<h2>Practice points*</h2><ul><li>Oral zinc sulphate and zinc gluconate, taken over a period of 6-12 weeks, have shown positive results. Efficacy has been demonstrated using 30 mg of elemental zinc5,6</li><li>Improve antioxidant status with vitamin C, vitamin E and selenium, combined with zinc6,7</li><li>Women with premenstrual aggravation of acne, often respond to supplementation with vitamin B6 (25-50 mg daily as pyridoxal-5-phosphate), possibly as a result of its role in normalising steroid hormones.</li><li>Topical treatments aimed at reducing C. acnes and having an anti-inflammatory effect include tea tree oil (5-15% solution),7 zinc sulphate (5% strength)8 and green tea (2% solution)9</li><li>A low-glycaemic load diet (LGLD) has shown some benefit in small trials. The diet was composed of 25% energy from protein, 45% from low-glycaemic index carbohydrates and 30% from fat2</li><li>Acne can adversely affect a person’s quality of life and psychological wellbeing4 therefore counselling can be helpful3</li></ul><h2>Description</h2><ul><li>Acne vulgaris is a common skin condition which occurs predominantly on the face and to a lesser extent on the chest, shoulders and back. These areas of skin have the most sebaceous glands.</li><li>Sebaceous glands release oily sebum into the hair follicles. Acne consists of blockages or plugs that trap oil, dead cells and bacteria in the hair follicles leading to local swelling and inflammation.1</li><li>The follicle wall may bulge and produce a whitehead, or the plug that blocks the hair follicle may be open to the surface and darken causing a blackhead.</li><li>Large, solid, painful lumps beneath the surface of the skin (nodules) are an infection that affects the deeper layers of the hair follicles.</li><li>An overgrowth of the bacterium Cutibacterium acnes (C. acnes), formerly Propionibacterium acnes (P. acnes) in the follicle, leads to infection.1</li><li>Individuals can have a genetic predisposition to excess sebum production, whilst stress and diet can increase acne risk.2 There is also a hormonal influence with increased circulating androgens that stimulate sebaceous gland activity. The resulting sebum production triggers hyperkeratosis.3</li><li>More than 90% of the world population is affected by acne at some point in their lives4, with 80% of adolescents, 54% of adult women and 40% of adult men affected.2</li></ul>

<h2>Management principles</h2><ul><li>Reduce sebum over-production and hyperkeratinisation (control oil build-up and prevent plug formation)</li><li>Reduce overgrowth of C. acnes bacteria</li><li>Lessen inflammatory and non-inflammatory acne lesions (redness, swelling)</li><li>Reduce oxidative load and improve antioxidant status</li></ul>

Management

<h2>Primary recommendations</h2><h2>ZINC</h2>Mechanism of actionPeople with acne seem to have lower serum and skin zinc levels5<ul><li>Possible anti-androgenic activity (and subsequent suppression of sebum production)8</li><li>Anti-inflammatory activity8</li><li>Zinc plays a role in retinol-binding protein formation, wound healing, immune system activity and tissue regeneration3</li></ul>Dosage information30 mg elemental zinc taken daily over 6-12 weeks. Larger doses are poorly tolerated.6Adverse effects<ul><li>Taking on an empty stomach may cause nausea.6 Always advise to have with a meal.</li><li>Toxicity signs include nausea, vomiting, diarrhoea, fever and lethargy after ingestion.6</li><li>High doses of zinc (100-150 mg/day) may interfere with copper metabolism.6</li></ul>Key interactions<a href="~/link.aspx?_id=4471DACF65C148EA8FD82B23FD6712D4&_z=z">Refer to Complementary medicine interactions guide</a>

Primary

<ul><li>Tea tree oil - significant antiseptic properties and is effective against C. acnes. Efficacy has been demonstrated with a 5% tea tree solution and also a 15% solution. Well tolerated but occasionally can cause contact dermatitis7</li><li>Zinc - topical 5% zinc sulphate shown to be effective in mild to moderate acne8</li><li>Green tea – a 2% tea solution reduces adhesion of C. acnes9</li><li>Lavender essential oil - is anti-bacterial and can reduce the inflammation associated with acne</li></ul>

Topical treatment

<h2>Diet and lifestyle recommendations</h2><ul><li>Eat protein with each meal including both lean animal protein and vegetarian protein, such as fish, lean meats, eggs, soy, beans and legumes, nuts and seeds.</li><li>Eat low-glycaemic carbohydrates such as wholegrains (e.g. brown rice, quinoa, buckwheat, rye and spelt) and starchy vegetables (e.g. pumpkin, sweet potato, parsnip, carrots and beans).</li><li>Limit high-glycaemic carbohydrates such as white, refined and sugary products (e.g. cakes, biscuits, chocolate, chips and white bread).</li><li>Eat 5 to 8 serves of vegetables each day. A serve = 1 cup of salad greens, 1/2 cup of cooked vegetables and 1/2 cup of cooked beans.</li><li>Eat 2-3 piece of fruit each day.</li><li>Eat foods rich in healthy fats such as avocado, extra virgin olive oil, nuts and seeds.</li><li>Limit foods high in processed trans-fats and hydrogenated vegetable oils such as take-away fried foods and pastries.</li><li>Avoid drinking liquid calories, such as fizzy sweet drinks, sports drinks and undiluted juices. Drink filtered water, green tea, diluted juice, herbal teas and vegetable juice.</li><li>Counselling – to support psychological wellbeing, counselling can be an important adjunct therapy.3</li><li>Phototherapy - blue light phototherapy has been trialled in the management of acne. It has been shown to reduce lesions, but not C. acnes colonies.3</li><li>Reduce bacterial levels on bedding - by changing pillow cases regularly. Higher bacterial environmental loads have been implicated in other skin conditions such as contact dermatitis which may also be a consideration for acne.3</li></ul>

Diet & lifestyle

<h2>References</h2>1. Treloar V. Acne. The underlying influences of nutrition. In Kohlstadt, I (Ed). Food and Nutrients in Disease Management. Boca Raton. CRC Press. 2009, 321-324. 
 2. Cao H et al. Complementary therapies for acne vulgaris. Cochrane Database Syst. Rev. 19 January 2016.
 3. Steel A. Acne vulgaris. In Saris J et al, Clinical Naturopathy. Churchill Livingstone, Elsevier, 2010, 463 – 476.
 4. Global acne market report for 2016- 2026. December 2017. <a href="https://www.reportlinker.com/p05251482/Global-Acne-Market-Report-for.htmAccessed" target="_blank">https://www.reportlinker.com/p05251482/Global-Acne-Market-Report-for.htmAccessed</a> 19 November 2018.
 5. Natural Medicines. Zinc. Last reviewed 10/25/2018. https://naturalmedicines.therapeuticresearch.com/databases/food,-herbs-supplements/ professional.aspx?productid=982Accessed 20 November 2018.
 6. Arthur R. Zinc in Braun L et al. Herbs &amp; Natural Supplements. An evidence-based guide. Vol 2 Elsevier Australia, 2015, 1210-1211.
 7. Traub M et al. Acne Vulgaris and Acne Conglobata. In Pizzorno J et al, Textbook of Natural Medicine. Elsevier, St Louis, Missouri, 2013, 1157-1161.
 8. Gupta M. Zinc therapy in dermatology; a review. Dermatol Res Pract, 2014, 1-11.
 9. Sharquie KE. Topical therapy of acne vulgaris using 2% tea lotion in comparison with 5% zinc sulphate solution. Saudi Med J, 2008 Dec; 29(12), 1757-61.

Acne

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