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J Cosmet Dermatol. 2019;00:1–5. wileyonlinelibrary.com/journal/jocd
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1© 2019 Wiley Periodicals, Inc.
Received: 29 October 2019
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Accepted: 26 November 2019
DOI: 10.1111/jocd.13255
ORIGINAL CONTRIBUTION
Evaluation of food consumption in patients with acne vulgaris
and its relationship with acne severity
Yesim Akpinar Kara MD1 | Deniz Ozdemir MSc2
1Depar tment of Dermatology, Yüksek Ihtisas
University, Koru Hospita l, Ankara, Turkey
2Depar tment of Nutrit ion and Dietetic s, Liv
Hospit al, Ank ara, Turkey
Correspondence
Yesim Akpinar Kara , Depar tment of
Dermatology, Yüksek Ihtisas Unive rsity,
Koru Hospital, 1428. sk No: 16/8,
Cukurambar, Ankara, Turkey.
Email: yesim_akpinar@yahoo.com
Abstract
Background: Acne vulgaris is one of the ch ronic skin diseases with bacterial and peri-
follicular inflammation in its etiology. In recent years, numerous studies have been
conducted on hormones and food consumption, which are thought to affect this
inflammation.
Aims: In this study, how effective various possible factors such as food consumption
habits and anthropometric measurement are in the etiology and severity of acne was
investigated in patients with acne.
Materials and Methods: A case-control study was conducted including 53 acne vul-
garis patients and 53 age-, gender-, and ethnicity-matched controls. Each patient's
acne score was calculated by a dermatologist ranging from 0-44 points based on
the Global Acne Grading System (GAGS) calculation. Dietary intake of milk and dair y
products along with carbohydrate, fat, protein ratios and body mass index and body
fat percentage were calculated. Statistical evaluation was carried out by calculat-
ing 95% confidence interval and prevalence rates between acne vulgaris and food
categories.
Results: Cheese consumption was higher in the acne vulgaris group than in the con-
trol group, and there was a statistically significant difference.(P < .05) There was a
statistically positive correlation between acne score and carbohydrate consumption
(P < .01) and a statistically negative correlation between acne score and fat consump-
tion. (P < .01).
Conclusion: In patients with acne vulgaris, it was observed that cheese consumption
increased acne formation and carbohydrate consumption increased acne severity,
while fat consumption did not increase acne severity.
KEYWORDS
acne score, acne vulgaris, dairy products, fat ty acids, food consumption
1 | INTRODUCTION
Acne vulgaris is an inflammatory disease characterized by inflam-
mation of the sebaceous glands, increased sebum production and
comedone, papule and pustule formation accompanied by hyper-
keratinization.1 Acne pathogenesis is quite complex and many
factors such as genetic predisposition, environmental factors,
hormonal disorders, and immunological dysfunction affect the oc-
currence of acne. Recently, many studies have shown that foods
taken with dai ly diet may be ef fec ti ve in acne form at io n an d aff ec t
acne severit y. A carbohydrate-rich diet induces androgen release
by increasing insulin secretion and serum insulin growth factor-1
(IGF-1) and triggers forkhead box protein O1 ( FoxO1)/mamma-
lian target of rapamycin complex 1 kinase (mTORC1) pathway,
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AKPINAR KA RA ANd OZd EMIR
resulting in expression of cytokines, follicular hyperkeratinization,
and increased sebum production.2 It is known that milk and dairy
products containing whey and casein protein lead to an increase
in the plasma levels of postprandial insulin and IGF-1, especially
in the Western pattern diet.3 The study by Adebamowo et al on
50 00 0 patients investigated the relationship bet ween acne and
milk and dair y product s and found a positive correlation between
acne and cottage cheese.4
There are studies suggesting that low levels of omega-3 polyun-
satured fatty acids (PUFA) taken with diet increases the inflamma-
tion phase of acne.5 In a randomized controlled study, a reduction
was observed in inflammatory and noninflammatory acne lesions
when omega-3 was added to the diet and oral supplement therapy
containing omega gamma linoleic acid was used for 10 weeks.6
The aim of this study was to investigate how ef fective the con-
tents of carbohydrate, protein, and fat taken with milk and dairy
products and diet are in the etiopathogenesis of acne and to what
extent they affect the severity of acne.
2 | MATERIALS AND METHODS
2.1 | Study design
This study was designed as a case-control study. The study included
53 patients with the complaint of acne vulgaris and 53 healthy
controls without acne vulgaris. The protocol was reviewed and ap-
proved by the ethics committee of hospital. (2018/003-017) The
subjects were informed that the study was designed to determine
the effect of diet on acne and informed consent form was obtained
from each patient. The t test was us ed to ev aluate wh et her the mean
value between the acne and control groups was significant. A power
analysis was carried out with the effect size obtained from previous
studies (50%) using the G-power analysis software and the power of
the study was determined as 81%.7,8
2.2 | Study population
The study was conducted in a hospital, the Departments of
Dermatology and Nutrition and Dietetics between October 2017
and May 2018. The study included 53 patients with acne vulgaris
aged between 13 and 4 4 years. Fifty-three controls (14-42 years of
age) were healthy individuals without acne vulgaris and consisted
of volunteers who had visited our outpatient clinic for reasons not
related to acne. At the beginning of the study, each acne patient was
evaluated by a dermatologist and acne severity was calculated ac-
cording to the Global Acne Grading System.9
Exclusion criteria: Those who were on systemic antibiotics, isotreti-
noin, and oral contraceptives for the last 6 months and who have
diabetes mellitus, gastrointestinal disease, food allergy, and vegetari-
anism, and a histor y of smoking and alcohol use were excluded from
the study.
2.3 | Measurements
In the study, a patient information record form consisting of three
sections was used to collect data in the depar tment of nutrition
and dietetics. Patients' information was recorded by the researcher
using the fa ce-to-f ace int er vi ew meth od . In the first sectio n, anthro-
pometric measurements including height, body weight, body mass
index (BMI), and body fat percentage of the individuals were re-
corded. At baseline, height and weight were measured in light cloth-
ing and without shoes. Height, weight, and body fat percentages
were calculated using the bioelec trical impedance analysis (BIA) (MC
780 MA 8-electrode TANITA) method. BMI was calculated by divid-
ing the weight (kg) over the square of height (m). In the second sec-
tion, the 3-day (2 weekdays and 1 weekend day) consumption record
of the participant s was questioned. The amount of each nutrient
was calculated. Total amount was divided into number of days, and
a daily amount of nutrient consumption was found. The standard
food recipe (calculation) was used to determine the amount of food
consumed by the participants.10 Food consumption of the partici-
pants was recorded in the Nutrition Information System (BEBIS) 7
full version program, and the amounts of daily energy and nutrient
intake such as carbohydrate, fat, and protein were calculated. In the
third section, the frequency of daily food consumption including five
foods was recorded to determine the consumption of milk and dair y
products of the participants. The participants were asked how often
they consume the specified amount of food on average (one glass of
milk, one bowl of yogurt, and a matchbox size of cheese).
2.4 | Statistical analysis
Statistical analyses were conducted using the Statistical Package
for the Social Sciences (SPSS) version 17 (SPSS Inc). The Shapiro-
Wilk test was used to test data normality. Continuous variables
(quantitative variables) obtained by measurement were presented
as mean and standard deviation. Frequency and percentage values
were used for the presentation of categorical variables (qualitative
variables). Descriptive analysis was done in order to elicit the per-
centage, mean and standard deviation (SD) for quantitative data.
The t test was used for the statistical comparison of patient and
control group values. The Pearson's correlation test was used to
evaluate the correlation between acne score and anthropometric
measurements, milk, and dairy products and continuous variables
such as protein, fat and carbohydrate ratio. Dif ferences were con-
sidered significant if the P value is <.05 and highly significant if the
P value is <.01.
3 | RESULTS
A total of 106 subjects, 53 acne vulgaris patients and 53 healthy
controls, were included in the study. The mean age of the acne group
was 24.47 ± 6.89 years, and the mean age of the control group was
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AKPINA R KAR A ANd OZdEMIR
26.25 ± 7.57 years. There was no significant difference between the
acne and control groups in terms of age, body weight, height, BMI,
and body fat percentage (P > .05; Table 1).
When the food consumption values of the acne group and the
control group were statistically compared, cheese consumption was
higher in the acne group (1434.05 ± 989.52 g) than in the control
group (1039.24 ± 669.04 g) and there was a statistically signific ant
difference bet ween the two groups. (P < .05; Table 2) No significant
association was found with the intakes of milk, yogurt, ice cream,
kefir, carbohydrate, fat, and protein. (P > .05; Table 3).
There was a statistically positive correlation between acne
score and carbohydrate consumption (P = .007, P < .01) and a sta-
tistically negative correlation between acne score and fat con-
sumption. (P = .00, P < .01; Table 4) According to the results, it
was found that acne severit y increased as carbohydrate consump-
tion increased in the acne group; however, acne severity did not
increase as fat consumption increased. There was a statistically no
correlation between acne score and milk and dairy products, pro-
tein consumption, and body mass index with body fat percentage
(Table 5).
4 | DISCUSSION
It is known that there are many etiologic factors affecting the patho-
genesi s of acne vulg ar is. It is th ought that the prod uct io n of ski n se bu m
is af fec ted by die tar y nut ri ent s an d th at the re is a rela ti onship between
acne and nutrition. In this context, some foods and nutrients are as-
sociated with acne vulgaris. Despite the presence of numerous stud-
ies on the relationship between diet and acne, different results have
been reported. The studies conducted have shown that acne forma-
tion is increased in individuals fed with high-calorie carbohydrate-rich
diet containing high glycemic load.11 This diet, which increases the
production of sebum, provides an optimal environment for P.acnes
and other microorganisms responsible for the pathogenesis of acne.12
Carbohydrates are known to play a role in the pathogenesis of acne
by inducing insulin release due to their high glycemic content.13 In our
study, it was also found that acne severity increased in parallel with
high carbohydrate consumption in the acne patients. Kwon et al14
compared two groups of acne patients with low glycemic index and
carbohydrate-rich diet and found that inflammatory and noninflamma-
tory lesions decreased after 10 weeks of low glycemic index diet.
Acne patients (n = 53) Controls (n = 53)
P valueMean Std deviation Mean Std deviation
Age (year) 24.47 6.89 26.25 7.57 . 21
Weight (kg) 67. 8 6 15.82 6 7. 42 15.71 .88
Height (cm) 166.04 8.19 166 .32 9. 2 8 .86
BMI 24.72 5.59 24. 63 5.05 .92
Body fat p er-
centage (%)
25.93 7.3 6 25.14 7.5 7 .58
Note: Significant difference, P < .05, t test.
TABLE 1 Demographic characteristics
case and control group
NMean SD P value
Cheese (gram) Acne group 53 143 4.05 989. 52 .018
Control group 53 1 039. 24 669.04 <.05
Note: Significant difference, P < .05 (t test).
TABLE 2 Comparison of cheese
consumption between acne and controls
Acne group (N = 53) Control group (N = 53)
P valueMean ± SD Mean ± SD
Milk (cc) 2641.50 ± 3023.39 2643.39 ± 2516.90 .99
Yogurt (cc) 3532.07 ± 3012 .45 3837.73 ± 3594.39 .63
Kefir (cc) 254.71 ± 938.40 87.73 ± 198.28 .20
Ice cream ( g) 741.51 ± 1100.47 812.26 ± 754.42 .70
Carbohydrate (%) 52 ± 6.3 51 ± 4.6 .47
Fat (%) 35 ± 5.0 35 ± 3.1 .69
Protein (%) 12 ± 3.5 12 ± 3.0 .59
Abbreviation: SD, standard deviation. Signific ant dif ference, P > .05.
TABLE 3 Comparison of milk and dair y
products, percentage of carbohydrate,
fat and protein intake between cases and
controls
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AKPINAR KA RA ANd OZd EMIR
Although there was no significant correlation between acne and
milk in our study, cheese consum ption cau sed by ferment at ion of mil k
was associated with acne. During the processing of milk, it is known
that in dairy products such as cheese, additional testosterone is pro-
duced from precursors such as androstenedione and estrone depend-
ing on the fermentation phase.15 I t is als o rep o r t e d that da ir y prod ucts,
even if fermented, cause three to six times higher insulinemic effect
despite their low glycemic indexes.16 The mai n protein fraction of cow
milk is casein (80%), and the remaining 20% are whey proteins. It has
been reported that whey protein increases the glycemic load by stim-
ulating insulin secretion, while casein increases it by increasing IGF-1
secretion, and is involved in the pathogenesis of acne.17
In the study by Adebamowo et al, skimmed milk was reported to
be associated with acne more than normal milk. It was reported that
milk was independent of fat content and responsible for hormonal
content and that estrogen found in whole milk more than skimmed
milk had a tendency to reduce acne.4,18 It was reported that hor-
monal components of skimmed milk were more comedogenic.19 It
was found that significant amount and regular intake of exosomal
mic roRN As fou nd in pasteurized cow mi lk reduced TG Fβ expression,
and by inhibiting Fox-1, caused acne formation in individuals with
genetic predisposition.20
In the study by Burris et al21, it was found that milk consumption
was higher in the acne group. In a case-controlled study, 44 acne
patients and 44 control groups were compared and it was found that
the acne group had a significantly higher glycemic load, and milk and
ice cream consumption was higher in the acne group. 22 In a survey
study on Norwegian adolescents, it was found that the incidence of
acne was higher in males and females consuming t wo cups of whole
milk or more daily.23
In a study on the adult age group in Denmark, no correlation was
found between acne and milk intake.24 In the study by La Rossa et
al25, it was reported that there was no statistically significant dif-
ference between the acne and control groups in terms of daily milk
consumption. Another study on 2201 adolescents found no cor-
relation between acne and milk, yogurt, and cheese consumption.23
Moreover, a study from Malaysia reported no correlation between
cheese consumption and acne.22
In our study, there was no parallel correlation between fat con-
sumption and acne severity in acne patients. Less evidence exists
supporting the association between fatty acids and acne compared
with other dietary fac tors. Jung and Wei found an association be-
tween frequent consumption of high-fat food and acne.18,2 6 In con-
trast, other cross-sectional studies have not observed an association
between a high-fat diet and acne.27
The high rate of saturated fatty acid intake in the nutritional pat-
tern triggers the mechanisms affecting the occurrence of acne. A
diet with a high content of saturated fatty acids raises the concen-
tration of IGF-1, while a diet with a low saturated fatty acid con-
tent reduces the concentration of IGF-1 and androgen and increases
the concentration of sex hormone binding globulin (SHBG).28 In the
western diet, the ratio of omega-6 to omega-3 is 10:1, whereas this
ratio is 2:1 in nonindustrialized societies such as Japan. Omega-6 is
a precursor of proinflammatory mediators especially such as inter-
leukin-8, and increases inflammation in acne; in contrast, omega-3
reduces hyperkeratinization of sebaceous follicles by both reducing
these mediators and lowering IGF-1 levels. 29 A 2007 cross-sectional
study found no correlation between high-fat diet and acne develop-
ment, while another study conducted in 2010 found a correlation
between high-fat diet and acne depending on frequent intake of
fried foods.5
5 | CONCLUSION
The results from this case-control study suggest a relationship
between dietary carbohydrate, cheese, and acne. In our study,
there was a statistically positive correlation between acne sever-
ity and carbohydrate and cheese intake, and we think that the
dietar y intake of these foods may have increased acne severity
by exhibiting an inflammator y effect. Giving weight to carbohy-
drates with low gl ycemic index in the nutritional pattern may help
reduce acne lesions and their severity. Future research is needed
TABLE 4 Acne score with fat and carbohydrate correlation
Carbohydrate (%)
Correlation coefficient P
Akne score 0.36 .007*
N = 53 53
Fat (%)
Correlation coefficient P
Akne score 0.49 .00*
N = 53 53
*Significant difference, P < .01, Pearson correlation test.
TABLE 5 Acne score with BMI, BFP, milk and, dairy products, protein
BMI
Body fat
percentage Milk Yo gur t Cheese Kefir Ice cream Protein
Acne score 0.12 0.05 0.05 0.08 0.34 0.12 0.16 0.01
N53 53 53 53 53 53 53 53
P0.37 0.68 0.72 0.53 0.01* 0.036 0.24 0.9 2
Abbreviation: BFP, body fat percentage; BMI, body mass index.
*Significant difference, P < .01, Pearson correlation test.
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AKPINA R KAR A ANd OZdEMIR
to determine the relationship between eating habits and acne and
acne severity.
5.1 | Limitation
In this study, the acne scores and food consumptions of the pa-
tients were evaluated by the researchers. This type of evaluation
contribu te d to th e objec tivit y of th e stu dy comp ar ed with the se lf-
limited studies. On the other hand, the classification of dietary in-
take of fat ty acids in the form of saturated and unsaturated fatty
acids could more clearly demonstrate the correlation between
these two groups of fat acid and acne severity. Thus, the degree
to which saturated and unsaturated fatty acids af fect acne will be
more pronounced.
ACKNOWLEDGMENT
I would like to thank Alican Gülden who suppor ted my statistics and
helped me get result s of better qualit y.
CONFLICTS OF INTEREST
None.
ORCID
Yesim Akpinar Kara https://orcid.org/0000-0003-3834-1858
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How to cite this article: Akpinar Kara Y, Ozdemir D.
Evaluation of food consumption in patients with acne vulgaris
and its relationship with acne severity. J Cosmet Dermatol.
2019;00:1–5. https ://doi.org/10.1111/jocd.13255
