Make yourself healthy: Searching for the cause of acne

Martha Rotter, a software engineer, grew up near St. Louis. She did not have skin problems in high school or college. After college, she spent six years in Seattle. Her skin got a little worse. In 2007, she moved to Dublin to work for an Irish branch of Microsoft. Six months after the move, she noticed her skin was worse than it had been in Seattle. In Seattle she would get a little acne or blemishes for a week or so and then they would go away. In Dublin, they weren't going away.

Her skin got worse. A year after moving to Dublin, it was always bad. The spots and sores were always uncomfortable -- "a headache on my face," she says. They were painful to touch. At one point Martha got a massage. Forgetting her warning, the masseuse rubbed oil on Martha's face. She screamed. "One of the most painful things ever," she says.

Is my job making my skin bad? she wondered. She was working a lot, taking clients out, losing sleep. She started to go out less so that she could get more sleep. She stopped working on weekends. This didn't help.

She tried many skin creams and face washes. "Neutrogena and Clearasil make a lot of products," she says. "On a bad day I could easily drop $50 on two or three things." For several months, she spent $100/month on creams, astringents, and soaps trying to find something that worked. Nothing did.

She tried fitness. She went to the gym four or five times per week. She took yoga. Maybe this would help her relax and improve her mood, she thought. Her skin stayed bad.

In the summer of 2008, she read The Acne Prescription (2003) by Nicholas Perricone. The book says that certain foods, such as salmon, blueberries, and spinach, will make your skin better. It had many before and after pictures. "Now people would be more cynical because of his skin care line and vitamins," she says. "Back then they weren't around or I didn't know about them." Perricone's advice didn’t help.

In December 2008, she went home for Christmas. She hadn't seen her family for nine months. "They were surprised by my face," she says. They asked about it. "When a family member mentions something, that makes you realize it's obvious to everyone." She had been pretending to herself that other people didn't notice. After her family's comments, she didn't want to leave the house or have any pictures taken.

Her mom suggested they see a dermatologist. Martha hadn't done this. In Ireland, she had medical insurance but the strangeness of the system was daunting. Another problem was that she didn't know anybody who saw a dermatologist and she didn't want to pick one at random. In the United States, she didn't have insurance but maybe it would be worth it. She went with her mom to a dermatologist who had helped her sister with eczema. A 5-minute visit cost $150. The doctor was reassuring. "This happens sometimes," he said, giving her hope it might be temporary. "It's not your fault." He meant there's nothing she could have done to keep it from happening.

"Do you think it's something I'm eating?" said Martha. He dismissed the idea. We all know what you eat doesn't affect your skin, he said. Don't worry about that. We'll take of this. (The American Academy of Dermatology Guidelines of Care for acne, published in 2007, says "dietary restriction (either specific foods or food classes) has not been demonstrated to be of benefit in the treatment of acne.") Martha left with a year's worth of three prescriptions: 1. An antibiotic (minocycline, a pill). 2. An astringent (a cream). 3. A Retin-A-like drug (a cream). At a pharmacy, Martha learned that the prescribed medicines would cost about $300/month. She didn't want to spend that much. She just got 1-2 months worth of the antibiotic.

She didn’t want to take antibiotics, but she was desperate. "In a week I could tell they were working," she says. Her acne went from 100% to 10-15%. There was still some redness, but no more painful blemishes. The biggest problems were gone. But it wasn't a long-term solution. She didn't want to take antibiotics for a year, much less forever. She knew that women who take antibiotics for a long time often have trouble with yeast infections. (She was told to eat yogurt to prevent yeast infections.) If she stopped the antibiotics, presumably the acne would return. When she finished the jar of pills, she didn't refill it. As she feared, the acne came back. A month after stopping the antibiotics, her skin was just as bad as it had been before she started them.

Am I allergic to something? she wondered. At Thanksgiving, she had met her brother's wife's nieces, who had discovered they were allergic to gluten. What a difference it had made to give up gluten, they said. They had more energy, no longer felt bloated. The Dublin health food store she patronized had an in-house food allergist. In 2009, she had a test ($60) in the back of the store. The allergist had 20 little tins in front of him. He did a test (called a vega test) that measures the electrical resistance of your skin. "He would touch your skin with a little metal thing. It would light up if you were allergic," she says. It took an hour. The results implied she had strong allergies to soy and chicken and a few other things and slight allergies to dairy and caffeine. (This study of the test found it worthless for detecting mite and cat dander allergies.) The allergist recommended she start taking primrose oil, a probiotic, and wheat grass shots, drink a caffeine-free coffee replacement rather than coffee or tea, and stop eating chicken and soy. The recommended products cost about $40/month.

She stopped eating chicken and soy. She didn't eat much soy to begin with. She had been eating a couple of chicken breasts per week and would roast a chicken once or twice a month. She replaced chicken with fish. She also followed the rest of the allergist's recommendations. She took the wheat grass, primrose oil, and probiotic. She drank the caffeine replacement. She waited two months. "Nothing really changed," she says.

Should she try Accutane? That was her dermatologist’s recommended next step. Try antibiotics again? Or something else? “Reading your blog made it easier for me to stop trusting experts,” she says. “To realize my doctor is not the be-all end-all. That it was okay to try other things.” At CureTogether and other forums, she found “lots of people trying lots of solutions to lots of problems.” They encouraged her to believe she could do something besides follow her dermatologist's recommendations. “Your blog made me aware that the answer might not be obvious,” she says. “There’s lots of experimenting we need to do.” She started cutting foods out of her diet one by one to test the allergy idea. She got ideas about what to test from forums. She also asked herself: What could I cut out that would make a pretty big difference in what I eat? She tried each change for a month. Here, in order, are the foods she cut out:

1. gluten
2. meat (including eggs but not fish)
3. carbs (rice, lentils, quinoa, barley, couscous, grains in general, wheat)
4. alcohol
5. caffeine (she drank a lot of tea)
6. sugar (including honey and artificial sweeteners such as saccharin and aspartame)
7. soy (more thoroughly than before, when she had only cut out obvious soy products such as soy sauce)
8. starches (potatoes, corn, bananas, beets, and squashes)
9. seafood and shellfish (there is a lot of farmed fish in Ireland -- was it that?)
10. nothing (on vacation)
11. salt
12. dairy

She decided to cut out dairy because the food allergist had mentioned that breakouts around the jaw and chin are often due to hormones. “You hear about hormones in American cows,” she says. She drank “a good amount” of milk. She also had lattes, added milk to coffee, cooked with milk (e.g., béchamel sauce), and ate yogurt and cheese. She cut out all dairy at the end of November 2010. In two weeks, she could see her skin was getting better. It was entirely clear by the end of the year.

She waited a few months before testing the boundaries. She really missed cheese and lattes. She tried goat cheese. That was okay. Sheep cheese was okay. Goat milk was okay. “Every so often over the last year when I'm at a restaurant I'm tempted by a dessert with cheese. Sometimes I eat it just to try it. Or I have coffee with regular milk. A few hours later I can tell there is going to be a spot,” she says. She recognizes the feeling.

Martha had eaten lots of dairy in Seattle without much trouble. Since she figured out that cow dairy was the cause, she hasn’t tried American dairy so it's unclear if American and Irish dairy differ in an important way. Before she realized dairy was the cause, she went to Nepal for a month and had lots of milk tea. “My skin was horrible the entire trip,” she says, which implies it’s not just Irish dairy.

Here are several stories about the effect of cutting out dairy on acne. Sometimes it had a big effect, sometimes no effect. If there are large differences from one person to the next, self-experimentation is vital.

I have not encountered an expert who recommends self-experimentation for acne nor has Martha. The Acne Prescription, for example, says nothing about cutting out foods. In an interview about acne, Loren Cordain, author of The Dietary Cure For Acne (2006), says "What you don’t want to eat is processed foods, refined sugars, salts, cereal grains or dairy products.” Many paleo advocates say something similar. In Martha’s case, the list of forbidden foods is much too long. Almost all of them turned out be okay, including goat and sheep dairy. Cordain's forbidden foods would have been a good place to start -- a good source of ideas to test, one by one -- but not a good place to end. Among non-experts, cutting out foods one by one and waiting a few weeks is sometimes recommended. In this Paleohacks discussion about acne, someone says "I would try the supplements first for at least a week or 2 if you get no results then start eliminating foods." In this one, a woman says she learned a lot about what caused her acne from "a ton of n = 1 self experimentation stuff."