milk and 2001.12:1. and depression. milk. Adisen E. most acne specialists 1997. atricians. BMJ. 2007. 2004.48:1216-1219. 14.69:2123-2130. Salvemini JN. Nguyen V. 2007. Fried RG. 2000. Feldman S. Metabolism. 3. skim milk might affect acne risk by altering the 6. 1999. et al. Pityrosporum yeasts—what’s new? Mycoses. Faergemann J. 19. a significant limitation of this 1997. high REFERENCES glycemic-load diet on biochemical parameters associated with acne vulgaris: a randomized. 1986. Acne is a common disorder that is associated with 13. 21. Kaymak Y. et al.23:657-664. J Am Acad Dermatol. Mann NJ. Berkey CS. Esrefoglu M. Managing adolescent acne: a guide for pedi. Acne vulgaris: a disease of Western civilization. Lindeberg S. Am Fam Physician. Perioral dermatitis in children. acne are not well established at present.26:250-261. Leyden JJ. although the benefits of dietary 18. study was that it relied entirely on participants’ retro. and that estrogens may 8. Dermatol Online J. Management of common superficial fungal infec- tions in patients with AIDS. trolled trial. PROCEEDINGS acne.57:247-256. growth factor binding protein 3. Bayram N. Wechsler A. 2005.31:S60-S63. The effect of a high-pro- tein. 2006. Pediatrics. results provide some evidence for an association 9. 20. for acne management. Depression and skin dis- The pathophysiology of acne involves a series of com.115:386. Milk con- 2. during adolescence. more estrogen than skim milk.138:1584-1590. Gupta AK. Alai NN. 2006. ing estrogens. Karincaoglu Y. Lindahl B. modification to reduce the incidence or severity of 2002. Hancox J. Keratosis infection. low glycemic-load diet versus a conventional. et al. For example. insulin. Psychological problems in the acne patient. Thiboutot DM.118:1188-1199. Ilter N. et al. Layton AM. between acne and the consumption of dairy products 10. 1994. Further teins that might potentially influence acne risk. includ. Am J Clin Dermatol. J Am Acad Dermatol.3:444-446. Adebamowo CA. Krowchuk DP. including chocolate. 12. Bulusu L. fact be linked to diet. 2004. and others. Williamson B. Recognizing an index case of tuberous sclerosis.336:1156-1162. Smith RN. Aycan O. Cunliffe WJ. J Am Acad Dermatol. J Am Acad Dermatol. Braue A. Wilcoski S. Although these Accessed November 25. and leptin levels in patients Some newer studies have suggested that acne may in with acne. Johns Hopkins Advanced Studies in Medicine ■ 105 . insulin-like growth factor-I.19:237-240.61:703-708. Elmets CA. Optimal management of acne to prevent scarring precursors. Diagnosis and treatment of acne. plex interactions between hormones. The authors noted that milk contains numerous pro. ease. Lindeberg S. Cordain L. 1999. androgens and androgen 1972. have argued that there is no clear association between 17.55:781-785. anger. Cotterill JA. and french fries. soda. observations on the pathogenesis of acne. 5. Ahrén B. Cunliffe WJ.40(suppl 1):29-32. Available at: http://www. investigator-masked. 2006. Br J Dermatol. IGF-1. N Engl J Med. keratinization of the sebaceous glands. 4.2:135-141.emedicine. Dietary glycemic index and glucose. Expert committee recommendations sumption and acne in adolescent girls. Arch Dermatol. 2007. Hurst JS. progesterone. Zaenglein AL.