Because food is at the heart of Filipino culture, dietary restriction comes up as a frequent question during consults with the doctor. Much of our cuisine is flavorful, comforting, and tend to be on the greasy side. No wonder that after a trip to the doctor, we’d be told to cut down on certain foods to improve our health.  We come to realize the role food plays in diseases, oftentimes leading to assumptions. 

“I have pimples because I’ve been eating a lot of [insert food item] lately,” is a statement us dermatologists have heard too often. You may have been advised some time ago that they have nothing to do with each other. This is because in truth, the role of diet as a trigger for acne took decades to establish. Even with new research coming out regularly, the verdict for certain foods is still not absolute. In the midst of the abundance of anecdotes out there, evidence-based research updates are continuous, so here we are, setting the record straight with the evidence to date:

Food that promote acne:

1) Sugary foods (High glycemic index / glycemic load foods)

Glycemic index is a numeric score that indicates how rapidly a certain food is digested and elevates your blood sugar. The more refined and processed the carbohydrate is, the faster it metabolizes into glucose (high glycemic index). On the other hand, glycemic load is a ranking system that takes into account both the glycemic index of a food and the portion that you consume. 

Several studies support that diets high in glycemic index / glycemic load exacerbate existing acne, and can prolong its duration. Therefore, be wary of products that are refined and those that have “added sugar” on the label. Consume foods rich in fiber, fat and protein because these release glucose more slowly, so they have a lower glycemic index.

2) Dairy

Consumption of cow’s milk – whole, low-fat and skim, has consistently been linked to acne exacerbation and break-outs in several studies, including an advisory from the American Academy of Dermatology. Interestingly, dairy products such as yogurt and cheese were not observed to influence acne.

3) Whey protein supplements

Commonly drank as protein shakes for body building and fitness, whey is the main protein component (80%) of milk. Dermatologists often encounter severe acne in protein shake drinkers. Supported by studies, severe acne in these patients persists even with appropriate medication, and respond only when whey protein is discontinued. 

Food that protect from acne:

1) Low glycemic index / glycemic load foods

Just as how high glycemic index / glycemic load foods aggravate acne, low glycemic index / load foods reduce the inflammation, count and severity of acne consistently across multiple studies to date.

2) Omega-3 fatty acids and linoleic acid

These fatty acids, often associated with a Mediterranean diet and fish, have also been consistently observed to reduce inflammatory acne.

3) Vegetarian / vegan diet

Eating a fruit and vegetable-rich diet has been shown in recent studies to be acne protective. 

Food that have been studied and deemed to not affect acne:

1) Salt

No association between salty food intake and acne was observed in studies.

2) Yogurt, cheese and other dairy products

As mentioned earlier, these milk products have no effect on acne in contrast to milk itself.

Food that have been studied but found to have insufficient evidence to either improve or aggravate acne:

1) Chocolate

This is food item is a popular question during an acne consult. Different studies varied in the brands and purity of chocolate (vs. its milk and sugar content) used, as well as the population involved, and have produced inconclusive results. Therefore, to date, chocolate is not yet proven to influence acne. Also be aware, however, that chocolates can easily become a high glycemic index food with dairy.

2) Probiotics

Probiotics have attracted attention for its gut health benefits over the recent years, and its effect on acne is not exempt from that. While initial studies are promising, further research and evaluation are needed to conclusively say it is beneficial for acne. 

While there is some evidence supporting the relationship of acne and diet, this cannot replace proper evaluation of the cause of your acne and its corresponding management done in the setting of a Dermatology consult. Use the above information as a guide for your everyday food choices, rather than a treatment for your acne. Note that the evidence does not demonstrate that a certain type of food causes acne, rather they may influence existing acne positively or negatively.

Every year more and more evidences are unearthed about this topic, so stay tuned.

References:

1. Dall’Oglio F, Nasca MR, Fiorentini F, Micali G. Diet and acne: review of the evidence from 2009 to 2020. International Journal of Dermatology 2021;60(6):672-685. doi: 10.1111/ijd.15390.
2. Baldwin H, Tan J. Effects of Diet on Acne and Its Response to Treatment. American Journal of Clinical Dermatology 2021;22:55–65. https://doi.org/10.1007/s40257-020-00542-y
3. Barbieri JS. Diet and Acne –Challenges of Translating Nutritional Epidemiologic Research Into Clinical Practice. JAMA Dermatol. 2020;156(8):841-843. doi:10.1001/jamadermatol.2020.1601
4. Matsui M. Update on Diet and Acne. Cutis 2019;104(1):11-13.
5. Spencer EH, Ferdowsian HR, Barnard ND. Diet and acne: a review of the evidence. International Journal of Dermatology 2009;48:339-347.
6. What are high and low glycemic index foods? https://www.medicalnewstoday.com/articles/high-glycemic-index-foods#factors-affecting-gi

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Acne is a hormonal skin condition that manifests as comedones known as “blackheads” or “whiteheads”. Comedones can become inflamed due to bacteria and turn into painful red bumps that become pustules or cysts. Our skin naturally produces oil or sebum and excess production can lead to clogging of the pores, this is what causes acne. Some factors that can contribute to the development or flaring of acne are:

• Hormones
• Genetics
• Stress
• Certain foods
• Oily facial and hair products

When acne is left untreated, it can become severely inflamed and this can lead to scarring. Common types of acne scars are:

• Rolling scars
• Box type scars
• Ice pick scars
• Hypertrophic scars

The best way to avoid scarring is to treat acne early and avoid picking on your skin. Different treatments can improve acne and acne scarring and this is best determined through a consultation with a board- certified Dermatologist. She/ he may suggest different treatments depending on the type of acne or acne scar you have.

“Maskne” or “Mask acne”  is a new term that was coined due to the recent pandemic. It covers a wide range of skin conditions brought about by mask- wearing. Some cases may be real acne, but other conditions can also cause bumps on the skin. Some of these conditions are:

• Contact dermatitis
• Perioral dermatitis
• Rosacea
• Milia
• Folliculitis

“Maskne” can be treated with proper diagnosis and treatment by a board- certified Dermatologist and should never be a reason to stop wearing masks in public. Some ways to prevent developing these conditions are:

• Wearing a clean mask
• Keeping your face clean and moisturised on a daily basis 
• Avoiding make-up in areas covered by the mask
• Avoiding irritating products 
• Taking 15- minute “mask breaks” after 4 hours of mask- wearing, in a safe outdoor area with safe social distancing measures

Make sure to consult with a Board-Certified PDS Dermatologist!

REFERENCES:

Fitzpatrick’s Dermatology 9th edition

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Dr. Mara Padilla Evangelista-Huber, FPDS, FDSP, MClinRes

What are the main major differences between acne and “fungal acne”? 

Who is at risk of developing “fungal acne”? 

• Adolescents (likely due to increased sebaceous gland activity)
• Individuals who are prone to increased sweating (e.g. patients with hyperhidrosis, athletes or those with frequent physical activity, overweight/obese individuals) 
• Those with previous use of topical or oral antibiotics (e.g. tetracyclines) and oral corticosteroids and other immunosuppressive agents (e.g. chemotherapy, etc)
• Conditions with immunosuppression (e.g. AIDS, diabetes) 
• Generally seems to be more common in males

Malassezia species are present on an estimated 92% of the world’s population as part of normal skin flora – but it does not overgrow in everyone who has it on their skin. 

Can you distinguish “fungal acne” from acne with your naked eyes?

The diagnosis of Malassezia folliculitis is usually made based on the patient’s history and physical examination, but occasionally, there are challenging cases where further examination is warranted. 

Because both acne and folliculitis affect the pilosebaceous unit, they can appear similar in presentation. In addition, like C. acnes, Malassezia has been shown to induce skin cells to generate inflammation via a similar pathway, adding to the potential overlap in clinical appearance. 

What are the diagnostic tools commonly used to diagnose “fungal acne” and the treatment options? 

Some of the diagnostic tools include: 

• Scraping the skin lesion gently to get a sample of skin cells, and adding a substance called potassium hydroxide or KOH (KOH examination or smear) and looking at this under the microscope: positive findings are seeing abundant  round,  spores or  budding  yeast  cells.
• Using a handheld device with black light (Wood’s light) to examine skin lesions –  affected areas may fluoresce a bright  yellow green color (some studies suggest blue-white color too) in a follicular pattern (where hair follicles are located).
• Taking a sample of your skin via a biopsy. The biopsy will show clusters of yeasts within the enlarged hair follicles surrounded by inflammatory cells. Staining the specimen with Periodic-Acid  Schiff (PAS) stain may also aid in the visualization of the yeasts. 

Treatment options:

• Topical antifungals (creams, body wash, shampoo) e.g. ketoconazole, clotrimazole, miconazole, ciclopirox olamine, etc
• Oral antifungals (fluconazole, itraconazole)
• Very limited evidence on isotretinoin

Because topical antifungals do not penetrate well into the hair follicle, first-line treatment is generally with oral antifungals. Improvement is expected within 1–2 months.

Supportive measures:

• Eliminate predisposing factors, if possible e.g. if the patient is on oral medications, discontinuation may result in improvement in the folliculitis without any specific treatment.
• Malassezia folliculitis may be chronic, and may wax and wane, depending on the weather, humidity, and the patient’s activity level. 
• Wear loose clothing when it’s hot and humid. 
• Change out of clothes immediately after working out or sweating a lot.

References:Rubenstein RM, Malerich SA. Malassezia (pityrosporum) folliculitis. J Clin Aesthet Dermatol. 2014;7(3):37-41.

Ayers K, Sweeney SM, Wiss K. Pityrosporum folliculitis: diagnosis and management in six female adolescents with acne vulgaris. Arch Pediatr Adolesc Med.&�Բ�����;2005;159:64–67.

Gaitanis G, Velegraki A, Mayser P, et al. Skin diseases associated with Malassezia yeasts: facts and controversies. Clin Dermatol.&�Բ�����;2013;31:455–463

Yu HJ, Lee SK, Son SJ, et al. Steroid acne vs Pityrosporum folliculitis: the incidence of Pityrosporum ovale and the effect of antifungal drugs in steroid acne.  Int J Dermatol.&�Բ�����;1998;37:772–777

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