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The Acne Patient: Quality-of-Life and Clinical Questions Anthony J. Mancini, MD, FAAP, FAAD Researchers are expanding their work beyond studies on the impact of acne on quality-of-life (QoL) issues and investigating the potential role of diet in managing the care of individuals with acne vulgaris. This article reports on various study findings relating to the impact of acne on the lives of people with this condition, focusing on the implications of a low-glycemic load (LGL) diet in the management of acne. Impact of Acne on QoL Issues Research indicates that acne vulgaris imparts a substantial negative impact on QoL of those affected by this condition. 1 QoL factors—such as anxiety, frustration, and perceptions of negative effects on employment and personal relationships—contribute to adverse effects on mood and self-esteem and can contribute to clinical depression and, in extreme cases, suicide. 1 Groups at high risk for compromised QoL include people who do not seek treatment and people whose skin conditions are not optimally managed in the medical setting. Each group has an increased risk for adverse consequences of acne, such as disfigurement, scarring, 2 and psychologic morbidity. 3 Fear of these consequences and the discomfort of acne vulgaris resulted in 4.4 million doctor visits for people seeking treatment during 2006. 4 Another indicator of the serious consequences of acne is revealed by the Dermatology Life Quality Index (DLQI), a health-related QoL questionnaire that specifically focuses on skin conditions. 2 To estimate the impact of skin conditions on QoL measures, the DLQI has been administered to various populations suffering from skin diseases. For example, the DLQI instrument asks a series of questions about the effects of the condition on specific situations (such as feeling embarrassed about the condition) and its interference with such activities as playing sports or engaging in social activities. Applying the DLQI scoring measures ranging from zero (indicating no impairment of life quality) to 30 (indicating maximum impairment), the average DLQI score was 8.8 for patients with psoriasis as compared with the average DLQI score of 11.9 for patients with acne. 2 These findings suggest that patients with acne may feel that their condition poses a higher threat to their QoL than that of patients with psoriasis. 2 Psychological studies have found that patients with acne experience impaired self-worth as well as high levels of anger, anxiety, obsessiveness, and clinical depression. 1 These negative emotions can become severe enough to impair their ability to function. 1 According to a study by Mallon and colleagues, the stress resulting from the impact of acne on an individual’s QoL can be disabling, 5 comparable to the disability resulting from chronic disorders such as diabetes and asthma. 3 Psychological studies have found that patients with acne experience impaired self-worth as well as high levels of anger, anxiety, obsessiveness, and clinical depression. Patients with acne often report that the disease has had negative effects on their social interactions, academic studies, employment, and other aspects of their lives, including a negative impact on participation in sports and activities such as dating or eating out with friends. 1,6 For many of these patients, the emotional state of anger is associated with perceptions of QoL deficits and dissatisfaction with medical treatment. 7 Patients with severe acne had higher scores for trait anger than did patients with less severe acne, suggesting that anger may affect disease severity. 8 These QoL issues may contribute to clinical depression and suicidal ideation among these patients. Patients with depression often express feelings of low self-worth and unattractiveness. 3 Studies have found that clinical depression and suicidal ideation occur in 7.2% of all patients with acne. 3 In a secondary analysis of a crosssectional survey (known as “Youth 2000”) of 9,567 secondary school students between 12 and 18 years of age, self-reported rates of acne were associated with clinical depression, anxiety, and, to a slightly lesser degree, suicide attempts (odds ratio [OR]: 2.04, 2.3, 1.83, respectively). The strong correlation between suicide attempts and acne remains even after controlling for the other two factors (OR: 1.5). 9 Acne is not regarded as the only dermatologic condition that increases the risk for suicide. The self-reported prevalence of suicidal ideation among patients with other dermatologic conditions was 8.6%, compared with the 7.1% prevalence of suicidal ideation among patients with acne (See Table). 10 Furthermore, researchers have found that the most rapid rise in suicide rates is among males between 15 and 24 years of age. 3 This finding is of special concern because acne has its peak occurrence during this age period. Some Common Beliefs Although often poorly compliant to medical regimens, patients with acne are often impatient for results 11 and often ask their physicians about common beliefs and myths. One question often posed is whether or not acne is caused by diet, particularly chocolate, soda, sweets, and greasy foods. Recent literature suggests a possible relationship between diet and acne. For example, Cordain and colleagues reported a strikingly different incidence of acne in fully modernized societies compared to that in populations with nonwesternized diets. 12 These researchers studied acne incidence in two populations: the Aché hunter/gatherers of Paraguay and the Kitavan Islanders of Papua, New Guinea. No papules, pustules, or open comedones were observed during examinations for skin disorders in the entire Kitavan population (n=1,200). Of the 115 subjects in a hunter/gatherer cohort from Aché, no active cases of acne vulgaris were observed, although one 18- year-old male appeared to have acne scars. 12 The nonwesternized diets of both the Kitavan Islanders and the hunter/ gatherers of Aché consist of minimally processed plant/animal foods, which are 4 Therapeutic Challenges and New Approaches to the Patient With Acne
devoid of western carbohydrates that may lead to high glycemic loads to elevate insulin levels. These two nonwesternized populations maintain low glucose serum levels and high levels of insulin sensitivity; such levels are believed to be mediated by androgens, insulin-like growth factor 1 (IGF-1), and insulin-like growth factor binding proteins (IGFBPs). 12 TABLE. Suicidal Ideation and Acne Potential Role of Glycemic Load in Acne Pathogenesis Building on the work of Cordain and colleagues, other researchers have investigated a possible link between nutrition-related lifestyle factors, hyperinsulinemia, and the incidence of acne. A study conducted by Smith and colleagues involved the use of the glycemic index (GI), exploring the concept that high intakes of refined, high-GI carbohydrates may be a significant contributor to the high incidence of acne in westernized countries. 13 The GI measures the potential of carbohydrate foods—and various combinations of carbohydrate and noncarbohydrate foods—to cause rapid increases in blood glucose. These blood glucose spikes are known as the glycemic load (GL). Accumulating evidence suggests that LGL diets may have a role in the prevention of hyperinsulinemia by improving insulin sensitivity and lowering postprandial insulin levels. 13 To study the effects of a LGL diet, the trial conducted by Smith and colleagues was a parallel-design, investigator-blinded controlled trial using a 12- week randomized dietary intervention for 50 males (15 to 25 years of age) with acne. 13 A total of 43 subjects completed the study; 7 subjects did not complete the study (5 males in the control group and 2 males in the LGL group), and 4 subjects were removed from the data set (2 males because of noncompliance and 2 males who began medications known to affect acne). Study participants in the control group were allowed to eat carbohydratedense (high-glycemic) foods. The intervention group followed a LGL diet that provided 25% of its energy from protein and 45% from low-GI carbohydrates. Before the intervention began, acne counts were made for each participant. After adjusting for variables, the reduction in total lesion counts was significantly greater (P=0.02) in the LGL group than in the control group. The researchers also noted a greater reduction in total weight, body mass index, and free androgen index measurements. 13 A study published in 2007 by Kaymak and colleagues reported on their findings when comparing 49 college students with acne at 42 colleges to students without acne (the control group). 14 Measures for fasting glucose, insulin, IGF-1, IGFBP, GI, and overall dietary GL levels were recorded before the study and re-measured at study end. However, no differences between patients with acne and patients without acne were found. 14 Milk is an LGL food, according to the GI. 15 Data from the Nurses’ Health Study II showed that milk intake was associated with a self-reported history of teenage acne, with a stronger effect for those who drank skim milk. 16 One study published in 2005 by Adebamowo and colleagues found a positive association with acne for intake of total milk and skim milk, based on data from 47,355 women who completed questionnaires on their diet during high school. 16 Adebamowo and colleagues also conducted a prospective cohort study of 6,094 females, 9 to 15 years of age. Their dietary intake was reported via questionnaires at three points in the study from 1996 to 1998. Data on the recalled presence/severity of acne were also compiled and analyzed. These researchers concluded that the data showed an association between milk intake and increased risk of acne in teenaged girls. Based on their multivariate analysis, they calculated the following prevalence ratios (listed highest to lowest intake): 1.20 (total milk), 1.19 (whole milk), 1.17 (low fat milk), and 1.19 (skim milk). 17 The hypothesis in both of these studies by Adebamowo and colleagues was that the hormonal content of milk Prevalence of suicidal ideation (SI) among patients with dermatologic conditions Outpatients (294), inpatients (172) Patients completed self-report instruments 40/466 (8.6%): SI in last 2 weeks Prevalence of SI among patients with acne: 7.1% affects acne. Previous articles have reported that 75% to 90% of the milk brought to market is derived from pregnant cows. 18 Some researchers have suggested that ingestion of dairy products from pregnant cows exposes humans to various hormones, including progesterone, other dihydrotestosterone precursors, prolactin, somatostatin growth hormone-releasing factor, gonadotropinreleasing hormone, insulin, IGF-1, and IGF-2, as well as many others. 18 The Dietary Link to Acne In response to the findings of these studies and others, some researchers have posed questions about whether other dietary factors might also be involved. Researchers have observed that nonwesternized populations eat more fish than do westernized populations; one study found that the primary signs of acne were substantially lower among teenagers who consumed a diet high in saltwater fish and seafood. 19 This study also showed that fish oil is rich in polyunsaturated fats, containing anti-inflammatory omega-3 fatty acids. Furthermore, omega-3 fatty acids are well documented to have leukotriene B 4 inhibiting properties in humans. 20 Data have indicated that people in nonwesternized cultures ingest 30% more fiber than do people in westernized cultures; this finding also may have a therapeutic effect on various skin conditions. 21 Katzman and Logan have hypothesized that certain nutritional factors, combined with a weakened antioxidant defense system and altered intestinal microflora, have overlapping effects on both acne and depressive/anxious mood states. 22 These authors have pointed out that zinc/selenium levels are lower in patients who suffer from both depression and acne than in people who do not have these conditions. Furthermore, they also hypothesize that other nutrients that might have beneficial effects against acne include folic acid, chromium, and nicotinamide. Further study is needed on the role of antioxidants and oxidative stress, the role of intestinal microflora, and the potential benefits (if any) of probiotic supplementation. 22 Summary Acne vulgaris presents a challenge to the QoL of patients with this condition and may even contribute to clinical depression and suicidal ideation. For years, clinicians have discounted the influence that western diets may influence the incidence and severity of acne. However, recent epidemiologic research has presented some evidence that a link Adapted from: Picardi A et al. 10 continued on page 11 Therapeutic Challenges and New Approaches to the Patient With Acne 5
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