Unlike getting a driver's license or going to rock concerts, acne is one of those rites of passage teenagers would love to bypass. But only a lucky few manage to escape it: 85 percent of teens are afflicted with pimples. And for about 5 percent of adults, leaving their teens behind doesn't necessarily mean they have said goodbye to blemishes.
Acne vulgaris, commonly known as teenage acne, is caused by the increased production of certain hormones during adolescence. During puberty, a group of male hormones called androgens causes the sebaceous, or oil, glands under the skin to enlarge and produce more sebum, a skin lubricant made of oils and waxes. (Though androgens are known as male hormones and are responsible for the appearance of secondary sex characteristics in boys, females also produce them; they're less active but still cause acne.) As the excess sebum passes through hair follicles to empty onto the skin's surface, it causes cells along the follicle wall to be shed in greater numbers than usual; these cells and sebum stick together to form a plug.
If the plug breaks through the surface of the skin, it forms a blackhead; if it remains below the surface, it becomes a whitehead. Pimples - the hard, red blemishes most people associate with acne - form when bacteria break down the sebum trapped in the plugs and create pus, which causes inflammation; in severe cases, the pimples can develop into cysts.
Among adults, acne vulgaris primarily affects women in their 20s through 40s, and seems to be caused by a hormonal imbalance, says Stanley Miller, M.D., assistant professor of dermatology at Johns Hopkins Medical Institutions in Baltimore. For female patients, his usual recommendation is to take birth-control pills to balance the hormones. The standard treatment for adults and teens, however, is to attack specific cogs in the acne factory. Topical antibiotics and topical treatments such as benzoyl peroxide and tretinoin (better known by its brand name, Retin-A) work to break up the oily plugs and prevent scarring. Oral antibiotics such as tetracycline and erythromycin fight the bacteria that act on sebum. Vitamin A-derived treatments such as isotretinoin (known as Accutane) work on severe acne to reduce the amount of sebum the glands produce.
But some of these drugs are only temporarily effective. For instance, two studies found that acne returned in nearly 25 percent of patients treated with isotretinoin, often within a year and a half (British Journal of Dermatology, 1993, vol. 129). Oral antibiotics also may have only short-term effects; according to a study in the British Medical Journal (Feb. 27, 1993), the acne bacteria in 38 percent of patients became resistant to one or more antibiotics, most commonly erythromycin, as well as clindamycin and tetracycline.
Conventional drugs also may have side effects, some of them serious. Isotretinoin, for example, has been shown to increase the risk of birth defects, and dermatologists win not prescribe it to women unless they are using birth control. Even benzoyl peroxide, the popular over-the-counter topical preparation used for more than 25 years, has come under scrutiny. Several Japanese studies conducted in the mid-1980s indicated that benzoyl peroxide promoted skin tumors in mice exposed to ultraviolet rays. Based on these studies, die U.S. Food and Drug Administration (FDA) proposed in 1995 that benzoyl peroxide products warn users to avoid sun exposure. The FDA will not issue any final regulation, however, until it sees more definitive safety studies; in the meantime, benzoyl peroxide is considered safe to use, says FDA spokesperson Brad Stone.
Before resorting to such medication, natural-medicine practitioners encourage patients to address factors that may have thrown their bodies out of balance. Rather than simply try to suppress the symptom - pimples - holistic practitioners encourage patients to address an array of issues that can help the body heal itself.
FIGHT FROM THE INSIDE OUT
The First place to start is by eating a balanced diet. Ideally, you should eat a vegetarian diet, low in fat and high in fiber, says Joseph Pizzorno, N.D., a naturopathic physician and president of Bastyr University, a naturopathic medical school in Seatlle; he also is co-author of the Encyclopedia of Natural Medicine (Prima Publishing, 199 1). According to Pizzorno, a vegetarian diet is more likely than a meat-based one to be high in the essential fatty acids linoleic and linolenic acid, and low in saturated fats; these essential fatty acids thin the oil secreted through the skin and make it less likely to clog pores than oil containing saturated fat. Furthermore, adds Pizzorno, animal fats contain arachindonic acid, a fatty acid that promotes inflammation. Fiber is beneficial because it helps the body eliminate hormones that promote excess sebum production.
As for typical "forbidden foods" such as chocolate or cola, they've never been proven to cause acne. However, Pizzorno says that a combination of empirical evidence and scientific studies shows that eliminating certain other foods can be helpful. He suggests avoiding refined carbohydrates, including sugar and white flour, which appear to suppress the immune system. "If the body uses the immune system to fight the food, it may not have any immune system power to fight the bacteria that promote pimples and cysts, " Pizzorno says. In a study of more than 1,000 subjects, those who had acne reported consuming significantly more refined carbohydrates than those who did not have acne (South. Med. J. 69, 1976). Pizzorno also recommends avoiding fried foods, because the partially hydrogenated oils that they're usually cooked in contain saturated fat, and foods high in iodine, which seem to trigger acne in some people (Cutis 28, 1981). Seafood and salty snacks prime sources of iodine in most American diets. Miller, who says that improving a deficient diet can be effective against acne, is more circumspect about direct links between certain foods and acne. Nevertheless, many patients swear their blemishes disappear after they eliminate certain foods, says Miller, adding that if a particular item seems to make your acne worse, by all means avoid it.
VITAMINS CAN SMOOTH
Consuming plenty of certain vitamins and minerals also is important to clearing up acne, says John G. Collins, N.D., a dermatology professor at the National College of Naturopathic Medicine in Portland, Ore. You may be able to get adequate amounts from food; if not, Collins recommends taking supplements. The doses recommended below are considered safe, though you should avoid increasing them, because high levels of some vitamins and minerals can cause problems. Too much zinc, for example, can lower your levels of copper and possibly lead to anemia.
Vitamin A is important, because it helps reduce sebum production. Unfortunately, taking too much can lead to toxic levels. To be on the safe side, Collins recommends consuming beta carotene, which the body can safely convert to vitamin A. About 10,000 International Units (IU) of vitamin A is the suggested amount to fight acne; about 20,000 IU to 30,000 IU of beta carotene - the amount in four medium-size carrots - will convert to this level of vitamin A. Other rich sources of beta carotene include sweet potatoes, cantaloupe, spinach, tomatoes, squash and apricots. You should also consume 300 IU to 400 IU a day of vitamin E, which helps you properly metabolize the vitamin A, says Tammy Alex, N.D., a family practitioner who specializes in acne and guest lectures on nutrition at Yale University Medical School in New Haven, Conn.
Zinc is beneficial because it helps break down androgens into less detrimental forms, says Pizzorno. Zinc also is essential for proper immune functioning, and it helps heal acne scars. Zinc is found primarily in animal foods, so vegetarians need to make a conscious effort to get the 25 milligrams (mg.) per day that Pizzorno recommends. Whole grains are rich in zinc, and nuts are a fairly good source. Or Pizzorno suggests taking a supplement of zinc citrate or zinc picolinate.
Chromium appears to help clear up acne, though the reason why is unclear; one study suggests that it helps the body make better use of essential fatty acids (Med. Hypotheses, 14:307-10, 1984). Pizzorno recommends taking 150 micrograms (mcg.) a day of chromium picolinate.
Vitamin [B.sub.6] is especially helpful for girls and women whose acne is aggravated by their menstrual cycles, because it helps the body break down excess hormones, says Pizzorno, who recommends taking 25 mg. of vitamin B complex daily. Finally, selenium helps control inflammation, which is why Pizzorno recommends 150 mcg. daily.
The most effective way to treat the skin is not always the most direct. Herbs that support the liver can be helpful, says Alex, because the liver breaks down androgens and supports the immune system. To strengthen the liver and increase its activity, try dandelion root, milk thistle or burdock root, either individually or in combination. The amount of herb per capsule varies by herb and brand; follow directions on the label or start with two capsules per day. If you don't experience relief, you can increase the level to no more than six capsules daily. These are all non-toxic herbs, so you can take them for as long as six months or even a year. Your acne win probably start to clear up within a couple of months though; taper off the amount as your skin improves, and stop taking the herbs once outbreaks have ceased.
Poor digestion can aggravate acne when bacteria in the intestines create toxins like ammonia and hydrogen sulfide, says Collins. These toxins overload the liver, impairing its work of processing excess hormones. To strengthen digestion, Alex says that a combination capsule of gentian and skullcap can be helpful; gentian improves digestion by stimulating gastric and pancreatic functions, and skullcap promotes relaxation for calm digestion. Alex recommends taking one to two capsules with meals three times a day, tapering off as your skin clears. These herbs also are non-toxic and may be taken indefinitely.
If you've taken antibiotics for your acne - or any other illness for that matter - you may want to take Lactobacillus acidophilus, a beneficial bacteria in the colon that is killed off by antibiotics. Acidophilus keeps a common intestinal yeast, Candida albicans, in check, says Pizzorno. "When the yeast overgrows, it becomes a powerful immune suppressant," he explains. "A week's use of tetracycline can lead to this candida overgrowth." Though yogurt with active cultures contains acidophilus, it's usually not enough to kill off the yeast, so Pizzorno recommends taking three to four capsules of acidophilus a day, between meals; you could also try eating several doves of garlic a day, taking advantage of garlic's antibiotic properties. As an alternative to antibiotics, Collins recommends short-term use of echinacea, an herb that supports the immune system, and goldenseal, an antibiotic herb; Collins suggests taking 40 drops of combined echinacea-goldenseal tincture three times a day until acne improves. (The combined tincture is commonly available in natural food stores and even some drugstores.)
As for topical treatment of pimples, research conducted at Australia's Royal Prince Alfred Hospital in Camperdown found that for mild to moderate acne, a 5 percent tea tree oil gel was as effective as a 5 percent benzoyl peroxide lotion but was significantly less drying. Tea tree oil has a strong odor, similar to eucalyptus, and can be found at natural food stores. For best effect, look for tea tree oil with a terpenine level of at least 30 percent and a cineol level of less than 10 percent, says Collins; these should be listed on die label. Dab tea tree oil all over your face and any other place where you get acne, such as your back or chest.
Finally, don't underestimate die effect stress can have. "When people are going through problems in their relationships, or with family, or with school or work, their acne becomes exacerbated, " says Vivek Shanbhag, N.D., a dermatology professor at Bastyr University and chair of its Ayurvedic medicine department. Ayurveda is an ancient system of medicine from India.) "Stress creates a hormonal imbalance that can trigger acne." Exercise is one of the best methods to reduce stress, says Shanbhag, adding that it opens your pores to encourage greater excretion of sebum. Other routes to relaxation include meditation, yoga and breathing exercises (see "What? Me Relax?," March 1996). One of these methods may be just the thing to help you become free of blemishes.
About one in 600 adults - especially middle-aged, fair-skinned women - find themselves coping with a skin condition often confused with acne vulgaris. This adult acne, called acne rosacea, usually begins as a temporary facial flushing, often after eating a spicy food or entering a hot environment. Symptoms can progress to include inflammatory lesions that look like pimples and, occasionally, a bulb that forms upon the nose.
Little is known about rosacea's causes, but unlike acne vulgaris, it does not appear to be related to the excess production of hormones or sebum. Diet is the basis of treatment by John G. Collins, N.D., a naturopathic physician who teaches dermatology at the Portland, Ore.-based National College for Naturopathic Medicine. "You should avoid foods that might cause the flushing you see in acne rosacea, such as hot, spicy foods and alcohol," Collins says. "Blushing seems to aggravate rosacea." Collins reports that several patients improved after eliminating foods to which they were allergic.
To treat acne rosacea topically, Vivek Shanbhag, N.D., a dermatology professor at Bastyr University in Seattle, recommends a paste made with anti-inflammatory herbs. Mix 2 teaspoons turmeric powder and 6 teaspoons coriander powder with enough milk to form a paste. Bring paste to a boil, then remove and cool. Twice daily, or when flushing occurs, apply to your face and leave on for 10 minutes.
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