Acne vulgaris is a common chronic inflammatory skin condition affecting the pilosebaceous units. Characterized by lesion pleomorphism, it manifests as inflammatory lesions (papules, pustules, and nodules) and non-inflammatory lesions (comedones). Its multifaceted pathogenesis involves hyperseborrhea, hyperkeratinization, colonization by Propionibacterium acnes, and perifollicular inflammation. Oxidative stress and gut dysbiosis are also linked to acne development.
The prevalence of acne varies by time, country, and lifestyle. It affects 70-80% of adolescents and persists into adulthood. Acne can significantly impair quality of life, and its assessment is recommended by international guidelines. The Dermatology Life Quality Index (DLQI) is widely used in dermatology studies, particularly in acne research, to evaluate the overall impact of skin disease on quality of life.
Obesity, often associated with inflammation, may also be linked to acne. A very low-calorie ketogenic diet (VLCKD) has anti-inflammatory and antioxidant effects, potentially impacting acne and associated inflammatory and gut dysbiosis components.This article delves into the possible connection between keto diets and acne, analyzing recent research and offering insights into how this dietary approach might affect your skin.
Understanding the Ketogenic Diet
The ketogenic (keto) diet is a high-fat, moderate-protein, and very low-carbohydrate diet. The goal is to induce ketosis, a metabolic state where the body primarily uses fat for energy instead of carbohydrates. When carbohydrate intake is drastically reduced, the body starts breaking down fat into ketone bodies, which serve as an alternative fuel source.
Foods to Eat and Avoid on Keto
Keto dieters eat foods that are high in fat but low in carbs. Foods like pasta, rice, bread, potatoes, chocolate, cake, sweets, and beer are out. Whilst eggs, cheese, meat, seafood, butter and oils are in. A normal diet with plenty of carbs, your body breaks down the carbs into sugar. If you switch to a diet that’s low in carbs, your body doesn’t have enough sugar to fuel itself. So, it starts to burn fat instead.
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The Potential Link Between Keto and Acne
The relationship between the ketogenic diet and acne is complex and not fully understood. Some individuals report improvements in their skin, while others experience breakouts.
Potential Benefits of Keto for Acne
Reduced Inflammation: Keto diets are often high in omega-3 fatty acids from sources like avocados and nuts, which can help reduce systemic inflammation. Lower inflammation can improve conditions like acne and rosacea. The keto diet has also been shown to reduce inflammatory processes in the body.
Lower Insulin Levels: The keto diet can decrease insulin levels, often dramatically. By reducing insulin levels, ketogenic diets decrease insulin levels, often dramatically. A high glycemic diet, one that’s rich in refined carbohydrates and sugar, will result in blood sugar spikes. When blood sugar is high, insulin is secreted to bring glucose from the blood into your cells. The problem is that excess insulin also increases your levels of insulin-like growth factor (IGF-1). Like androgens, IGF-1 increases sebum production, which sets the stage for acne. Multiple studies have found that eating sugar and carbohydrates (especially simple or refined carbs) cause acne or make it even worse. Sugar and carbs increase blood glucose, which then causes a rise in your insulin levels.
Decreased IGF-1 Levels: Restricting carbs helps keep IGF-1 levels low.
Weight Loss: Keto and low carb diets can naturally prevent acne by lowering carbohydrate intake and promoting weight loss.
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Potential Drawbacks of Keto for Acne
Increased Dairy Consumption: Some report improvements due to reduced insulin spikes, while others may experience breakouts due to increased dairy consumption (a common component of keto). Diets high in dairy and oils have been linked with acne. Some authors have reported that the hormones in milk (designed to help the calves grow into massive animals) may survive milk processing and stimulate the many processes that lead to acne production. Common keto-friendly dairy products like high-fat yogurt and heavy cream will contain some of the hormones and whey protein that can stimulate acne production.
Potential for Dry Skin: The high-fat content may benefit skin hydration, but some people might experience dryness due to reduced carbohydrate intake. Ensure you’re getting a variety of healthy fats, including those from nuts, seeds, and fatty fish, to support skin hydration. Incorporate low-carb, hydrating vegetables like cucumbers and leafy greens to maintain moisture levels.
Keto Rash: For some people, ketone production triggers a skin condition known as “keto rash”. This is the only true acne-like skin condition that keto can cause. In rare cases, ketogenic diet has caused prurigo pigmentosa, or “keto rash,” which is an itchy, red, raised patch of bumps especially common in adult women. Switching to a ketogenic diet may stress your body, particularly at first.
Increased Sebum Secretion: The keto diet causes the secretion of sebum in excess, which is the food for the bacteria type P. Acnes that live deep within the hair follicles and outer skin layer.
Recent Study on VLCKD and Acne
A study aimed to investigate the efficacy of a 45-day active phase of VLCKD in reducing the clinical severity of acne in young women with treatment-naïve moderate acne and grade I obesity. Thirty-one women with treatment-naïve moderate acne, grade I obesity (BMI 30.03-34.65 kg/m2), aged 18-30 years, meeting inclusion/exclusion criteria, and consenting to adhere to VLCKD were recruited. Baseline and post-intervention assessments included anthropometric measurements, body composition, phase angle (PhA), trimethylamine N-oxide (TMAO) levels, and reactive oxygen metabolite derivatives (dROMs) as markers of inflammation, dysbiosis, and oxidative stress, respectively. A comprehensive dermatological examination, incorporating the Global Acne Grading System (GAGS) and the Dermatology Life Quality Index (DLQI), was conducted for all women.
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VLCKD resulted in general improvements in anthropometric and body composition parameters. Significantly, there were significant reductions in both the GAGS score (Δ%: − 31.46 ± 9.53, p < 0.001) and the DLQI score (Δ%: − 45.44 ± 24.02, p < 0.001) after the intervention. These improvements coincided with significant decreases in TMAO (p < 0.001) and dROMs (p < 0.001) levels and a significant increase in PhA (Δ%: + 8.60 ± 7.40, p < 0.001). Changes in the GAGS score positively correlated with changes in dROMs (p < 0.001) and negatively with PhA (p < 0.001) even after adjusting for Δ% FM. Changes in the DLQI score positively correlated with changes in dROMs (p < 0.001) and negatively with PhA (p < 0.001) even after adjustment for Δ% FM.
In this small pilot trial, the 45-day very low-calorie ketogenic diet demonstrated notable improvements in acne severity that seemed to be attributable to the known antioxidant and anti-inflammatory effects of the diet.
Study Protocol
The study protocol encompassed a series of five visits (T0-day 0, T1-day 7, T2-day 21, T3-day 35, T4-day 45) over a total span of 45 days. At baseline (T0), a comprehensive assessment carried out by a team of Endocrinologist, Dermatologist, and Nutritionist was conducted to ascertain the eligibility of patients. Those meeting the criteria for inclusion and exclusion were enrolled in the study and provided their written informed consent. At this point, the Endocrinologist carried out the first medical examination to ascertain the inclusion criteria for the study. Then, the dermatologist performed the clinical acne assessment and confirmed the inclusion criteria for each patient. Finally, the Nutritionist carried out nutritional status assessments (anthropometry and body composition) and drew up the VLCKD dietary therapy. All participants were then given personalized instructions for adhering to the diet. Simultaneously, with the support of nursing staff, blood samples were collected for general biochemical tests, oxidative stress evaluation, and trimethylamine N-oxide (TMAO) levels. Finally, women were advised to maintain the same lifestyle habits.
In the subsequent follow-up visits (T1-day 7, T2-day 21, and T3-day 35), a nutritionist carried out a telephone interview to evaluate adherence to the diet and the state of ketosis. Adherence to the diet was assessed by asking the patient if she was consuming the number of VLCKD replacement meals, if she was drinking at least 2 L of water per day, and if she was respecting the written indications on dietary therapy. Ketosis status was assessed through ketone body measurements extracted from capillary blood samples, and the Nutritionist recorded only whether the patient had ketosis or not (YES/NO). In all of these follow-up visits, the Nutritionist also documented any changes in physical activity levels or food and drink consumption patterns outlined in the VLCKD protocol.
In the last visit (T4-day 45), a final round of endocrinological, dermatological, and nutritional assessments was conducted. Blood samples were collected once more for the repetition of oxidative stress and TMAO analyses.
Every woman underwent a comprehensive dermatological examination, which included the use of the GAGS, a quantitative scoring system designed to evaluate the severity of acne. Initially developed by Doshi et al. [36], the GAGS score is calculated by adding six regional subscores. Specifically, each point is determined by multiplying the factor assigned to each region (3 for the chest and upper back, 1 for the chin and nose, and 2 for the forehead and each cheek) by the highest weighted lesion within that region (4 for ≥ one nodule, 3 for ≥ one pustule, 2 for ≥ one papule, and 1 for ≥ one comedone). These regional factors consider the density of pilosebaceous units, their surface area, and distribution. The cumulative local scores yield the global GAGS score, ranging from 0 to 52. The severity of acne was categorized into three GAGS groups: mild (GAGS score 1-18, characterized by several non-inflammatory comedones with fewer inflammatory lesions), moderate (GAGS score from 19 to 30, marked by numerous comedones, papules, and pustules, but without nodules), and severe (GAGS score from 31 to 38, indicating the presence of inflammatory nodules in addition to papules and pustules) [32, 33]. A single experienced dermatologist clinically assessed the GAGS score. To prevent rating biases, the dermatologists conducting the evaluations were kept unaware of the study's design.
Women in the study filled out the DLQI, a questionnaire consisting of 10 items designed to evaluate the overall impact of skin disease on quality of life. The total score spans from 0 to 30, where 0 signifies no influence of the skin disease on quality of life, and 30 indicates the maximum impact on quality of life. The grading system is as follows: 0-1 denotes no effect on the patient’s life, 2-5 signifies a small effect, 6-10 indicates a moderate effect, 11-20 suggests a very large effect, and 21-30 implies an extremely large impact on the woman’s life.
Optimizing Your Keto Diet for Clear Skin
If you're considering the keto diet to improve your skin, here are some tips to minimize potential drawbacks and maximize benefits:
Limit Dairy Intake: If dairy seems to be causing keto acne, it may be best to remove it from your diet. Replace milk with coconut milk. Replace heavy cream with coconut cream. Replace dairy-based cheese with vegan cheese.
Focus on Whole, Unprocessed Foods: Eat mostly whole, minimally-processed foods. Even if you don’t eat sugary and starchy foods, you may still be consuming ingredients that can cause skin issues. Bologna and other processed meats often contain sugar, corn syrup, fillers or other additives that raise insulin and inflammation levels. If you can’t avoid them completely, protect yourself by making a habit of reading food labels, including the ingredients list. Don’t settle for the claims on front labels, which can sometimes be false and misleading.
Incorporate Anti-Inflammatory Foods: Adding sources of omega-3 fats to your diet will help to balance out the naturally occurring omega-6 and support your inflammatory pathways. Omega-3s are found in fatty fish like salmon, tuna, mackerel, and sardines. Consume fatty fish a couple of times a week. Long-chain omega-3 fatty acids found in fish are anti-inflammatory and may improve skin health. Eat low-carb vegetables with every meal. Leafy green and cruciferous vegetables may help promote hormonal regulation and improve skin health. Drink green tea. Green tea is the best source of the antioxidant EGCG (Epigallocatechin gallate).
Stay Hydrated: During fasting periods, it’s crucial to stay hydrated to avoid dehydration, which can negatively impact skin health.
Consider Intermittent Fasting: Experiment with intermittent fasting. By restricting your calorie intake to an 8-hour eating window every day, you can decrease your insulin and IGF-1 levels more than you would by eating normally throughout the day.
Prioritize Sleep: Research has shown that poor sleep quality doesn’t only increase your risk of overall all-cause mortality, but at a superficial level, it may also worsen acne. If you’re not making sleep a priority, now is the time to consider your sleep hygiene.
Exercise Regularly: Exercise can help with acne by regulating blood sugar, reducing insulin resistance, and flushing toxins out of your system. There are plenty of exercises you can do while in ketosis. Try running, biking, weight lifting, and yoga.
Limit Alcohol Intake: Alcohol is toxic to the body, so the liver’s top priority is to detoxify it immediately upon consumption.
Limit Dark Chocolate Consumption: A 2016 study found that even sugar-free 99% dark chocolate might significantly worsen breakouts in acne-prone men.
Additional Factors to Consider
Genetics: Genetics can strongly influence a patient’s risk of developing acne, but acne-causing genes cannot explain the current acne epidemic.
Western Diet: More specifically, the western diet seems to be the primary instigator of the current acne epidemic in western societies. People who live in non-westernized societies tend to eat more whole foods that don’t require high insulin levels to maintain homeostasis, while people in westernized societies eat much more processed food that causes a rapid increase in blood sugar.
How Long Before Seeing Results?
Follow the keto diet for at least a month. It took almost three months for the subjects in the low glycemic load diet group to experience an average of 50% reduction in acne.
The Importance of a Holistic Approach
Armed with that knowledge, we can look at the ketogenic diet as something that affects us from the inside out. Here’s a good question for you as you’re weighing the pros and cons of your skincare regimen versus ketosis: why are you going on the diet? It should go without saying that it’s important to talk with your doctor and possibly even a nutritionist or dietician before you approach a dietary change of this size.