Sue McGarrigle ND Copyright Bionutri 2021 Acne

• Acne is one of the most common multifactorial chronic inflammatory diseases of the pilosebaceous follicles involving: • Androgen induced • Altered follicular keratinisation • Hormonal imbalance • Immune hypersensitivity • Bacterial (Propionibacterium acnes) colonisation Acne vulgaris

• Acne is a chronic skin disease, and the common form is called vulgaris which is the medical term for "common". It is given this name to distinguish it from less common variants of acne. • Acne vulgaris occurs when hair follicles as a result of obstruction and are blocked with dead skin cells, bacteria, and oil (sebum). The blocked follicles cause blemishes on the skin. • Acne vulgaris is characterized by comedones, , pustules, and nodules and/or in a sebaceous distribution (e.g., face, upper chest, back). • A , or basic acne lesion, is a hair follicle that has become clogged with oil and dead skin cells. Comedones (the plural of comedo) can develop into bumps called whiteheads and blackheads. A whitehead (closed comedone) or a blackhead (open comedone) is without any clinical signs of inflammation. • Products that may trigger comedones are called "comedogenic." • Papules and pustules are raised bumps with inflammation. Acne

The 6 main types of caused by acne: • Blackheads – small black or yellowish bumps that develop on the skin; they're not filled with dirt, but are black because the inner lining of the hair follicle produces colour • Whiteheads – have a similar appearance to blackheads, but may be firmer and will not empty when squeezed • Papules – small red bumps that may feel tender or sore • Pustules – like papules, but have a white tip in the centre, caused by a build-up of pus • Nodules – large hard lumps that build up beneath the surface of the skin and can be painful • Cysts – the most severe type of spot caused by acne; they're large pus-filled lumps that look similar to boils and carry the greatest risk of causing permanent scarring Acne Acne-rarer forms

• : a very severe form of nodulocystic acne. (next slide) Zeichner J; Acneiform Eruptions in Dermatology: A Differential • : sudden, severe inflammatory Diagnosis, 2013. reaction which causes deep ulcerations and erosions; may be associated with fever and arthralgia. Singh S, Mann BK, Tiwary NK; revisited: a case- control study shows a dose-dependent inverse association • Acne excoriée: mainly affects young women and is characterised by self-inflicted wounds associated between overall cosmetic use and post-adolescent acne. with a psychological or emotional problem. Dermatology. 2013226(4):337-41. doi: 10.1159/000350936. • : caused by pressure, friction or Epub 2013 Jul 10. rubbing from clothing. • Acne cosmetica: caused by contact comedogenic Patterson AT, Kaffenberger BH, Keller RA, et al; Skin diseases products with the skin. One study found the link associated with Agent Orange and other organochlorine between acne and cosmetics was weak but exposures. J Am Acad Dermatol. 2016 Jan74(1):143-70. doi: conceded that it was possible with some products. 10.1016/j.jaad.2015.05.006. Epub 2015 Jul 22. • : caused by occupational exposure or military exposure to halogenated hydrocarbons. It presents with many large comedones. Acne-conglobata

• Acne conglobata is one of the most severe forms of acne and can affect the neck, chest, arms, and buttocks. It involves many inflamed nodules that are connected under the skin to other nodules. • Deep abscesses • Inflammation • Severe damage to the skin • Scarring • Comedones (blackheads) which are obvious and widespread, often occurring on the face, neck, trunk, upper arms and/or buttocks • Inflammatory nodules may form around multiple comedones and grow until they break down and discharge pus. Deep ulcers may form under the nodules, producing keloid-type , and crusts may form over deeply ulcerated nodules. Abscesses can form deep, irregular scars. • Acne conglobata may be preceded by acne cysts, papules or pustules that do not heal but instead rapidly deteriorate. Occasionally, it flares up in acne that had been dormant for many years. Acne Conglobata and Rarer Forms of Acne • This type of acne is more common in men and is Authored by Dr Laurence Knott sometimes caused by taking steroids or testosterone. Timely treatment by a dermatologist is essential. Acne-mechanica

• Acne mechanica is caused by heat, friction, and pressure against the skin, often the result of wearing sports gear such as a helmet or baseball cap. It is sometimes called "sports-induced acne" because it occurs frequently in athletes. • Preventive measures include wearing an absorbent material under sports equipment and showering immediately after activity. Acne

• Acne is known to run in families. If both your mother and father had acne, it's likely that you'll also have acne. • Acne is very common in teenagers and younger adults. About 95% of people aged 11 to 30 are affected by acne to some extent. • Acne is most common in girls from the ages of 14 to 17, and in boys from the ages of 16 to 19. • Most people have acne on and off for several years before their symptoms start to improve as they get older. • Acne often disappears when a person is in their mid-20s. • In some cases, acne can continue into adult life. About 3% of adults have acne over the age of 35.

NHS Acne-hormone links

• Acne is commonly linked to the changes in hormone levels during puberty but can start at any age. Can occur in PCOS. • Acne during puberty is often associated more with growth hormone (GH) than with testosterone and oestrogens. GH goes from the brain to the liver and triggers the release of Insulin Like Growth Factor-1 (IGF-1). IGF-1 promotes skin cell growth/division, sebum production, efficacy of luteinizing hormone (LH) and the production of oestrogens. • During times of hormonal fluctuation (like puberty) excess sebum production likely occurs to protect hair follicle growth. • Acne severity doesn’t seem to correlate with total androgen levels in the body. Rather, androgens play a permissive role in priming or initiating acne such as women with PCOS or someone starting a cycle of anabolic/androgenic steroids. People can experience a surge of circulating androgens and IGF-1, along with lower levels of sex hormone binding proteins. • This can cause the grease-producing glands next to hair follicles in the skin to produce larger amounts of abnormal sebum. • This abnormal sebum changes the activity of a usually harmless skin bacterium called Propionibacterium acnes, which becomes more aggressive and causes inflammation and pus. • The hormones also thicken the inner lining of the hair follicle, causing blockage of the pores. Cleaning the skin does not help to remove this blockage. • Environmental pollution can increase IGF-1 Propionibacterium acnes

• Propionibacterium acnes is the relatively slow- growing, typically aerotolerant anaerobic, Gram- positive bacterium (rod) linked to acne; it can also cause chronic blepharitis and endophthalmitis, the latter particularly following intraocular surgery. • Chronic inflammatory acne cannot be defined as an infectious disease, since the bacteria are normally present on the skin of a vast majority of individuals, irrespective of the presence of acne lesions. • P. acnes apparently only triggers the disease when it meets favourable dermatophysiological terrain. • The 4 major recognized pathophysiological features of acne include androgen stimulated seborrhea, hyperkeratinization and obstruction of the follicular epithelium, proliferation of P. acnes, and then inflammation. Propionibacterium acnes

• Comedogenesis, the transformation of the follicle into the primary acne lesion, the comedone, is the product of abnormal follicular keratinization related to excessive sebum secretion. During this process, P. acnes often gets trapped in layers of corneocytes and sebum and rapidly colonizes the comedonal kernel, resulting in a microcomedone, a structure invisible to the naked eye (Plewig and Kligman, 2000). A microcomedone can develop into larger structures, the comedones. • Closed comedones cannot evacuate the thread- looking conglomerate of cell debris, sebum, P. acnes and its products to the skin surface, and this makes them more prone to inflammation and rupture. In inflammatory acne, comedones rupture and the follicular material becomes dispersed in the dermis rather than on the skin surface. Depending on the extent of the damage to the comedone wall, various types of inflammatory lesions are produced, and these are classified as the papules, pustules, or nodules. • P. acnes are directly involved in the rupture the comedone epithelial lining (Holland et al., 1981). Propionibacterium acnes

• The chronic inflammatory condition of the pilosebaceous follicle caused by P. acnes is generally considered non-pathogenic. However, there is a growing body of evidence that point to the bacterium as being a low virulence pathogen in several types of postoperative infections and other chronic conditions. • A preliminary study from Japan (Ishige et al., 1999) has shown that P. acnes DNA can be detected in lymph nodes of Japanese individuals with sarcoidosis. Sarcoidosis is a granulomatous disease that results in the inflammation of lymph nodes, lungs, eyes, liver, and other tissues. P. acnes have also been implicated in sciatica, a chronic inflammatory condition of the lower back. • It also appears to be significant that P. acnes have been isolated from several orthopaedic infections, silicone breast prosthesis, and prosthetic joint infections (Yu et al., 1997; Tunney et al., 1999).

PROPIONIBACTERIUM ACNES AND CHRONIC DISEASES Ajay Bhatia, Ph.D., Jean-Francoise Maisonneuve, Ph.D., and David H. Persing, M.D., Ph.D. Acne

• Comedones that stay closed at the surface of the skin are called whiteheads. This happens when oil and skin cells prevent a clogged hair follicle from opening. Acne

• Blackheads are comedones that are open at the surface of the skin. They are filled with excess oil and dead skin cells. • It's not dirt that causes the comedone to turn black. The black hue results from the irregular reflection of light coming from clogged hair follicles. Acne

• -when excess oil, bacteria, and dead skin cells push deeper into the skin and cause inflammation (redness and swelling), it will cause small, red bumps. • This type of acne blemish is a papule. They feel hard. If you have a lot of papules, the area may feel like sandpaper. • They may be sensitive to the touch. Picking or squeezing can make the inflammation worse and may lead to scarring. • Many papules may indicate moderate to severe acne. • To clear this type of acne blemish, dermatologists recommend an acne face wash that contains benzoyl peroxide or salicylic acid. Acne-pustular

• Pustules are another kind of inflamed pimple. They resemble a whitehead with a red ring around the bump. The bump is typically filled with white or yellow pus. • Picking can cause scars or dark spots to develop on the skin. • Benzoyl peroxide or salicylic acid are usual recommendations. Acne-nodular

• Nodules are large, inflamed bumps that feel firm to the touch. They develop deep within the skin and are often painful. Nodules should be treated by a dermatologist since they can . Acne-cystic

• The formation of large acne lesions deep within the skin is medically known as cystic acne. It is a severe form of acne, which is often painful. • Cysts are large, pus-filled lesions that look similar to boils due to their appearance as large, red bumps on the face and form due to severe inflammation of a blocked skin pore. As a result, the skin cell wall might weaken and rupture, enabling the spread of infection, which causes more acne. • Like nodules, cysts can be painful and should be treated by a dermatologist since they also can scar. These acne blemishes penetrate deep into the skin, and often cause permanent acne scars when they heal. Cystic acne is often a source of low self- confidence and self-esteem for those affected. • People who develop nodules and cysts are usually considered to have a more severe form of acne. • While the exact cause behind the development of cystic acne is not known, it is suggested that androgen hormones play a role. • As the androgen hormones increase during puberty, sebum production and the growth of skin cells increase, raising the risk Acne-cystic

The following factors may contribute to the development of cystic acne:

• Hormonal imbalance in women around menstruation • Pregnancy-related hormonal fluctuation • Reaction to skin products such as cosmetics, lotions, and cleansers • Sweating and humidity • Exposure to toxins or chemicals • Certain medicines such as lithium, phenytoin, corticosteroids, and isoniazid Acne-cystic

The following factors can predispose you to the development of cystic acne:

Adolescence Family history of cystic acne Hormonal changes during puberty or pregnancy Friction on the skin, caused by tight collars, backpack, helmet, cellphones, and other similar items Contact with or use of oily substances such as creams and lotions Acne falls into the "mild" category if you have fewer than 20 whiteheads or blackheads, fewer than 15 inflamed bumps, or fewer than 30 total lesions. Acne categories Mild acne is usually treated with over- the-counter topical medicine. It may take up to eight weeks to see a significant improvement. Acne-nodulocystic

• Severe Nodulocystic Acne • People with severe nodulocystic acne have multiple inflamed cysts and nodules. The acne may turn deep red or purple. It often leaves scars. • Prompt treatment by a dermatologist can minimize scarring. In some cases, a doctor may inject corticosteroids directly into nodules and cysts to reduce the size and painful inflammation. Acne

Prescription medicines that can be used to treat acne include:

• topical/oral retinoids • topical antibiotics • azelaic acid • antibiotic tablets • in women, the combined oral contraceptive pill Acne-systemic therapy

Systemic therapy refers to acne medication that is taken by mouth. • Antibiotics like tetracycline, minocycline, doxycycline, or erythromycin may treat moderate to severe acne by targeting excess bacteria, redness and reducing inflammation. Tetracyclines can make skin sensitive to sunlight. • Other systemic therapies include oral contraceptives, which can reduce acne in some women, spironolactone, an anti-androgen hormone pill, and isotretinoin. • Isotretinoin(high-dose prescription derivative of vitamin A) is a very strong drug that may be prescribed under one of it’s brand names like Roaccutane. Retinoids which is the drug class and work by reducing the amount of sebum made by glands in skin, reducing bacteria and inflammation and opening clogged pores. Potential side effects include vision and hearing problems, birth defects, liver or pancreas problems and joint pain. Acne-topical therapy

• Over-the-counter topical products can often help mild acne. They may contain ingredients like benzoyl peroxide, resorcinol, salicylic acid, or sulfur. • Salicylic acid is more effective for blackheads and whiteheads. • Benzoyl peroxide works well for mild pustules. Benzoyl peroxide works by peeling away the skin to get rid of dead skin cells, excessive oil, and excess P.acnes that may be trapped underneath. Such effects can lead to dryness, as well as redness, irritation and excessive peeling. (Causes sensitivity to sunlight) • Resorcinol helps prevent comedones by removing the buildup of dead skin cells. (Clearasil is resorcinol and sulfur) • Sulfur helps dry out the surface of the skin to help absorb excess oil (sebum) that may contribute to acne breakouts. It also dries out dead skin cells to help unclog pores. • Azelaic acid is a naturally occurring acid found in whole grain cereals. It helps the skin to renew itself more quickly and therefore reduces pimple and blackhead formation. It also helps to kill the bacteria that cause acne and . It works in a similar way to alpha-hydroxy acids, by penetrating the skin and breaking up acne-causing blockages. Comedolytic, it works to exfoliate deep within the pores, is keratolytic, anti- inflammatory, and has antioxidant properties. • Prescription products such as antimicrobial or retinoid/retinoic acids or tretinoin are often useful for moderate acne. These can be prescribed alone or in combination with other ingredients. • To unclog pores, dermatologists recommend using a retinoid. One retinoid, adapalene, is available without a prescription. Cystic Acne- treatments Oral antibiotics • These are often the first treatment method prescribed to those with cystic acne. Antibiotics help control the infection; however, they must be used for only a short term to prevent the development of bacterial resistance. Topical products may be given along with oral antibiotics. Isotretinoin • Inhibits the flow of sebum. Isotretinoin can help control excessive oil production, clogging of pores, bacterial growth, and inflammation, all of which contribute to cystic acne. Isotretinoin is found to have a permanent effect in around 85% of patients. However, it may have side effects. Oral contraceptives • Women can take birth control pills for acne caused by hormonal imbalance. These are generally used along with antibiotics in the case of cystic acne. Surgery • This involves the excision of acne cysts to help drain out the pus and to remove the infected skin cells. • Corticosteroid injections into lesions to reduce inflammation Acne-treatments

YAG laser • A YAG laser beam works by vaporizing the scarred tissue off the top skin layer. The energy absorbed by the skin also helps stimulate collagen production. Chemical peels • This treatment method involves the application of mild alpha and beta hydroxy acids on the face for a few minutes. This helps remove the epidermal skin layer, revealing newer, smoother skin. Treatment may be repeated until desired results are seen. Comedone extractor • a small pen-shaped instrument that can be used to clean out blackheads and whiteheads Acne Acne rosacea-symptoms

• Redness and flushing on the face or body that looks like a sunburn. Many people with rosacea have a history of frequent blushing or flushing. This facial redness may be accompanied by a sense of heat, warmth or burning comes and goes, and is often an early feature of the disorder. Itching or a feeling of tightness may also develop. • Broken blood vessels-in many people with rosacea, prominent and visible small blood vessels called telangiectasia develop on the cheeks, nasal bridge, and other areas of the central face that look like spider veins. • Rough, raised, dry red patches called plaques • Small red solid bumps or pus-filled pimples often develop. While these may resemble acne, blackheads are absent. • Sensitivity • Oily skin or enlarged pores • Bumpy skin texture/skin thickening All these have been subtyped Acne rosacea

• Although rosacea may develop in many ways and at any age, patient surveys indicate that it typically begins any time after age 30 as flushing or redness on the cheeks, nose, chin or forehead that may come and go. • Left untreated, inflammatory bumps and pimples often develop. • Individuals with fair skin who tend to flush or blush easily are believed to be at greatest risk. • The disorder is more frequently diagnosed in women but tends to be more severe in men. Acne and acne rosacea

• Subtype One: Erythematotelangiectatic Rosacea- the most well-known form of rosacea characterized by persistent redness, flushing, and enlarged blood vessels. • Studies have shown that over time the redness tends to become ruddier and more persistent. Acne rosacea

• Subtype Two: Papulopustular Rosacea that occurs with acne-like breakouts. It can also show up as hardened patches called plaques and excessive oiliness. • Subtype Three: Phymatous/ Rosacea-a rare type of rosacea that causes thickening skin on the cheeks, chin, forehead, ears, or nose (Rhinophyma). • Subtype Four: Ocular Rosacea Acne rosacea

• Subtype Three: Phymatous/Rhinophyma Rosacea-a rare type of rosacea that causes thickening skin on the cheeks, chin, forehead, ears, or nose (Rhinophyma). • In severe cases — particularly in men — the nose may grow swollen and bumpy from excess tissue. Ocular rosacea

• Subtype Four-In many rosacea patients, the eyes may be irritated and appear watery or bloodshot, a condition commonly known as ocular rosacea. The eyelids also may become red and swollen, and styes are common. Crusts and scale may accumulate around the eyelids or eyelashes, and people may notice visible blood vessels around the lid margins. Severe cases can result in corneal damage and loss of visual acuity. • Chalazia are enlargements of an oil gland deep in the eyelid caused by an obstruction of the gland's opening. Styes are usually infected eyelash follicles. A chalazion is inflamed but not infected. A stye is usually caused by a staphylococcal infection. Acne Rosacea-causes

• Although the cause of rosacea remains unknown, researchers have now identified major elements of the disease process that may lead to significant advances in its treatment. • Recent studies have shown that the facial redness is likely to be the start of an inflammatory continuum initiated by a combination of neurovascular dysregulation and the innate immune system. • The role of the innate immune system in rosacea has been the focus of groundbreaking studies including the discovery of irregularities of key microbiological components known as cathelicidins. • A protein that normally protects the skin from infection, cathelicidin, may cause the redness and swelling. How the body processes this protein may determine whether a person gets rosacea. • Further research has now demonstrated that a marked increase in mast cells, located at the interface between the nervous system and vascular system, is a common link in all major presentations of the disorder. Acne Rosacea-causes

• Researchers have also discovered that two genetic variants of the human genome may be associated with the disorder. • H pylori, is common in people who have rosacea. • Beyond neurovascular and immune system factors, the presence of a microscopic mite called Demodex folliculorum has been considered as a potential contributor to rosacea. This mite is a normal inhabitant of human skin but has been found to be substantially more abundant in the facial skin of rosacea patients. D. folliculorum lives within the hair follicles on human skin, feeding on dead skin cells. • Tea tree oil, dill weed oil and caraway oil will eradicate. • Other recent studies that have found associations between rosacea and increased risk for a growing number of potentially serious systemic diseases, suggesting that rosacea may be an outcome of systemic inflammation. Although causal relationships have not been determined, these have included cardiovascular disease, gastrointestinal disease, neurological and autoimmune diseases and certain cancers. Rosacea.org Acne Rosacea-common triggers

• Factors Percent Affected A survey of 1,066 rosacea patients found that the most common factors • Sun exposure 81% included the following: • Emotional stress 79% • Hot weather 75% • Wind 57% To help identify personal trigger factors, • Heavy exercise 56% rosacea patients are advised to keep a diary • Alcohol consumption 52% of daily activities or events and relate them • Hot baths 51% to any flare-ups they may experience. • Cold weather 46% • Spicy foods 45% • Humidity 44% • Indoor heat 41% • Certain skin-care products 41% • Heated beverages 36% • Certain cosmetics 27% • Medications 15% • Medical conditions 15% • Certain fruits 13% • Marinated meats 10% • Certain vegetables 9% • Dairy products 8% rosacea.org Acne Rosacea-common triggers

Foods Temperature-related

•Liver •Saunas •Yogurt •Hot baths •Sour cream •Simple overheating •Cheese (except cottage cheese) •Excessively warm environments •Chocolate Weather •Vanilla •Sun •Soy sauce •Strong winds •Yeast extract (bread is OK) •Cold •Vinegar •Humidity •Eggplant •Avocados Drugs •Spinach •Broad-leaf beans and pods, including lima, navy or pea •Citrus fruits, tomatoes, bananas, •Vasodilators red plums, raisins or figs •Topical steroids •Spicy and thermally hot foods •Foods high in histamine

Beverages Medical conditions •Alcohol, especially red wine, •Frequent flushing beer, bourbon, gin, vodka or champagne •Menopause •Hot drinks, including hot cider, •Chronic cough hot chocolate, coffee or tea •Caffeine withdrawal syndrome Emotional influences Physical exertion •Stress •Exercise •Anxiety •"Lift and load" jobs Skin care products •Some cosmetics and hair sprays, especially those containing alcohol, witch hazel or fragrances •Hydro-alcoholic or acetone substances •Any substance that causes redness or stinging Acne Rosacea-concurrent disease Women With Rosacea Twice as Likely to Have Coeliac Disease and Other Autoimmune Diseases —Specific HLA alleles associated with rosacea have been identified, some of which are associated with certain autoimmune conditions. What does that mean for clinicians? • Specific HLA alleles associated with rosacea have been identified; some of these HLA alleles previously have By Leslie Burgess been found to be associated with type 1 diabetes and References coeliac disease. 1. National Rosacea Society. http://www.rosacea.org. Accessed • In a large, population-based study, women with May 25, 2016. rosacea were more likely than matched controls to 2. Chang ALS, Raber I, Xu J, et al. Assessment of the genetic basis have concurrent type 1 diabetes, coeliac disease, of rosacea by genome-wide association study. J Invest Dermatol. multiple sclerosis, or rheumatoid arthritis. 2015;135:1548-1555. 3. Egeberg A, Riis Hansen P, Hilmar Gislason G, et al. Clustering of • The data suggest there may be benefit to asking autoimmune diseases in patients with rosacea. J Am Acad patients with rosacea about personal or family history Dermatol. 2016;74:667-672. of autoimmune disease and potentially screening 4. Two AM, Wu W, Gallo RL, et al. Part I. Introduction, them through a thorough history and review of categorization, histology, pathogenesis, and risk factors. J Am systems. Acad Dermatol. 2015;72:749-758 5. Van Zuuren EJ, Fedorowicz Z, Carter B, et al. Interventions for rosacea (review). Cochrane Database Syst Rev. 2015:CD003262 Acne Rosacea

• Antibiotics like doxycycline, tetracycline, or minocycline may reduce swelling, inflammation, and the acne like bumps that occur with Papulopustular Rosacea. • Roaccutane-retinoids work by reducing the amount of sebum made by glands in skin, reducing bacteria and inflammation and opening clogged pores. • Topical treatments like Brimonidine, an alpha2- adrenoceptor agonist, is used to narrow blood vessels to reduce redness. Acne-face mapping

• Acne and facial blemishes may develop in specific zones because of internal issues, which may include high blood pressure, dehydration, and digestive wellbeing, or from another organ in the body, such as the liver. Acne and diet

Source: Burris J, et al. Acne: The Role of Medical Nutrition Therapy. J Acad Nutr Diet 2013;113:416-430. Acne and potential pathways of gut-brain- skin axis

Gut-brain-acne interaction Source: Bowe WP & Logan AC. Acne vulgaris, probiotics and the gut-brain-skin axis – back to the future? Gut Pathogens 2011;3:1. ROS

• Reactive oxygen species (ROS) are subsequently generated from the hypercolonization of P. acnes. Although ROS perform a useful function in the skin barrier against acne microbes, excess formation affects by activating neutrophil infiltration. • ROS including singlet oxygen, superoxide anion, hydroxyl radical, hydrogen peroxide, lipid peroxide and nitric oxide (NO) play an important role in inflammatory acne as well as in tissue injury. Acne-don’ts

• Do not wash affected areas of skin more than twice a day. Frequent washing can irritate the skin and make symptoms worse. • Wash the affected area with a mild soap or cleanser and lukewarm water. Very hot or cold water can make acne worse. • Do not try to "clean out" blackheads or squeeze spots. This can make them worse and cause permanent scarring. • Avoid using too much make-up and cosmetics. Use water- based products that are described as non-comedogenic. This means the product is less likely to block the pores in the skin. • Completely remove make-up before going to bed. • If dry skin is a problem, use a fragrance-free water-based emollient. • Shower as soon as possible once you finish exercising as sweat can irritate your acne. • Wash your hair regularly and try to avoid letting your hair fall across your face. Acne-don’ts

• Dairy can cause hormone fluctuations, prompting an overgrowth of skin cells (increases IGF-1) that block pores and trap bacteria, eventually causing acne. • The unfavourable associations between dairy and acne haven’t been noticed with fermented dairy products, maybe because bacteria in fermented dairy use IGF-1, leaving less for us to absorb. • Omega 6 to Omega 3 imbalance can increase inflammation • Whey protein promotes a spike in insulin which, in turn, causes an overgrowth of skin cells, oil production, and inflammation. Increases IGF-1 • Gluten elimination check especially if GI tract stressed • Excess iodine irritates the sebaceous glands Acne-don’ts

• High androgen foods-animal foods and saturated fats tend to get the biggest response. Lower fat, higher fibre diets can increase levels of sex hormone binding proteins, thus lowering free levels of circulating androgens. • Greasy, fast, refined and sugary foods • Too many high GI foods • Elevated blood sugar triggers insulin which imbalances hormones, including increased activity of androgens which prompt sebum production. High insulin levels and insulin resistance are associated with worse acne and more sebum (more body fat can lead to more insulin resistance). • Hyperinsulinemia increases circulating levels of IGF-1 and insulin-growth factor-binding protein-3, directly impacting keratinocyte hyperplasia and apoptosis • When stressed, we produce more androgens, which stimulate the oil glands and hair follicles in the skin, leading to outbreaks. • Lifestyle factors include poor diet and sleep, exposure to pollution and other environmental aggressors, and a poor skincare regime that is over or under-zealous, or simply not right for the individual. All of these can put the body in an inflammatory state. Acne-do’s

• Remove oil-based products • Keep skin hydrated with a good serum • Prioritise strengthening and rebuilding of the skin barrier, decongestion of pores and reduction of oil. • Blot the face dry with a thick cotton towel. Never pull, tug or use a rough washcloth. • Use a natural and gentle exfoliating cleanser • Reduce bacteria on the skin (Clinisept) • Only use non-comedogenic products • Use barrier building ingredients like hyaluronic acid, niacinamide and ceramides. • Use SPF factor 30 sunscreen • Work with a professional beautician-they may use treatments such as chemical peels, using glycolic, mandelic or salicylic acid. (Glycolic acid helps to dissolve the bonds which bind dead cells to the skin’s surface). And sometimes vitamin A peels. Also LED for reduction of bacteria. Laser, micro needling and resurfacers. Acne-multitargeted approach Control inflammatory responses Reduce sebum and increase SHBG to control testosterone levels Antioxidant nutrients Balance gut flora and use probiotics in conjunction with digestive enzymes (Papain is antioxidant and helps to protect the body from cellular damage. Bromelain helps to maintain healthy inflammatory and immune responses) Use antimicrobials to control infection Use dietary protocols to enhance skin health There is strong support for the reduction of acne with regular consumption of omega-3 fatty acids and low-GI and low-GL diets Use topical protocols for the skin Hormone balance Control mast cell activity Histamine balance (histamine receptors present in sebum) Acne

Effects of Diet on Acne and Its Response to Treatment Hilary Baldwin & Jerry Tan American Journal of Clinical Dermatology volume 22, pages55– 65(2021) Acne-do’s

• Acne doesn’t seem to appear in non-Westernized populations eating traditional diets. • Many spices (e.g., cinnamon, ginger, turmeric) and fresh herbs (e.g., basil, oregano, garlic) support inflammatory and immune responses as well as antimicrobial support. • Spices such as cinnamon can also help to regulate insulin. • Green tea can suppress enzymes and androgens involved in acne formation and support inflammatory processes. • Unprocessed fats-increase Omega 3-decreases IGF-1 and inhibits synthesis of inflammatory leukotriene B4, which in turn reduces inflammatory acne lesions • Eat fermented foods or supplement with beneficial bacteria for gut health and motility • Fibre can also bind to and excrete excess hormones that contribute to acne. • Whole, unprocessed foods including a lot of fruit and veg • Tree nuts such as almond and walnuts • Non wheat grains (cut out the white stuff) • High zinc and selenium foods • Rosmarinic acid, garlic and thyme oil are effective against P.acnes Acne-do’s

• Hormone-generated acne may benefit from a diet rich in lignans. Lignans are associated with the normal homoeostasis of sex hormones of both men and women. • Lack of fruit, vegetables, grains and food processing can cause a deficiency in the diet. • Since androgens (testosterone) play a major role in acne, lignans may have a positive role to play in its treatment. • A protein, sex hormone binding globulin produced by the liver bonds oestrogen and testosterone to control how much is circulating in the blood producing a balancing effect. • Phytoestrogens help to stimulate the production of SHBG. • The lignan found in flaxseed is called secoisolariciresinol diglucoside (SDG). This phytonutrient is classed as a polyphenol. • The health benefits of flaxseed lignans are also due to antioxidant activity. • The presence of large amounts of lignans can lead to a decrease in several inflammatory markers. Rosehip

• High in vitamin C, carotenoids, EFA’s and tretinoin • Helps the passage of fluids between cells through osmosis • Antioxidant • Helps in tissue injury • Glycosides have an anti-inflammatory effect and antinociceptive activities including actions on arachidonic acid metabolism and inhibition of cyclooxygenases. • Nourishes the skin (collagen and elastin) Rutin

• Rutin from buckwheat, apricots, cherries, grapes, grapefruit, plums, and oranges protects cellular function, circulates in the bloodstream, seeking out toxic free radicals or poisonous metals and inactivating them, before these can damage cells (Arch Biochem Biophys 1998;355: 43-8) • Strengthens small arteries and veins under the skin (J Mal Vasc 1998;23(3):176-82). • Stabilises effects of vitamin C Ginger

• Ginger inhibits several genes that contribute to inflammation. • Ginger Root is an excellent anti- oxidant, helping to scavenge free radicals from multiple sources including drugs and environmental toxins. The antioxidants in ginger suppress cellular production of nitric oxide, a compound that produces toxic free radicals that promote tissue damage and inflammation. • Multiple research studies outlined in the review established that ginger helped to manage multiple biochemical pathways activated in chronic inflammation without blocking enzymes vital for maintaining healthy tissues. Quercetin

• Quercetin is a powerful anti- inflammatory and is a component of rutin which has been shown to maintain the integrity of blood vessels. • Anti-oxidant • Stabilises mast cells, inhibits histamine release Grape seed extract

• Improves quality of blood- reducing stickiness • Contains oligomeric proanthocyanidin complexes(OPCs) derived from polymers of catechin and epicatechin, water soluble which are very effective at preventing collagen breakdown • Extremely beneficial to human health • Blood vessel health – opcs have a high affinity for constituents of arterial walls • Protects capillaries • Enhances the structure and tone of cells • Protects tissues and vessels from excess enzyme activity which induces fluid and abnormal permeability • Antioxidant Thyme

Contains Thymol • Assists the absorption of DHA into cell structures. • Decreases lipid peroxidation mediated oxidative stress • Stops the activity of elastase, a marker for collagen degradation and prevents the invasion of inflammatory cells to the injured site Rosemary

• Contains rosmarinic acid • Rosmarinic acid has been shown to improve blood vessel (endothelial) and blood cell health via its antioxidant and anti-inflammatory properties. • Rosmarinic acid, carnosol, and carnosic acid; three bioactive compounds of rosemary, show differential modulatory effects on P. acnes–induced cytokine production reducing P. acnes– induced inflammation

60 Chamomile and Milk Thistle

Chamomile The plant's healing properties come from its daisy-like flowers, which contain volatile oils Chamomile contains alpha-bisabolol, which accelerates the skin’s healing process. Chamomile is also an anti- irritant, so it compliments a skincare regimen that may incorporate more aggressive anti-acne ingredients (like retinol). The dried flowers contain many terpenoids and flavonoids including luteolin and apigenin which maintain normal epithelial function. Luteolin is a citrus flavonoid found in many plants including chamomile and dandelion and has multiple biological effects in maintaining normal cell health. Apigenin is a flavonoid antioxidant and helps to maintain normal inflammatory responses. Milk Thistle is a demulcent that improves the health of the bodies mucous membranes. This reduces inflammation within the skin cells. Milk Thistle also helps soften and improve the moisturization of the skin, This is especially helpful for individuals with acne. Dandelion

• All parts of the plant contain several antioxidants, essential fatty acids and phytonutrients including apigenin and luteolin important for cell health and inflammatory responses. • Current research is starting to demonstrate Dandelion's broader supportive role in maintaining normal epithelial cellular function.

L. plantarum increases the bioavailability and biological activity of plants including Chamomile, Dandelion and Milk Thistle. Vitamin C

Vitamin C, the most plentiful antioxidant in human skin, forms a part of the complex group of enzymatic and non-enzymatic antioxidants that co-exist to protect the skin from reactive oxygen species (ROS). Vitamin C increases the synthesis of collagen, a protein responsible for the skin's structure and vital for rebuilding healthy skin. As a result, this may accelerate the healing of acne wounds. Vitamin C has potential anti-inflammatory activity and can be used in conditions like acne vulgaris and rosacea. It can promote wound healing and prevent post- inflammatory hyperpigmentation. Helps maintain the microcirculation and strength of the connective tissue Stabilises mast cells, inhibits histamine release Aquasol-unique instant pure herb teas

• We source the best quality organic herbs around the world, fair trading with skilled farmers who maintain the complexity and full integrity of the herb. • Superfine grade, smaller granules • Whole herb is consumed-zero waste • Liquids, hot and cold, food or yogurts Acne-do’s

Camu Camu-high in vitamin C, helps scars fade, antioxidant. Elderflower Green Tea-long term support for removal of toxins from small vessels Guarana Artichoke Leaf Lemon Balm Leaf Echinacea Root-P. acnes induced inflammation Devils Claw Root Turmeric Root-anti-inflammatory, anti-scarring Hibiscus Flower-natural acids break down dead skin cells, antioxidant, supports collagen and elastin synthesis. Pink Rose Petal-antioxidant, promotes healthy skin, astringent, antiseptic, anti-inflammatory White Ginseng Root Red Ginseng Ginger Root-antiseptic and antioxidant, skin renewal, improves blood circulation, anti-inflammatory, hyperpigmentation Gota Kola-soften tissue and reduce sebum Nettle Root Acne-topicals

• Neostrata • CeraVe • Clinique • Plenair • Murad • Medik8 • L’Oreal Revitalift Laser • Pixi • La Roche Posay Effaclar • Mario Badescu • The Inky list • Paula’s Choice

Practitioner Support

• Website for clients to browse www.bionutri.co.uk and a password protected practitioner page where you have access to video clips, catalogue pages and seminar listings for online registration • We are also on Facebook/Bionutri for practitioners • Professional Product catalogue/product leaflets • Technical Support by Skype/phone or email-Sue McGarrigle ND ([email protected]) and Edward Joy Herbalist ([email protected]) • Product training-one to one or small groups by telephone, at home or Skype • Kinesiology samples • Samples for sensitive clients Product sources

Practitioner/Patient

Bionutri The Natural Dispensary References

Biomed Res Int. 2014; 2014: 301304. New Perspectives on Antiacne Plant Drugs: Contribution to Modern Therapeutics Priyam Sinha, Shruti Srivastava, Nidhi Mishra, and Narayan Prasad Yadav* https://dermnetnz.org/topics/acne-and-other-follicular-disorders/ https://www.aad.org/public/diseases/acne/diy/types-breakouts https://patient.info/doctor/acne-conglobata-and-rarer-forms-of-acne Jundishapur J Microbiol. 2015 Nov; 8(11): e25580. Medicinal Plants for the Treatment of Acne Vulgaris: A Review of Recent Evidences Hamid Nasri,1 Mahmoud Bahmani,2 Najmeh Shahinfard,3 Atefeh Moradi Nafchi,4 Shirin Saberianpour,4 and Mahmoud Rafieian Kopaei4,* J Med Food. 2013 Apr; 16(4): 324–333. Rosmarinus officinalis Extract Suppresses Propionibacterium acnes–Induced Inflammatory Responses Tsung-Hsien Tsai,1 Lu-Te Chuang,2 Tsung-Jung Lien,3 Yau-Rong Liing,3 Wei-Yu Chen,4 and Po-Jung Tsai corresponding author3