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Acne Vulgaris.

Acne is the most common of all skin problems. Although genetics is a contributing factor, several other factors play a key role in initiating this condition. "The pathogenesis of acne is traditionally attributed to four pathogenic factors: hyperkeratinization, excess sebum production, colonization by Propionibacterium acnes, and inflammation. (P. acnes is a normal inhabitant of the skin and its role in acne is not well understood). It was previously believed that hyperkeratinization of the acne and colonization by P. acnes preceded inflammation in the progression of the acne comedo. However, recent evidence suggests that subclinical inflammatory events may actually precede hyperkeratinization." (1) "In addition to the above four pathogenic factors, it is believed that oxidative stress likely plays a key role in the development of acne. In fact, it is thought that cutaneous lipid peroxidation may be the match that lights the inflammatory cascade." (2) "New insights into the role of the androgen receptors and sebum production have also been proposed. It is known that androgenic hormones stimulate androgen receptors and lead to increased sebum production." (3) "The increased and altered sebum that produces the oiliness of the skin so characteristic of acne has been ascribed to increased testosterone and dihydrotestosterone (DHT), increased insulin, increased IGF-1 (insulin growth factor -1) ["Insulin at high levels can interact with IGF-1 receptors. IGF-1 promotes expression of enzymes responsible for androgen biosynthesis and conversion." (4)], Increased PPAR alpha and decreased PPAR gamma (peroxisome proliferator-activated receptor), increased corticotropin releasing hormone (CRH) [elevated Cortisol due to chronic stress thickens sebum], increased substance P and localized, insufficient action of vitamin A." (5)

Integrative Medicine Clinical Pathophysiological Considerations of the Onset Acne Vulgaris

* Fatty acid imbalance: "Fatty acid and fatty acid signaling via PPARs play important roles in all four of the components of acne pathogenesis: hyperkeratinization, sebum overproduction, P. acnes overgrowth, and inflammation." (6)

* Insulin dysregulation: "A little recognized, but well-documented phenomenon of adolescence is the rise and fall of insulin resistance that mirrors acne activity." (7) Insulin is one of the major anabolic hormones and tends to rise with elevation of growth hormone; an increase in insulin levels during a period of rapid growth and development is expected.

* Insulin-like Growth Factor-1: Insulin, growth hormone, and insulin-like growth factor-1 interweave in their physiology. Insulin and IGF-1 can bind each other's receptors and may stimulate similar processes.

* Oxidative Stress: "Measurement of markers of oxidative injury (stress) and activity of antioxidant enzymes showed significant oxidative damage in acne patients compared to controls. Reactive oxygen species generated by neutrophils contribute to follicular wall injury and inflammation. (8)

* Psychogenic Stress: "Several lines of evidence suggest that psychogenic stress plays a role in acne. Stress has been shown to elicit the release of the neuropeptide, substance P, which appears to increase lipogenesis of sebocytes and also increases inflammation via mast cell release of LI-6 and TNF-alpha.

"What roles do these factors play in acne? Insulin appears to decrease hepatic production of sex-hormone binding globulin, which leads to higher circulating levels of unbound, active androgen, triggering all the well-established androgen effects of proliferation and differentiation of sebocytes as well as upregulation of lipid production." (9) "The skin of acne patients shows greater activity of 5-a-reductase, the enzyme that converts testosterone to a more potent, androgen dihydrotestosterone. This increased activity is independent of androgens and explains the poor correlation between systemic levels of androgens and the severity of acne lesions. Receptors for growth hormone and insulin-like growth factor-1 are present on the sebaceous gland and these hormones stimulate sebum production. Insulin or high levels, can interact with IGF-1 receptors." (10)

Acne vulgaris should be differentiated from rosacea and perioral dermatitis.
Condition   Form of lesion           Distribution of lesions

Acne        * Follicular; pustular   * Widespread across the
Vulgaris      comedones                whole face, chest, back,
                                       neck and shoulders
Rosacea     * Greater vascular       * Central part of the
              involvement              face (across the cheeks
            * Erythema                 and nose)
              Telangiectasis
            * Hyperplasia of
              the nose leading to
              rhinophyma
Perioral    * Eczematous appearance  * Primarily located around
Dermatitis    (small dry, inflamed     the mouth and eyes
              lesions)


Environmental Medicine

"Acne-like lesions can occur in response to various compounds: corticosteroids, halogens, isonicotinic acid, diphenylhydantoin, and lithium carbonate. Exposure to various industrial pollutants also causes acne: machine oils, coal tar derivatives, and chlorinated hydrocarbons. Cosmetics, pomades, over washing, and repetitive rubbing can produce acne." (11)

Acne Vulgaris Treatment Considerations

The primary integrative medicine approach is to assess and address the underlying causes of the condition, which may include: gastrointestinal dysfunction/dysbiosis, emotional stressors and hormonal imbalance.

Dietary

* Try a dairy-free diet for three to six months. No milk, cream, yogurt, ice cream, cheese of any kind (including cream and cottage). Decrease use of butter or switch to ghee (clarified butter). [Milk contains estrogens, progesterone, and androgens as well as glucocorticoids and IGF-1].

* Food high in iodine should be eliminated.

* Consume low-glycemic index foods.

* Eat three nutrient-dense meals and two "mini-meal" snacks daily.

* Eat five to eight servings of vegetables and two servings of fruit per day. All colors of the rainbow.

* Eat 2.5 to 3 palm-sized servings of protein-rich foods (meat, poultry, eggs, fish) daily; including fish, one to two times weekly.

* Minimize or avoid refined carbohydrates (e.g. candy, etc.).

* Eat vegetable carbohydrates (e.g. squash, sweet potatoes, root vegetables, etc.).

* Eliminate hydrogenated oils (trans-fats) and decease oils rich in omega-6 fatty acids (e.g. safflower, sunflower, peanut, soy, cottonseed).

* Eliminate high fructose corn syrup.

* Do not drink calories (e.g. soda, sports drinks, chocolate, undiluted juice).

* Drink filtered water, sparkling water, green tea, diluted juice, herbal teas, juiced vegetables.

* Limit alcohol intake.

Supplementation Considerations

* Vitamin A: High daily dose for 3 months has been considered (150,000 IU/day) followed by a decrease to 5000 1U per day. Be aware of signs and symptoms of toxicity (e.g. headaches, fatigue, emotional liability, muscle and joint pain).

* Zinc: 25 - 60 mg per day (picolinate form).

* Vitamin C: 1000 mg/day.

* Probiotics: Lactobacillus spp. 1 x [10.sup.9] cfu/g/day.

* Selenium: 200 mcg/day.

* Vitamin E: 400-800 IU/day.

* Chromium: 200 - 400 mcg/day.

* Fish oil: 3 grams /day (equivalent to 360 mg DHA and 540 mg EPA).

Botanical Medicine (12)

(Dose 1 tsp t.i.d. in water sipped before meals)
Herbal Medicine             Inflammation-modulating  Antimicrobial

Oregon grape (Mahonia
aquifolium)                       [check]               [check]
Scute
(Scutellaria baicalensis)         [check]
Yarrow
(Achillea millefolium)            [check]
Turmeric
(Curcuma longa)                   [check]
Gugul
(Commiphora mukal)                [check]?
Licorice
(Glycyrrhiza glabra)              [check]               [check]
Devil's claw
(lopanax horridum)
Chaste tree (*)
(Vitex agnus-castus)
Saw palmetto (**) (Serenoa
repens)

Herbal Medicine             Anti-comedogenic  Other

Oregon grape (Mahonia
aquifolium)                     [check]
Scute
(Scutellaria baicalensis)       [check]
Yarrow
(Achillea millefolium)
Turmeric
(Curcuma longa)
Gugul
(Commiphora mukal)              [check]?
Licorice
(Glycyrrhiza glabra)
Devil's claw                                  If stress is a factor
(lopanax horridum)
Chaste tree (*)                               Hormonal balancing
(Vitex agnus-castus)
Saw palmetto (**) (Serenoa                    If androgen is a factor
repens)

(*) Chaste tree (Vitex agnus-castus) acts in the pituitary to balance
secretion of luteinizing hormone and follicle- stimulating hormone,
thus regulating estrogen and progesterone levels.
(**) If polycystic ovarian syndrome or documented high-serum androgens
are present, saw palmetto should be considered to help offset the
negative effects of excessive androgens. Saw palmetto does this by
moderately inhibiting 5-alpha reductase (which activates testosterone
to the much more potent dihydrotestosterone form) and by antagonizing
the androgen receptor.

Additional Herbal Medicine Considerations

Commiphora molmol    * Anti-inflammatory
(Myrhh)              * Vulnerary
                     * Antimicrobial
                     * 25 mg of guggulsterone
                       twice daily for 3 months
Echinacea spp.       * Anti-inflammatory
                     * Immune-modulating
Zingiber officinale  * May help increase the
(ginger)               bioavailability of other
                       herbs


Topical Medicine (13)

* Melaleuca alternifolia (Tea tree oil): 5% to 15 % preparations--oil gel--antiseptic an antifungal properties

* Azelaic acid: naturally occurring nine-carbon dicarboxylic acid. 20% azelaic acid cream--antibiotic activity against P. acnes

* Vitamin C: sodium L-ascorbyl-2-phosphate 5% lotion --antioxidant

* Nicotinamide: topical nicotinamide inhibits the release of lysosomal enzymes, vasoamines and activity against P. acnes lipase. (4% gel)

Lifestyle Modifications

* Stress reduction: meditation, prayer, breathing exercise, counseling, etc

* Proper sleep

* Exercise; walking strengthen training, Tai Chi, etc.

Sample Treatment Protocol

* Herbal medicine:

** Echinacea purpura 1:2 liquid extract 30 ml

** Commipora molmol 1:5 liquid extract 10 ml

** Zingiber officinale 1:2 liquid extract 10 ml

** Mix liquid herbal extracts; Dose--2.5 ml t.i.d. before meals

* Dietary recommendation as previously mentioned

* Tea tree oil 5% gel applied to lesions t.i.d.

About the Author

Dr. Wayne Sodano is a Board Certified Chiropractic Internist, Diplomate of the American Clinical Board of Nutrition, Certified Functional Medicine Practitioner, and is Board Certified in Traditional Naturopathy. He is a former instructor of the DABCI program and currently dedicates his time to research and development in the areas of integrative and functional medicine as the Director of Medical Education at the College of Integrative Medicine (www.CollegeofIntegrativeMedicine.org) and serves as Director of Clinical Support and Education at Evexia Diagnostics. He frequently lectures live through other venues both nationwide and internationally. Dr. Sodano is also creator of iMedLogics (www.iMedLogics.com), a comprehensive health history analysis and patient management software program.

References

(1.) Bowe WP, Glick JB. Integrative Management of Acne. In: Norman RA, Shenefelt PD, Rupani RN. Integrative Dermatology. Oxford: Oxford University Press; 2014. p. 224.

(2.) Ibid.

(3.) Ibid. p. 225.

(4.) Traub M, Murray MT. Acne Vulgaris and Acne Conglobata. In: Pizzorno JE, Murray MT.

(5.) Treloar V Acne and Diet. In: Kohlstadt I. Advanced Medicine with Food and Nutrients. 2nd Ed. Baco Raton; CRC Press; 2013. p. 419.

(6.) Treloar V Acne and Diet. In: Kohlstadt I. Advanced Medicine with Food and Nutrients. 2nd Ed. Baco Raton; CRC Press; 2013. p. 421.

(7.) Ibid.

(8.) Ibid.

(9.) Ibid.

(10.) Traub M, Murray MT. Acne Vulgaris and Acne Conglobata. In: Pizzorno JE, Murray MT. Textbook of Natural Medicine. 4th Ed. St. Louis: Elsevier; 2013.p.1158.

(11.) Traub M, Murray MT. Acne Vulgaris and Acne Conglobata. In: Pizzorno JE, Murray MT. Textbook of Natural Medicine. 4th Ed. St. Louis: Elsevier; 2013. p. 1157.

(12.) Yarnell E, Abascal K, Roundtree R. Clinical Botanical Medicine. New Rochelle: Mary Ann Liebert, Inc; 2009. p. 6.

(13.) Traub M, Murray MT. Acne Vulgaris and Acne Conglobata. In: Pizzorno JE, Murray MT. Textbook of Natural Medicine. 4th Ed. St. Louis: Elsevier; 2013. p. 1160.

by: Dr. Wayne Sodamo DC, DABCI, DACBN, BCTN
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Date:Jun 1, 2018
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