Lots of unpleasant, painful and upsetting symptoms occur in recovery that are the result of the damage an active eating disorder causes to the body. Acne is just one of several symptoms that show up for many during the recovery process. And of course, the unsurprising solution often suggested by both medical and alternative healthcare providers will be to remove food groups (most commonly sugar and/or milk products). Removing food groups reduces mortality outcomes for everyone, and is particularly damaging for those with eating disorders as restriction of any kind precipitates relapse of the eating disorder. 1, 2, 3
The hormone known to be a key player in the pathogenesis of acne is dehydroepiandrosterone (DHEA). In fact dehydroepiandrosterone sulphate (DS) can be found in concentrated levels in pre-menarchical young girls who present with acne. 4 What this means is that pubertal development will temporarily mix up the various androgen and estrogen levels and the acne resolves with sexual maturation.
It is common for patients undergoing recovery from eating disorders to have a period of severe acne and it coincides with something akin to going through puberty yet again as the body re-establishes its natural sex hormone balance.
“Compared with healthy women, both AN and BN patients exhibited increased plasma levels of 3α,5α-THP, DHEA, DHEA-S, and cortisol but reduced concentrations of 17β-estradiol.” 5
The above quote reflects that under the duress of restricting energy intake, cortisol (the stress hormone suite) is high, androgens are high and estrogens are low. That will create a predisposition for the presence of acne. It suggests that both during the time when a patient is actively restricting and when she enters recovery, acne may be present as a direct result of the impact of restriction on both stress and reproductive hormones in the body.
Treatment for acne has historically involved broad-spectrum antibiotics as there is a bacterium intimated in the pathogenesis of the condition, namely Propionibacterium acnes (P. acnes). However, recent dermatology association position papers recommend the use of oral contraceptives (either in the presence or absence of excess androgens) for women. In fact P. acnes is more of a symbiont than pathogen and is responsible for the breakdown of oils to provide the skin with natural moisturizer. However different strains of P. acnes appear to generate distinctly different inflammatory responses within the pilosebaceous follicle of the skin. 6 Recent clinical studies suggest that acne is an inflammatory skin disorder where genetic, hormonal and presumably the strain of P. acnes all play a part in its pathogenesis for individual patients. 7 This recent understanding may explain why antibiotic treatment (either topical or broad spectrum pill form) is falling out of favor in up-on-the-research dermatology circles: it really is a rather ham-fisted smack down of a normally symbiotic bacterium at the end of a chain of immunoendocrinological anomalies that will not address the underlying anomalies.
Let’s just take a moment to consider the complexity of the appearance of acne: sexual hormonal development and maturation, circulating levels of stress hormones, as well as possible genetic, inflammatory and pathogenic inputs all appear to need to be present for acne to show up. And yet we figure that cutting out sugar or milk will be just the ticket to fix it all—it’s a wonderful example of “when all you have is a hammer, everything looks like a nail”.
But why take my obviously biased opinion of the uselessness of dietary restriction as a cure in this case? Let’s look at systematic reviews in peer-reviewed published scientific literature instead.
Despite the poor design and short follow-up of a few studies in the 1960s and 70s, up to 72% of the general population still believes that chocolate bars, peanuts, cheeses, fats and sugars contribute to the onset of acne. 8, 9
In one systematic review, the authors were able to locate one retrospective study that suggested dairy consumption was linked to acne during the teen years. As you all know, retrospective studies rely on the subjects’ recall and therefore provide quite questionable data given our memories are always highly suspect. The correlation itself was also weak and interestingly a bit stronger (in relative terms) for skim milk products: 1.12 for whole milk; 1.16 for low-fat milk; and 1.44 for skim milk. 10 The children of the subjects in this original retrospective epidemiological survey were then prospectively studied (meaning they were surveyed moving forward in time rather than having them depend upon memory recall). 11, 12 And the same correlation of around 1.19 showed up.
Here’s what the authors of this systematic review had to say regarding these epidemiological studies:
“On the basis of these results, the authors speculate that the nonfat portion of milk contains hormones and bio-active molecules, such as androgens, progesterone, and insulin growth factor-1 (IGF-1), that can have an acne- stimulating effect. These cohort studies, however, can only suggest correlation but not causation. Family history of acne and other possible confounding factors such as steroid use were not included in the analysis. In addition, though the children graded their amount of acne on a five-category scale, investigators did not examine if the amount of milk intake correlated with acne severity.” 13
Just as a refresher, a correlation that ups the risk of acne onset from 1.00 (the point at which there is no link between the items being studied) and 1.19 or even 1.44 is statistically significant but not clinically significant. In other words, when you are a real patient and not a statistic, this correlation is so tiny as to be irrelevant to your experience. Furthermore, having only two epidemiological surveys means that there is no way any relevant conclusion can be drawn regarding this presumed correlation. But if you want to use this questionable data then the take home message might be stick to whole milk products.
What do the clinical trial data say about sugar and acne onset? Within this same systematic review I am quoting, the authors reference only one randomized investigator-masked, controlled trial with 43 males ages 15 to 25. Both the study group placed on a high-protein low-glycemic index diet and the control group (no special diet) had a reduction in total lesion counts. In real numbers, the study group experienced 21.9 fewer lesions and the control group experienced 13.8 fewer lesions—or essentially 8 fewer acne pimples (lesions) for the study group compared to the control group. 14 The authors of the systematic review had this to say regarding the results:
“However, the LGL [low-glycemic load] group also had a significant reduction in weight and BMI [body mass index]. Weight loss is known to decrease circulating androgen and insulin levels; thus, whether the skin improvements were due to the dietary differences or the concomitant weight reduction is unclear.” 15
Weight loss is not sustainable for 99.997% of the population (see here). Those with eating disorders who choose to remove sugar (a low-glycemic index diet) from their diets to treat acne will have the opportunity to perhaps experience 8 fewer acne lesions and risk full-blown relapse of the eating disorder as well.
I understand that it’s hard not to go and play in the sandbox of dietary silliness along with the rest of our misguided society, but honestly it’s not just an unpleasant place to be, it’s also downright dangerous if you have an eating disorder.
What are you supposed to do if you have a painful and severe outbreak of acne while you are in recovery from an active eating disorder? You can most certainly see your doctor or dermatologist to discuss whether oral contraceptives might be an option for you. Oral contraceptives do not interfere with your body’s ability to continue along its recovery path and they may help reduce the acne outbreak while your stress and reproductive hormones sort themselves out.
Beyond that, don’t underestimate how relevant psychoeducational treatment can be (seeing a therapist). I am not saying that the acne outbreak is treatable in this way; I am however saying that relaxation techniques and learning to handle the distress of approaching and eating the food with guidance from an appropriately trained therapist will lower stress hormone levels over time and we know that these hormones are one contributory facet of the onset of acne for most. 16 Some decent studies suggest that various forms of yoga breathing have a direct impact on lowering cortisol, DHEA and adrenocorticotropic (ATCH) levels. 17, 18, 19 There are also smatterings of clinical data on the use of both biofeedback and hypnosis for improving the severity of acne as well. 20
As with all other distressing symptoms in recovery, time is the most powerful mediator in resolving the symptom completely for almost everyone. No one wants to hear that, but it’s true.
1. Kant, Ashima K., Barry I. Graubard, and Arthur Schatzkin. "Dietary patterns predict mortality in a national cohort: the National Health Interview Surveys, 1987 and 1992." The Journal of nutrition 134, no. 7 (2004): 1793-1799.
2. Klopp, Sheree A., Cynthia J. Heiss, and Heather S. Smith. "Self-reported vegetarianism may be a marker for college women at risk for disordered eating." Journal of the American Dietetic Association 103, no. 6 (2003): 745-747.
3. Kadambari, Rao, Simon Cowers, and Arthur Crisp. "Some correlates of vegetarianism in anorexia nervosa." International Journal of Eating Disorders 5, no. 3 (1986): 539-544.
4. Lucky, Anne W., Frank M. Biro, Gertrude A. Huster, Alan D. Leach, John A. Morrison, and Joan Ratterman. "Acne vulgaris in premenarchal girls: an early sign of puberty associated with rising levels of dehydroepiandrosterone." Archives of dermatology 130, no. 3 (1994): 308-314.
5. Monteleone, Palmiero, Michele Luisi, Barbara Colurcio, Elena Casarosa, Patrizia Monteleone, Raffaele Ioime, Andrea R. Genazzani, and Mario Maj. "Plasma levels of neuroactive steroids are increased in untreated women with anorexia nervosa or bulimia nervosa." Psychosomatic Medicine 63, no. 1 (2001): 62-68.
6. Nagy, István, Andor Pivarcsi, Andrea Koreck, Márta Széll, Edit Urbán, and Lajos Kemény. "Distinct strains of Propionibacterium acnes induce selective human β-defensin-2 and interleukin-8 expression in human keratinocytes through toll-like receptors." Journal of Investigative Dermatology 124, no. 5 (2005): 931-938.
7. Holland, Diana B., and Anthony HT Jeremy. "The role of inflammation in the pathogenesis of acne and acne scarring." In Seminars in cutaneous medicine and surgery, vol. 24, no. 2, pp. 79-83. WB Saunders, 2005.
8. Al-Hoqail, Ibrahim A. "Knowledge, beliefs and perception of youth toward acne vulgaris." Saudi medical journal 24, no. 7 (2003): 765-768.
9. Rigopoulos, D., S. Gregoriou, A. Ifandi, G. Efstathiou, S. Georgala, J. Chalkias, and A. Katsambas. "Coping with acne: beliefs and perceptions in a sample of secondary school Greek pupils." Journal of the European Academy of Dermatology and Venereology 21, no. 6 (2007): 806-810.
10.Adebamowo, Clement A., Donna Spiegelman, F. William Danby, A. Lindsay Frazier, Walter C. Willett, and Michelle D. Holmes. "High school dietary dairy intake and teenage acne." Journal of the American Academy of Dermatology 52, no. 2 (2005): 207-214.
11. Adebamowo, Clement A., Donna Spiegelman, Catherine S. Berkey, F. William Danby, Helaine H. Rockett, Graham A. Colditz, Walter C. Willett, and Michelle D. Holmes. "Milk consumption and acne in teenaged boys." Journal of the American Academy of Dermatology 58, no. 5 (2008): 787-793.
12.Adebamowo, Clement A., Donna Spiegelman, Catherine S. Berkey, F. William Danby, Helaine H. Rockett, Graham A. Colditz, Walter C. Willett, and Michelle D. Holmes. "Milk consumption and acne in adolescent girls." Dermatology online journal 12, no. 4 (2006).
13. Tom, Wynnis L., and Victoria R. Barrio. "New insights into adolescent acne." Current opinion in pediatrics 20, no. 4 (2008): 436-440.
14.Smith, R., N. Mann, A. Braue, H. Makelainen, and G. Varigos. "The effect of a high-protein, low glycemic-load diet versus a conventional, high glycemic-load diet on biochemical parameters associated with acne vulgaris: A randomized, investigator-masked, controlled trial." Journal of the American Academy of Dermatology 57, no. 2 (2007): 247-256.
15. Tom, Wynnis L., and Victoria R. Barrio. "New insights into adolescent acne." Current opinion in pediatrics 20, no. 4 (2008): 436-440.
16. Chiu, Annie, Susan Y. Chon, and Alexa B. Kimball. "The response of skin disease to stress: changes in the severity of acne vulgaris as affected by examination stress." Archives of dermatology 139, no. 7 (2003): 897-900.
17. Sulekha, Sathiamma, Kandavel Thennarasu, Appajachar Vedamurthachar, Trichur R. Raju, and Bindu M. Kutty. "Evaluation of sleep architecture in practitioners of Sudarshan Kriya yoga and Vipassana meditation*." Sleep and Biological Rhythms 4, no. 3 (2006): 207-214.
18. Narnolia, Pramod Kumar, Bijender Kumar Binawara, Akhil Kapoor, Mamata Mehra, Manoj Gupta, Khemlata Tilwani, and Sitaram Maharia. "Effect of Sudarshan Kriya Yoga on Cardiovascular Parameters and Comorbid Anxiety in Patients of Hypertension."
19. Vedamurthachar, A., Nimmagadda Janakiramaiah, Jayaram M. Hegde, Taranath K. Shetty, D. K. Subbakrishna, S. V. Sureshbabu, and B. N. Gangadhar. "Antidepressant efficacy and hormonal effects of Sudarshana Kriya Yoga (SKY) in alcohol dependent individuals." Journal of affective disorders 94, no. 1 (2006): 249-253.
20. Shenefelt, Philip D. "Biofeedback, cognitive‐behavioral methods, and hypnosis in dermatology: Is it all in your mind?." Dermatologic Therapy 16, no. 2 (2003): 114-122.