12. acne, diet, washing, & sunlight

8/2/2019 12. Acne, Diet, Washing, & Sunlight

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The Author (2005). Published by Oxford University Press. All rights reserved. For Permissions, please email: [email protected]

doi:10.1093/fampra/cmh715 Family Practice Advance Access originally published online on 11 January 2005.This version published 11 January 2005

A systematic review of the evidence for myths and

misconceptions in acne management: diet,

face-washing and sunlight

Parker Magina, Dimity Ponda, Wayne Smithb and Alan Watsonc

Magin P, Pond D, Smith W and Watson A. A systematic review of the evidence for myths and

misconceptions in acne management: diet, face-washing and sunlight. Family Practice2005;

22: 6270.

Background. Lay perceptions that diet, hygiene and sunlight exposure are strongly associated

with acne causation and exacerbation are common but at variance with the consensus of current

dermatological opinion.

Objectives. The objective of this study was to carry out a review of the literature to assess the

evidence for diet, face-washing and sunlight exposure in acne management.

Methods. Original studies were identified by searches of the Medline, EMBASE, AMED (Alliedand Complementary Medicine), CINAHL, Cochrane, and DARE databases. Methodological

information was extracted from identified articles but, given the paucity of high quality studies

found, no studies were excluded from the review on methodological grounds.

Results. Given the prevalence of lay perceptions, and the confidence of dermatological

opinion in rebutting these perceptions as myths and misconceptions, surprisingly little evidence

exists for the efficacy or lack of efficacy of dietary factors, face-washing and sunlight exposure

in the management of acne. Much of the available evidence has methodological limitations.

Conclusions. Based on the present state of evidence, clinicians cannot be didactic in their

recommendations regarding diet, hygiene and face-washing, and sunlight to patients with acne.

Advice should be individualized, and both clinician and patient cognizant of its limitations.

Keywords. Acne, diet, hygiene, sunlight.

poor facial hygiene3 as exacerbating factors in acne.Dietary factors (especially chocolate, oily or fatty foodsand high sugar-content foods) were nominated by 41%as exacerbating acne. The corollary of these beliefsabout aetiology were some of the treatment recommen-dations of the final year studentscleaners and washes,antiseptics and medicated soaps, and improved facialhygiene and diet.

In these matters the students responses reflectpopular attitudes and opinions, but they are at variance

with a consensus of dermatological opinion that diet,stress and uncleanliness are unrelated to acne patho-genesis and that skin cleansing and dietary manipulationare ineffective in acne treatment.421

Similarly, in a 2001 Australian study of obstetric warddoctors and nurses,22 12% of doctors and 20% of nursesbelieved sun exposure to be therapeutic for acne. Therehas been a lay and traditional dermatological opinionthat sunlight exposure was beneficial in acne and thatthis caused acne to improve in summer and worsen inwinter,3,4,19,2328 though this is now generally thought tobe more likely not to be the case.6,17,19,20

Received 2 June 2004; Accepted 27 September 2004.aDiscipline of General Practice, University of Newcastle,New South Wales, bCentre for Clinical Epidemiology andBiostatistics, University of Newcastle, New South Wales, andcDepartment of Dermatology, Royal Newcastle Hospital,Newcastle, New South Wales, Australia; Email: [email protected]

Introduction

This article reviews the evidence base for common layand medical beliefs regarding acne. A 2001 article1

advocated debunking myths about acne and, amongmyths nominated for debunking, were those related todiet (chocolate and fatty foods), hygiene, face cleansingand sun-exposure.

These perceived myths and misconceptions aboutacne causation, exacerbating factors and treatment

efficacies are common, and not just among patients. Inan analysis of examination answers of final year medicalstudents at Melbourne University, Green and Sinclair2

found that 67% of students identified stress, 10%identified smoking and alcohol, and 25% identified


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Methods

A literature search was performed in July 2003 using thedatabases Medline, EMBASE, AMED (Allied andComplementary Medicine), CINAHL, Cochrane, andDARE. Search terms used were acne vulgaris withcombinations of myths, misconceptions, diet, chocolate,

sugar, hygiene, wash, cleanse, sun, light, and ultraviolet.The search was confined to English language articles.Reference lists of identified articles were examinedfor further relevant studies. There were no pre-specifiedquality criteria for study inclusion. Methodolog-ical information was extracted to assist in interpre-tation of results. Many studies had methodologicalshortcomingsfor example, small sample sizes with nopower considerations, lack of control subjects, lack ofblinding, or unclear or unstated statistical methods.Given the paucity of high quality studies found and theseemingly considerable effect some studies of limitedmethodological quality have had on current opinion and

practice, no studies were excluded from the review onmethodological grounds. The methodological limita-tions of studies, and the resultant implications forinterpretation of findings, are noted.

Results

Medline, EMBASE, CINAHL and AMED searchesidentified 221, 171, 28 and 1 references, respectively.Examination of these citations and abstracts producedeleven trials of dietary, washing or ultraviolet-lightexposure treatment modalities. Hand-searching of

references from papers obtained in the search located afurther 14 studies.

The role of dietary factors (Table 1)

There are, perhaps surprisingly, few studies that examinethe role of diet in acne. Three studies have specificallyexamined the role of chocolate.

Grant and Anderson29 and Anderson30 performedtrials of chocolate, milk and roasted nuts in universitystudents and found no effect on acne, but the trials weresmall, uncontrolled, had very short follow-up, andinadequate statistical analysis. Fulton et al . in a single-

blind placebo-controlled cross-over trial in Americanhospital acne clinic attendees and male prisoners31

found no effect of chocolate on acne (or on sebumproduction or composition). A small study32 of patientswith acne (16 subjects and 13 matched controls) foundno difference in sugar consumption between the twogroupsthough patients with seborrhoeic dermatitishad higher levels of sugar consumption.

A study of 2720 British soldiers found no difference inweight between soldiers, aged 1519, with or without acne.Soldiers aged 2040 with acne however were significantlyheavier (5.6 kg) than soldiers aged 2040 without acne.33

This study has been quoted in the context of a possible linkbetween diet and acne,7 but the evidence of this study forsuch a link would appear tenuous.

Recently, a reappraisal of the current thinkingregarding diet and acne has been proposed following across-sectional study of acne in native, non-westernisedNew Guinean and Paraguayan populations.34 This study

showed no cases of acne in either of these populations,and this was contrasted with prevalence of acne inwestern populations. It is proposed that western diets,with characteristically high glycaemic indexes, lead tohyperinsulinaemia and a resulting cascade of endocrineconsequences (increased androgens, increased insulin-like growth-factor 1, altered retinoid signaling pathways)which mediate acne pathogenesis.34,35

A further recent study has demonstrated a correlationof worsening diet quality (during a pre-examinationperiod in university students) and exacerbation ofacne.36 The main factor examined in this study was theeffect of examination stress on acne severity, and the

dietary variable measured was self-assessed diet quality(on a scale 14) rather than a validated objectivemeasure of dietary components.

The role of dirt, hygiene, cleanliness and washing

(Table 2)

Soap has been advocated in the treatment of acne sincethe 19th century37 and Solomon and Shalita, in a 1996review of the use of detergents, soaps, cleansers, foamingsolutions, moisturisers and washes in acne, makedetailed recommendations regarding skin cleansing inacne.38 But they cite very little evidence for theirrecommendations.

Improvements in acne have been noted in a small (tensubjects) uncontrolled study of a medicated face wash,39

a further uncontrolled, and incompletely reported,study of face washing,40 a study in which an abrasive wasused in addition to a medicated wash in some subjectsbut had no non-wash controls,41 an open uncontrolledand incompletely reported study of a cleansing bar andthe Buf-puf abrasive device,42 and in studies in whichmedicated soap or acidic syndet bar was compared withunmedicated soap but in which, again, no non-washcomparison was studied.43,44 The large placebo effect inplacebo-controlled acne therapy trials1956% in a

sample of seven placebo controlled trials of tetracyc-lines in acne45,46must be considered in interpretingthese results.

Stoughton and Leyden,47 however, reported ran-domized controlled studies of a 4% chlorhexidinegluconate skin cleanser preparation with controls using,in one study, 5% benzoyl peroxide and, in another twostudies, the vehicle employed in the chlorhexidinepreparation. There was no significant difference in acnelesion counts at 8 and 12 weeks in the chlorhexidine/benzoyl peroxide study. The combined data of the twochlorhexidine/vehicle studies showed significantly less

Acne myths and misconceptions: a review 63


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Family Practicean international journal64

acne lesions at 8 and 12 weeks in the chlorhexidine-usingsubjects than in the unmedicated vehicle-using controls.

A povidone-iodine cleanser was reported to improveacne in randomized controlled trials,48 but statistical

reporting was deficient. Swinyer et al. studied the effecton acne of three treatment regimens. Each treatmentregimen included a different cleansing/washing modal-ity. However each regimen also included a different

TABLE 1 Trials of diet in acne

Study Design Brief description Population Sample size Summary of results andof intervention comments

Grant29 1965 SBA Chocolate University students 8 4 of the 8 subjects developed(9&3/4 ounces) with mild or moderate up to 5 new papules oron two acne. pustules. Considered not

successive days significant changebut nostatistical evaluation, verysmall sample size,uncontrolled, follow-up maynot be long enough to detectchanges.

Anderson30 1971 SBA Chocolate, milk University students Not specified Reporting limited. Noor peanuts with acne who apparent control group.(daily for one identified dietary Numbers and statisticalweek) triggers. analysis not reported.

Follow-up not clearpossibly 37 days followingdietary intervention.Treatment duration andfollow-up may not be long

enough to detect changes.Fulton31 1969 Single blind Chocolate bar Acne clinic patients 65 No difference in acne

vs placebo bar and male prisoners. severity during chocolateCross-over with similar Mild-moderate acne. and control bar studytrial caloric and fat periods. High fat content of

composition control bar could beacneigenic. 4 week durationof treatment in cross-overdesign may be too short,given natural history of acnelesions.

Bett32 1967 Cross- N/A Specialist outpatient 16 dermatitis No difference in sugarsectional clinic with seborrhoeic and 16 acne. consumption between

dermatitis or acne. 32 controls controls and acne patients.Controls: patients with Significantly greater

warts or no skin consumption of sugar bydisease. patients with seborrhoeicdermatitis than by controls.

Bourne33 1956 Cross- N/A Soldiers aged 1540. 2720 No correlation of acnesectional presence/severity in ages

1519. Aged 2040, subjectswith acne were significantlyheavier than those withoutacne.

Cordain34 2002 Cross- N/A Paraguayan and New- 1315 (315 aged No acne lesions observed insectional Guinean tribal 1525) any subject.

societies.

Chiu36 2003 Cohort N/A University students 22 An increase in stress (on thewith acne during exam Perceived Stress Scale) wasperiod. significantly correlated with

increases in acne severity.Self-assessed dietary quality(graded 14) was alsosignificantly correlated withacne severity (r = 0.48).


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TABLE 2 Trials of washing and cleansers in acne

Study Design Brief description of Population Sample Summary of results and commentsintervention size

Cunliffe39 SBA Facial washing with Mild or 10 Significant improvement in acne1972 medicated wash moderate acne severity after 3 months.

Uncontrolled. Method of severityassessment not reported.

Hulme40 SBA Facial washing Mild-moderate 55 Significant decrease in inflammatory1986 with a detergent- acne lesions, but not comedones.

containing product

Summary, only, of study and resultspresented. Methodology not clearlyapparent. Uncontrolled.

Fulghum41 Paired Cleanser vs Mild-moderate 44 No difference in acne severity or1982 design cleanser + poly- acne in adverse effects between the two

(right vs ethylene granules specialists products. No non-cleanser control.left side of practicesface)

MacKenzie42 SBA Abrasive polyester Comedonal, 97 Reported to be effective, but

1977 cleansing pad papular/pustular, uncontrolled, subjective assessmentor cystic acne of efficacy and no statistical analysis.

Bettley43 Cross-over Medicated wash + Not specified 41 Medicated wash significantly greater1972 trial clearasil cream vs improvement than unmedicated wash.

unmedicated wash +Means of assessment of severity and

clearasil creamof randomization of treatment ordernot clear. Periods of use (1 month)physiologically unlikely to be longenough to achieve therapeutic effect.Statistical analysis not specified.

Korting44 RCT Acidic Syndet Bar Mild acne 120 Significantly less inflammatory lesions1995 vs (pre-acne) with acidic syndet: evident at 4

Alkaline Soap Bar weeks and effect still present at 12weeks. No blinding. No non-washcontrols.

Stoughton47 RCT Chlorhexidine Acne with at 50 No difference in acne lesion counts at1987 gluconate skin least 10 8 and 12 weeks between 2 treatments.

cleanser vs 5% papules orbenzoyl peroxide pustules

Stoughton47 RCT Chlorhexidine Acne with at 110 Significantly less acne lesions at 8 and1987 gluconate skin least 10 12 weeks in chlorhexidine treated

cleanser vs placebo papules or group. Combined data of two studies(inactive vehicle) pustules reported.

Millikan48 RCT Povidine-iodine Mild acne 17 Reported superiority of povidone-1976 cleanser vs control iodine. But result seemingly non-

cleanser significant.

Millikan48 RCT Povidone-iodine Moderate to 27 No difference.1976 cleanser + severe acne

tetracycline vs

control cleanser +tetracycline

Swinyer49 RCT Soap + scrub + Hospital 118 Tretinoin + benzoyl proxide +1980 tetracycline vs out-patients cleanser as effective as tetracycline +

tretinoin + soap + with mild tretinoin + soap.tretinoin vs moderate acne

And more effective than tetracycline +cleanser + water

abradant scrub.avoidence +tretinoin + benzoyl

Unable to identify efficacy ofperoxide

individual components of regimens.


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systemic or topical antibiotic combination, so the role ofcleansing or washing cannot be adequately assessed inthis study.49

The role of sunlight (Table 3)

The authors of a Saudi Arabian study which found thatnew cases of acne at a hospital dermatology clinic

increased during the winter months concluded that thiswas due to the favourable effect of UV-light on acneduring the warmer months.28 But they do not present anydata on referral procedures and patterns, waiting times orother factors which might confound this observation.Elsewhere, acne has been found to improve in one third ofsubjects in summer, worsen in another third, and remainthe same in the other thirdthough these results were

obtained in a retrospective study26 and are thus prone torecall bias as well as not having controlled for potentialconfounders such as comedogenicity of sunscreens.

It might be thought that studies of the effect of naturalsunlight on acne might be inherently problematic method-ologically. In this circumstance, inferences drawn fromtrials of artificial light-sources may be of relevance.

Trials of artificial UV-B, UV-A and combined lightsources,27 and phototherapy with artificial blue-red, blue,violet, green and full-spectrum lightsources5053 havebeen found to improve acne, but methodologicalconcernsstatistical significance or lack of controls orlack of blindinglimit interpretation of these results tovarying degrees. While these studies may suggest apossible ameliorating effect of UV-light on acne, a trial

TABLE 3 Trials of influence of sunlight or UV-light on acne

Study Design Brief description of Population Sample Summary of results and commentsintervention size

Al-Ameer28 Cross- N/A Hospital 220 More patients were seen during the2002 sectional outpatients colder months.

No consideration of potentialconfounders.

Gfesser26 Cross- N/A All grades 139 One third had summer exacerbation,1996 sectional of severity. one third had winter exacerbation, and

Source not one third didnt vary seasonally.specified Exacerbation measured

retrospectively by patient recall. Noconsideration of confounders.

Mills27 Controlled UV-A vs UV-B vs Specialist 126 No reduction in comedones. UV-B1978 trial. UV-A + UV-B vs clinic and UV-B + UV-A reported to reduce

Means of photo- patients with overall lesion counts.

assignment chemotherapy vs 2 moderately But statistical significance not tested.to groups photo-sensitization severe acne

No non-phototherapy controls.not reported regimens

Insufficient reporting of methodology.

Papageorgiou50 RCT Artificial blue light Hospital 107 Significant improvement in2000 vs blue + red light out-patients inflammatory acne with blue-red light

vs white light vs with mild- compared to benzoyl peroxide orbenzoyl peroxide moderate white light.

acneSignificant improvement incomedonal acne with blue-red lightcompared to white light.Unblinded.

Ammad51 SBA Artificial blue light Mild- 21 Improvement in acne severity2002 moderate (significant for inflammatory lesions,

acne non-significant for comedones) andpatients quality of life.Uncontrolled.

Kawada52 SBA Artificial blue light Mild- 30 Improvement in acne lesion counts2002 moderate and physician rating of improvement

acne (greater for inflammatory thancomedonal acne). No controls.Statistical significance of results notstated.

Sigurdsson53 RCT Green vs violet vs Mild- 30 No differences in acne lesion counts1997 full-spectrum light- moderate for three light sources. All three light

source. No non- acne sources improved acne countslight controls significantly (but no non-light-source

control group).


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of UV-radiation has also found it to enhance thecomedogenicity of sebum in the ear skin of rabbitsthebest available animal model of human facial skin.54

Discussion

The context of the debate: lay beliefs regarding acnecausation

The question of whether common perceptions andbeliefs regarding diet, cleanliness and sunshine prove tobe fact or misconception is of considerable importancedue to the practical implications of these beliefs for acnemanagement, adverse effects, expense and potentialpsychological sequelae, and due to their prevalence andconsistency across different western cultures. Studiesfrom the United States,55,57 New Zealand,56 Britain,58

Germany,59 Nigeria,60 Saudi Arabia61 and Sweden62 reporthigh prevalence of belief in the causal or therapeuticroles of diet, cleanliness and sunlight in acne.

Diet. Dietary modifications are commonly practisedby patients with acne. Though not usually having thepotential for adverse nutritional sequelae of dietaryrestrictions employed in some other conditions, they cannevertheless be burdensome for patients. The evidencefor their efficacy or otherwise is not strong. Convincingtrials are lacking.

The studies of acne and chocolate of Grant andAnderson29 and Anderson30 have considerable metho-dological shortcomings. The subjective self-assessedmeasure of global dietary quality in Chiu et al .s study36

renders these findings of limited relevance to this review.The trial of Fulton et al.31 was methodologically stronger.But the findings of this study are worthy of closerinspection. Most importantly, the placebo bar was of asimilar fat and sugar composition to the study (chocolate)bar. Therefore, while this study might suggest no role forthe cocoa content of chocolate bars in acnegenesis, therole of the complete product remains open to question.Furthermore the treatment period for both chocolateand placebo bars was just four weeks. Consideration ofthe pathogenesis of acne lesions may be relevant. It hasbeen hypothesized that chocolate may exacerbate acneby production of more comedogenic sebumby

increasing blood lipid levels5

or by producing less fluidsebum63and thence greater obstruction of pilose-baceous follicles, setting the stage for follicle rupture andsecondary inflammatory changes. A further possiblemechanism by which acne could be exacerbated is viahyperinsulinaemia and changes in the HPA axis34,35 (seebelow). Neither of these mechanisms might be expectedto produce changes in a short time-frame. Certainly, allefficacious medical treatments of acne take two monthsor more to produce clinically significant changes.64,65

Given the four week treatment periods and three weekwash-out period in the cross-over design, it may be that

there was insufficient study duration to observe therelevant changes.

The New Guinea/Paraguay study cited is consistentwith the often quoted observations of Schaefer that acneused to be unknown among Eskimos, but one can see itreadily amongst [eskimo] teenagers . . . many eskimosthemselves blame their pimples on pop, chocolate and

candies.66

Furthermore, a physiological mechanism ofcausation (initiated by hyperinsulinaemia with subse-quent androgen increases) has been proposed. Indirectsupport for this proposition is to be found in the highrates of acne in the condition polycystic ovary syndromewhich is characterised by hyperinsulinaemia and highandrogen levels,67 and in studies which have found anassociation between acne in females and higher levels ofandrogens.68,69

But comparing the findings of studies in New Guineanand Paraguayan hunter-gathers with rates of acne inWestern populations, even when supported by biologicallyplausible hypotheses of mechanism of causation, does not

provide proof of a causal relationshipit is inherentlyprone to ecological fallacy70: the individual diet of thesubjects who develop acne is not known and confounderscannot be assessed. As has been commented on,35,71 theobvious alternative explanation of the low prevalence ofacne in these non-westernized populations is that ofgenetic susceptibility to acne.72 But, perhaps, of moreimmediate practical significance, is the fact that thetherapeutic institution of such a non-western diet isunlikely to be acceptable to adolescents with acne. Thedietary restrictions which Western adolescents with acneemploy in managing their condition are trivial comparedto the differences between their diets and those ofhunter-gatherers.

Thus, in 2003 there is not yet compelling evidence onwhich GPs or other clinicians can base advice regardingnutrition in relation to acne.

Facial hygiene and face cleansing. Not only are thefacial cleansing regimens of patients with acne oftenburdensome, they can be expensive. The evidence forthe role of a lack of facial hygiene in acne pathogenesisand for face cleansing in its management is mostly ofpoor quality. Furthermore, face-washing has beenproposed as being traumatising, and so exacerbating

acne73

and as increasing the skin irritation adverseeffects of topical tretinoin and isotretinoin (though notother topical therapies) in acne treatment.49,74,75

Additionally, commonly used soaps and shampooshave been found to be comedogenic when applied to therabbit ear.76 Even the author of one of the above citedstudies concedes face washing for acne continues to beempirical therapy.40

Sunlight. Convincing direct evidence for a positiveeffect of sunlight exposure on acne is lacking. Recentfindings suggesting various spectrums of artificial light to



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be efficacious may not be directly generalizable tonatural sunlight. Another consideration is that the long-term sequelae of sun exposure for acne therapy may wellbe an increased risk of melanoma and non-melanoma skinmalignancynotwithstanding the intriguing associationof acne with decreased melanoma risk.77 Additionally,photosensitivity is an issue with commonly used, effi-

cacious medical treatments of acnetetracyclines7880

and isotretinoin.81,82

Evidence from twin studies

Indirect evidence of a lack of a major role for envi-ronmental factors including diet and skin hygiene inacne pathogenesis comes from studies of the geneticdeterminants of acne. Research in this area has foundstrong evidence, especially from twin studies, for the roleof heredity in acne.83 A large twin study of 458 pairs ofmonozygotic and 1099 pairs of dizygotic female twinsin the UK84 was performed to assess the relativecontribution of genetic and environmental factors on the

liability to acne. The study found that 81% of the varianceof the disease was attributable to genetic factors and only19% to environmental factors. These results contradictthe results of an earlier study which found similar ratesof acne concordance in monozygotic and dizygotictwins85but this was a much smaller study (only 20 pairsof twins in each group). A further British casecontrolstudy of hospital dermatology adult patients withpersistent acne86 found a significantly greater risk ofadult acne in relatives of patients than in relatives ofcontrols (odds ratio 3.93), though this may be explainedby shared environmental exposures among families.

Thus, the potential for intervention in environmentalareas may be limited. The devotion of considerabletime, effort and expense on the part of patients in effortsto address purported environmental factors in theircondition might be reassessed and be better directedtowards optimising medical therapymanagementstrategies for which strong evidence of efficacy exists.9

Psychological implications

The psychological dimension of this debate should alsobe considered. A 1976 British Medical Journaleditorial,noting the potential for excessive or obsessional face-washing to exacerbate acne, suggested that obsessional

washing may be related to the perception that acne wascased by dirt and that it is regarded as an outward signof moral defilement.73 An academic dermatologist hasobserved most of the dietary manipulations advocatedby non-professional advisors seem more calculated topunish rather than to cure, and none are backed up byexperimental evidence.13 And Green and Sinclair2

suggest a worrying implication of the linkage of facialhygiene to acne aetiology and treatmentthe implicationthat acne is a consequence of being dirty and thatsufferers are unhygienic. A reasonable hypothesisfollowing from this proposition is that such misconce-

ptions may exacerbate the recognized psychologicalsequelae of acneespecially in the areas of self-esteem,shame and embarrassment.56,58,8791

Conclusion

The evidence base for current recommendationsregarding dietary, face-washing and UV-exposure

behavioural modifications in acne management isincomplete at best. Studies have often been of smallsample size, uncontrolled, or unblinded.

There are also, perhaps, a number of other factors thatmay influence recommendations to patients. The potentialfor sun-exposure to increase risk of skin malignancy mustbe considered. The anecdotal evidence of patients thatcertain foodstuffs exacerbate their acne cannot bedismissed out of hand. The cost of medicated washes foracne can be considerable. Methodologically rigorousresearch is clearly required to address the effect of theseexposures on acne.

The inescapable conclusion is that, given our present

state of knowledge, clinicians cannot be didactic in theirrecommendations. Advice should be individualized, andboth clinician and patient cognizant of its limitations.

Declaration

Funding: this journal article was written with supportfrom a NHMRC post-graduate medical scholarship anda NSW Primary Health Care Research Bursary.Ethical approval: n/a.Conflicts of interest: none.

References1 Clearihan L. Acne. Myths and management issues.Aust Fam Phys

2001; 30: 10391044.2 Green J, Sinclair RD. Perceptions of acne vulgaris in final year

medical student written examination answers. Aust J Dermat2001; 42: 98101.

3 Brieva J, McCracken GA, Diamond B. Update and treatment ofacne vulgaris. Med Update Psychiatrists 1997; 2: 161163.

4 Maddin S. Current concepts in the management of acne vulgaris.Can Med Assoc J1969; 100: 340343.

5 Fries JH. Chocolate: a review of published reports of allergic andother deleterious effects, real or presumed.Annals of Allergy

1978;41:

195207.6 Kaminester LH. When friends or family ask about acne.J Am MedAssoc 1978; 239: 21712172.

7 Rosenberg EW, Kirk BS. Acne diet reconsidered. Archives ofDermatology 1981; 117: 193195.

8 Landow K. Dispelling myths about acne. Postgraduate Medicine1997; 102: 9499, 103104, 110112.

9 Webster GF. Acne vulgaris. Br Med J2002; 325: 475479.10 Russell JJ. Topical therapy for acne. Am Fam Phys 2000; 61:

357366.11 Anonymous. What can I do about pimples.Am Fam Phys 2000; 61.12 Rothe MJ, Grant-Kels JM. Clearing up the myths about clear skin.

Consultant1995; 35: 251252.13 Marks R. Acnesocial impact and health education. J Royal Soc

Med 1985; 78 (Suppl 10): 2124.



8/9

14 Michaelsson G. Diet and acne. Nutr Rev 1981; 39: 104106.15 Maslansky L, Wein G. Effect of chocolate on acne vulgaris. J Am

Med Assoc. 1970; 211: 1856.16 Minkin W, Cohen HJ. Effect of chocolate on acne vulgaris. J Am

Med Assoc. 1970; 211: 1856.17 Mancini AJ. Acne vulgaris: a treatment update. Contemp Pedatrics

2000; 17: 122133.18 Hannuksela A, Hannuksela M. Soaps and detergents in skin

diseases. Clinics in Dermatology 1996; 14: 7780.

19 Hjorth N. Traditional topical treatment of acne. Acta Dermato-enereologica. Supplementum. 1980; Suppl 89: 5356.

20 Katsambas A. Nonsense acne therapy. J Eur Acad DermVenereology 1997; 9 (Suppl 1): S30.

21 Greener M. Acne: the PN role. Practice Nurse 2002; 24: 5254.22 Harrison S, Hutton L, Nowak M. An investigation of professional

advice advocating therapeutic sun exposure.Aust New ZealandJ Pub Health 2002; 26: 108115.

23 Scheck A. Teens forsake sunscreen, believe rays help acne.Dermatology Times 2000; 21 (September): S34.

24 Wharton JR, Cockerell CJ. The sun: a friend and enemy. Clinics inDermatology 1998; 16: 415419.

25 Abramovitz M. Clearing up those acne myths. Curr Health 2000;26: 30.

26 Gfesser M, Worret WI. Seasonal variations in the severity of acnevulgaris.Int J Dermat1996; 35: 116117.

27

Mills OH, Kligman AM. Ultraviolet phototherapy and pho-tochemotherapy of acne vulgaris. Archives of Dermatology1978; 114: 221223.

28 Al-Ameer AM, Al-Akloby O. Demographic features and seasonalvariations in patients with acne vulgaris in Saudi Arabia: ahospital-based study.Int J Dermat2002; 41: 870871.

29 Grant JD, Anderson PC. Chocolate and acne: a dissenting view.Missouri Medicine 1965; 62: 459460.

30 Anderson PC. Foods as the cause of acne. Am Fam Phys 1971; 3:102103.

31 Fulton JE Jr, Plewig G, Kligman AM. Effect of chocolate on acnevulgaris.J Am Med Assoc1969; 210: 20712074.

32 Bett DG, Morland J, Yudkin J. Sugar consumption in acnevulgaris and seborrhoeic dermatitis. Br Med J 1967; 3 (558):153155.

33 Bourne S, Jacobs A. Observations on acne, seborrhoea, and obesity.

Br Med J1956: 12681270.34 Cordain L, Lindeberg S, Hurtado M, Hill K, Eaton SB, Brand-Miller J. Acne vulgaris: a disease of Western civilization[comment].Archives of Dermatology 2002; 138: 15841590.

35 Thiboutot DM, Strauss JS. Diet and acne revisited [comment].Archives of Dermatology 2002; 138: 15911592.

36 Chiu AC, Chon SY, Kimball AB. The response of skin disease tostress: changes in the severity of acne vulgaris as affected byexamination stress. Archives of Dermatology 2003; 139:897900.

37 Routh HB, Bhowmik KR, Parish LC, Witkowski JA. Soaps: fromthe Phoenicians to the 20th centurya historical review. Clinicsin Dermatology 1996; 14: 36.

38 Solomon BA, Shalita AR. Effects of detergents on acne. Clinics inDermatology 1996; 14: 9599.

39 Cunliffe WJ, Cotterill JA, Williamson B. The effect of a medicated

wash on acne, sebum excretion rate and skin surface lipidcomposition. Br J Dermat1972; 86: 311312.40 Hulme NA, Parish LC, Witkowski JA. Skin cleansing as an

accompaniment to acne therapy.Int J Dermat1986; 25: 505.41 Fulghum DD, Catalano PM, Childers RC, Cullen SI, Engel MF.

Abrasive cleansing in the management of acne vulgaris.Archives of Dermatology 1982; 118: 658659.

42 MacKenzie A. Use of Buf-Puf and mild cleansing bar in acne. Cutis1977; 19: 370371.

43 Bettley FR. The effect of a medicated wash on acne. Br J Dermat1972; 87: 292293.

44 Korting HC, Ponce-Poschl E, Klovekorn W. The regular use of a soapor an acidic syndet bar on pre-acne.Infection 1995; 23: 8993.

45 Crounse RG. The response of acne to placebos and antibiotics.J Am Med Assoc 1965; 193: 906910.

46 Savin RC, Turner MC. Antibiotics and the placebo reaction in acne.J Am Med Assoc1966; 196: 365367.

47 Stoughton RB, Leyden JJ. Efficacy of 4 percent chlorhexidinegluconate skin cleanser in the treatment of acne vulgaris. Cutis1987; 39: 551553.

48 Millikan LE. A double-blind study of Betadine skin cleanser in acnevulgaris. Cutis 1976; 17: 394398.

49 Swinyer LJ, Swinyer TA, Britt MR. Topical agents alone in acne. Ablind assessment study.J Am Med Assoc1980; 243: 16401643.

50 Papageorgiou P, Katsambas A, Chu A. Phototherapy with blue(415 nm) and red (660 nm) light in the treatment of acnevulgaris. Br J Dermat2000; 142: 973978.

51 Ammad S, Edwards C, Gonzalez M, Mills CM. The effect of bluelight phototherapy on mild to moderate acne. Br J Dermat2002;147 (Suppl 62): 95.

52 Kawada A, Aragane Y, Kameyama H, Sangen Y, Tezuka T. Acnephototherapy with a high-intensity, enhanced, narrow-band,blue light source: an open study and in vitro investigation.

J Dermat Sci 2002; 30: 129135.53 Sigurdsson V, Knulst AC, van Weelden H. Phototherapy of acne

vulgaris with visible light. Dermat1997; 194: 256260.54 Mills OH, Porte M, Kligman AM. Enhancement of comedogenic

substances by ultraviolet radiation. Br J Dermat 1978; 98:145150.

55 Rasmussen JE, Smith SB. Patient concepts and misconceptions

about acne.Archives of Dermatology 1983; 119: 570572.56 Pearl A, Arroll B, Lello J, Birchall NM. The impact of acne: a studyof adolescents attitudes, perception and knowledge. NewZealand Med J1998; 111: 269271.

57 Emerson GW, Strauss JS. Acne and acne care. A trend survey.Archives of Dermatology 1972; 105: 407411.

58 Smithard A, Glazebrook C, Williams HC. Acne prevalence,knowledge about acne and psychological morbidity in mid-adolescence: a community-based study. Br J Dermat2001; 145:274279.

59 Niemeier V, Kupfer J, Demmelbauer-Ebner M, Stangier U, EffendyI, Gieler U. Coping with acne vulgaris. Evaluation of the chronicskin disorder questionnaire in patients with acne. Dermatology1998; 196: 108115.

60 Orafidiya LO, Agbani EO, Oyedele AO, Babalola OO, Onayemi O.Preliminary clinical tests on topical preparations of Ocimum

gratissimum Linn Leaf essential oil for the treatment ofacne vulgaris. Clinical Drugs Under Investigation 2002; 22:313319.

61 Al-Hoqail IA. Knowledge, beliefs and perceptions of youth towardacne vulgaris. Saudi Medical J2003; 24: 765768.

62 Berg M. Epidemiological studies of the influence of sunlight on theskin. Photo-Dermatology1989; 6: 8084.

63 Mackie BS, Mackie LE. Chocolate and acne.Aust J Dermat1974;15:103109.

64 Poyner T, Cunliffe B. Commentary: A UK primary care perspectiveon treating acne[comment]. Br Med J2002; 325: 475479.

65 Gollnick H, Cunliffe W, Berson D, Dreno B, Finlay A, Leyden JJet al . Management of acne: a report from a Global Allianceto Improve Outcomes in Acne.J Am Acad Dermat2003; 49(Suppl 1).

66 Schaefer O. When the Eskimo comes to town. Nutrition Today 1971;

6: 816.67 Lucky AW. Hormonal correlates of acne and hirsutism.Am J Med1995; 98 (1A): 89S94S.

68 Thiboutot D, Gilliland K, Light J, Lookingbill D. Androgenmetabolism in sebaceous glands from subjects with andwithout acne [comment].Archives of Dermatology. 1999; 135:10411045.

69 Lucky AW, Biro FM, Simbartl LA, Morrison JA, Sorg NW.Predictors of severity of acne vulgaris in young adolescent girls:results of a five-year longitudinal study [comment].J Pediatrics1997; 130: 3039.

70 Gordis L. Epidemiology (2nd edn). Philadelphia: WB Saunders;2000.

71 Bershad S. The unwelcome return of the acne diet. Archives ofDermatology 2003; 139: 940941.



9/9


72 Freyre EA, Rebaza RM, Sami DA, Lozada CP. The prevalence offacial acne in Peruvian adolescents and its relation to theirethnicity.J Adolescent Health 1998; 22: 480484.

73 Anonymous. Washing away at acne. Br Med J 1976; 2 (6040):834835.

74 Dunlap FE, Baker MD, Plott RT, Verschoore M. Adapalene 0.1% gelhas low skin irritation potential even when applied immediatelyafter washing. Br J Dermat1998; 139 (Suppl 52): 2325.

75 Millikan LE. Pivotal clinical trials of adapalene in the treatment

of acne.J Euro Acad Dermat Venereology 2001; 15 (Suppl 3):1922.

76 Mills OH, Kligman AM. Acne detergicans. Archives ofDermatology 1975; 111: 6568.

77 Beral V, Evans S, Shaw H, Milton G. Cutaneous factors related tothe risk of malignant melanoma. Br J Dermat 1983; 109:165172.

78 Vassileva SG, Mateev G, Parish LC. Antimicrobial photosensitivereactions.Archives of Internal Medicine 1998; 158: 19932000.

79 Layton AM, Cunliffe WJ. Phototoxic eruptions due todoxycyclinea dose-related phenomenon. Clin Exp Dermat1993; 18: 425427.

80 Garner SE, Eady EA, Popescu C, Newton J, Li Wan Po A. Minocyclinefor acne vulgaris: efficacy and safety (Cochrane Review).Cochrane Library Issue 1, Oxford: Update Software; 2003.

81 Mashford ML, Fischer G, Marks R, Quirk C, Rose A, Sinclair RD

et al . Therapeutic Guidelines: Dermatology. Melbourne:Therapeutic Guidelines Limited; 1999.

82 Sams M, Lynch P. Principles and practice of dermatology (2nd edn).New York: Churchill Livingstone; 1996.

83 Gollnick H. Current perspectives on the treatment of acne vulgarisand implications for future directions. J Euro Acad DermatVenereology 2001; 15 (Suppl 3): 14.

84 Bataille V, Snieder H, MacGregor AJ, Sasieni P, Spector TD. Theinfluence of genetics and environmental factors in thepathogenesis of acne: a twin study of acne in women.

J Investigative Dermatology2002; 119: 3171322.85 Walton S, Wyatt EH, Cunliffe WJ. Genetic control of sebum

excretion and acnea twin study [comment].Br J Dermat1988;

118: 393396.86 Goulden V, McGeown CH, Cunliffe WJ. The familial risk of adult

acne: a comparison between first-degree relatives of affectedand unaffected individuals. Br J Dermat1999; 141: 297300.

87 Gupta MA, Gupta AK, Schork NJ, Ellis CN, Voorhees JJ.Psychiatric aspects of the treatment of mild to moderate facialacne. Some preliminary observations. Int J Dermat1990; 29:719721.

88 Gupta MA, Gupta AK. The psychological comorbidity in acne.Clinics in Dermatology 2001; 19: 360363.

89 Hanstock TL, OMahony JF. Perfectionism, acne and appearanceconcerns. Personality & Individual Differences 2002; 32:13171325.

90 Kellett SC, Gawkrodger DJ. The psychological and emotionalimpact of acne and the effect of treatment with isotretinoin.Br J Dermat1999; 140: 273282.

91

Kilkenny M, Stathakis V, Hibbert ME, Patton G, Caust J, Bowes G.Acne in Victorian adolescents: associations with age, gender,puberty and psychiatric symptoms. Journal of Paediatrics &Child Health 1997; 33: 430433.

12. acne, diet, washing, & sunlight

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