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Few well-defined, evidence-based nutritional recom- influence a specific disease, stratified by evidence level,
mendations for people with skin diseases have been could support clinicians as well as researchers. Using a
Acta Dermato-Venereologica
published in the scientific literature and standard der- systematic review of acne vulgaris as an example, the
matological textbooks. Using a systematic review of aim of this study was to determine whether there are
acne vulgaris as an example, the aim of this study was systematic studies on the topic and, if so, of what quality.
to determine whether there are systematic studies
on the topic and, if so, of what quality. Four eviden-
ce levels were defined: (A) double-blind randomized METHODS
study; (B) randomized study with serious limitations/ PubMed and Cochrane searches were performed with the search
low number of cases; (C) case-control or cohort study; terms “nutrition”, “diet”, “meal”, “food”, each in combination
and (D) expert opinion/case report. PubMed and Co- with “acne”. The hits were then examined for relevant articles
chrane searches were performed using combinations
using pre-defined criteria. Initially, the timeframe for the sample
search was limited to 11 years (Cochrane; 2004–2014) and 6 years
of the terms “diet”, “nutrition”, “meal” and “food”
(PubMed; 2004–2009)1, respectively. Articles were classed as
with “acne”. Foodstuffs mentioned in relevant artic- relevant if foodstuffs, vitamins, trace elements, certain diets, food
les were subdivided by evidence level and recorded as forms, alcohol and nicotine were studied, or at least mentioned,
having a beneficial (+), neutral (0) or adverse (–) ef- as influencing factors in the skin disease, and an effect was rated
fect. However, only a small proportion of studies met
beneficial/neutral/adverse. Furthermore, only studies of per os
administration in humans, but no studies of topical application,
sufficiently high scientific standards that would enable
cell culture or animal experiments were considered. All foods
therapeutic recommendations to be made in practice. with the respective effect reported were listed alphabetically in
ActaDV
P atients often ask about the effects of nutrition on acne, in a table and illustrated by a graphical presentation with respect
Advances in dermatology and venereology
to the results/evidence.
but current research into this topic is very limited
compared with that of high-quality drug studies. One of
the main reasons for lack of research into nutrition and RESULTS
acne is the high cost of appropriate studies, since, unlike
for medications, the expected efficacy is low and there A total of 162/21 (PubMed/Cochrane) hits for acne were
is a lack of options for increasing the price of foods to found in the study timeframe, of which 58/6 relevant
finance research. Nonetheless, several nutritional studies articles on acne could be assessed based on the selec-
of various qualities have been published during the past tion criteria (for a complete reference list in alphabetical
few decades. However, very few high-quality studies order, see Appendix S12). Higher grade studies (evidence
meeting modern standards have been performed, and Levels A and B) were rarely found, while mentions of
those that have involve only a small proportion of the foods (evidence Level D) formed a clear majority.
wide range of foods available (1, 2). Some studies were
performed several years ago and, from today’s view-
point, have design flaws that would not allow dietary 1
This study was part of FF’s medical doctoral thesis and thus has to reflect
its results. The addition of PubMed listed papers for a further 5 years
recommendations to be made (3). The number of food
(2010–2014) would exceed the space limitations of the medical faculty
items that could be included in a meta-analysis is limited rules for medical doctor theses; thus, only the Cochrane database search
because there is no, or not good enough, evidence about was expanded (2004–2014).
many food items (1). An overview of all the foods that 2
https://www.medicaljournals.se/acta/content/abstract/10.2340/00015555-2450
This is an open access article under the CC BY-NC license. www.medicaljournals.se/acta doi: 10.2340/00015555-2450
Journal Compilation © 2017 Acta Dermato-Venereologica. ISSN 0001-5555 Acta Derm Venereol 2017; 97: 7–9
8 F. Fiedler et al.
For acne there were 370 mentions of 146 influencing Table II. The 10 most-frequently studied/mentioned foods (and
smoking) in the examined time-frame
foods. Evidence assessment showed none of Level A, 4
ActaDV
There are polarizing, often speculative, opinions concer- For explanation of evidence levels see Table I and Methods.
challenge (DBPCFC) including blinding of colour, shape addition to the tabular presentation. This enables a visual
and taste, as used in food allergy testing, but this would overview based on colour and distribution between right
substantially increase overall expenditure. and left over the study situation within the 12 possible
In order to include the results of survey articles on degrees of influence (evidence Levels A–D each with
knowledge of foods, as well as those used as remedies 3 categories: adverse/neutral/beneficial). Like a scale,
in natural medicines, and older articles cited currently evidence Level A, with the highest quality, is always po-
during the study period, the arrangement of evidence sitioned at the edge comparable to the greatest leverage.
levels as proposed by Atkins (4) and Bigby (5) was An identical distance right or left from the middle of
Advances in dermatology and venereology
modified and expanded by a Level D for citations/expert the chart thus corresponds to the same evidence level,
opinion/case reports. The results presented here, using but results with contradictory influence (left adverse
acne as an example, were selected because a connection and right beneficial). The colours were borrowed from
to nutrition is, or was, considered relatively certain by a traffic light: red for adverse (–), yellow for neutral (0)
both dermatologists and patients. In this respect, there are and green for beneficial (+) influence. Since graded as-
a number of articles in the defined publication timeframe signment of the evidence level with neutral relationship
that addressed the corresponding connections. causes neither positive nor negative lateral shift in the
Only human studies were taken into account for the results, the neutral results were entered vertically in
assessment of relevance. In vitro studies were excluded in yellow. Using milk in acne as an example (Fig. 1), an
order to limit our topic to practical relevance in nutrition. adverse influence can be observed with entered numbers
only in the left horizontal arm. In this, many results were
Table I. Assessed foods mentions arranged by evidence levela near the centre of the chart at the lowest evidence, Level
Level A Level B Level C Level D
D; but there are also 2 corresponding results at Level C.
Σ/–/0/+ Σ/–/0/+ Σ/–/0/+ Σ/–/0/+ Another 5 citations at Level D are shown in the lower
Acne vulgaris 0/0/0/0 4/0/1/3 45/15/28/2 321/163/70/88 middle, which did not cause any shift between beneficial
a
Level A corresponds to randomized double-blind studies with a high number of and adverse.
cases, Level B to randomized studies with serious limitations or a low number
of cases, Level C to case-control or cohort studies, and Level D to usually non-
For acne, 146 different foods were recorded a total
randomized studies expressing expert opinion or mention of the food. Within of 370 times in 60 relevant articles. There were only 49
each of the evidence levels, adverse (–), neutral (0) or beneficial (+) effects were
differentiated in a corresponding total of 12 groups. The results are summarized
studies with evidence Levels A–C. In these, none cor-
for each item (bold figures). responded to evidence Level A, 4 cases corresponded to
www.medicaljournals.se/acta
Acne and nutrition 9