89: Acne & Insulin Resistance - Why Diet Matters More Than You Think with Dr. Ben Bikman

Welcome to the Metabolic Classroom. I'm Professor Benjamin Bickman, a biomedical scientist and professor of cell biology. Today we are exploring a topic that affects millions of people worldwide, acne. Now, if you've ever wondered why acne is so common, we're going to talk about some of the reasons why. And you may be wondering why on earth is a metabolism scientist speaking about such a skin problem? Well, you'll be surprised to learn of the metabolic origins and connections when it comes to something as common as acne. Now, as a reminder, if you want to contribute to the discussion and interact with me and the others and want to ask some questions, you need to be a community insider. Go to Ben Bickman.com to learn more about that. So the lecture today will proceed generally as follows, with a bit of a definition of what acne is, how common it is. So some of the statistics, and then we will explore some of the conventional origins of it. Then we'll move on to the unconventional origins, which is to say we'll talk about the metabolic background. Of course, no surprise, we're going to talk about how the petite peptide or humble hormone insulin influences this both directly and indirectly by its effects on other hormones. And then we will look at some real well done scientific studies to explore the efficacy of certain metabolic medications as well as dietary changes that can influence insulin and how all of that plays into acne. By the end of the episode, you're definitely going to have a deeper appreciation of the metabolic roots of acne. And my hope is to have some practical strategies to help manage it. Okay, what is acne? Technically called acne vulgaris, it is considered a chronic inflammatory skin condition characterized by a handful of problems like clogged pores, blackheads, whiteheads, pimples, and even sometimes painful cysts. The usual places for this are the face, chest and back. And what they all have in common is that they are all areas rich in sebaceous or sebum or oil producing skin glands. Acne is incredibly common, affecting about 85% of anyone between the ages of 12 to 24. Now, you may be wondering about what that age span or you may not because it's so obviously related to puberty. And it is true that some young men will still be experiencing puberty into their early 20s. So that really does cover that adolescent range. Then after that, when we look solidly in adulthood, it actually tends to affect women a little more than men. And that's largely a result of just the real dynamic hormone changes that women will experience as opposed to their male Counterparts. It's no surprise that acne can really vary in severity, that for some it can just be as inconvenient as the occasional pimple, while for others it can be quite common and result in just some scarring and even some emotional issues as well. So it goes more than just beyond the cosmetic concerns. Now, the conventional view on acne is the one really embraced by conventional clinicians and dermatologists and even certain groups of scientists. They really attribute acne to four general origins or pillars. One is the increased production of sebum, or the kind of oily substance that's generally considered helpful or protective of skin, that the sebaceous glands are producing too much oil. And this is resulting in some clogged hair follicles. Another origin of acne is something called hyper keratin is a keratinization. And keratin is sort of some the cellular structure of the skin, but in this case, the dead skin cells will build up in a follicle, forming a plug, which results in the pimple. Another origin for acne is bacteria. Too much bacteria. In particular, a bacterium called cutobacterium acnes, which tends to grow in clogged pores. And then this itself promotes inflammation. And then inflammation is its own origin that people attribute acne to, where there's just some immune. We associate with certain forms of acne, which anytime you think of something big and angry, glucose. And far more than just regulating energy or energy use, you know, telling a cell to burn a fuel or energy storage. Insulin is an essential hormone. We need it for survival. But our part of our disease of civilization or the plagues of prosperity is that we have too much insulin. This is insulin resistance. And as much as insulin resistance is affecting debilitating chronic diseases that kill us, like heart disease, diabetes, certain cancers, it also affects some that go on the more inconvenient side, like acne. So let's explore that. Earlier, I had mentioned some specific origins, the. The conventional origins of acne. And we can kind of. We can revisit that as we discuss the influences of insulin and insulin resistance on acne. One is back to the production of sebum, or the sebaceous glands, that insulin directly stimulates sebaceous glands to produce more oil, which can then result in clogged pores. So as much as the conventional view just points the finger at the sebaceous gland, the deeper metabolic view would say, okay, well, what's stimulating the sebaceous gland? Oh, wouldn't you know it? Insulin is Part of this effect, another part of this is the excess androgen activity, where specifically high insulin levels increase the production of androgens, the prototypical male hormones like testosterone. Now just to confirm and remind you, females have androgens as well like testosterone, males just have more. But this effect in both sexes will further stimulate the sebaceous gland. So testosterone is also stimulating this. So this is a bit, a bit of a one, two punch where not only is the insulin having a direct effect at stimulating sebaceous gland activity, but insulin is promoting an increase in androgens, which is then further stimulating the sebaceous glands. Another effect is that chronically elevated insulin stimulates immune cells, thereby increasing inflammation and the production of pro inflammatory cytokines. This once again can worsen acne severity. And then lastly, too much insulin promotes hyperkeratinization. So insulin can increase the rate of skin cell production like the keratin tinocytes and shedding, which can result in these dead skin cells further clogging pores, contributing to acne. Now throughout all of this, it's possible you've been thinking of a child or some young individual, you know, a teenager. There is in fact a unique connection between acne and adolescence and metabolism that's worth mentioning. As I've mentioned in a, in previous metabolic classroom lectures, puberty or teenage years is naturally a time of what I call physiological insulin resistance. So this is a state where the insulin resistance is supposed to be happening because it's, it's promoting an accelerated growth and development of the body. So it's a good thing. So again, the difference between physiological insulin resistance and pathological insulin resistance, which is what you mostly hear me talk about and the subject of my books, pathological insulin resistance is when it's just promoting disease, it's not serving any good purpose, it's purely harmful physiological insulin resistance. Like puberty and pregnancy. Puberty is the one we're talking about more right now. That's when it's serving a good purpose. Again, promoting the growth of the body. But in some individuals, when we combine the natural physiological insulin resistance of puberty with the modern diet, which especially as teenagers, is very high in refined starches and sugars, this can lead to higher levels of insulin than even would normally be happening, which is in addition to potentially worsening, any problem could be worsening acne. And think about it, teenagers already have surging of sex hormones, which is already androgens included in males and females, which is itself going to increase the oil production on the skin, adding high insulin into the mix. And now you have a perfect storm for acne. And this certainly explains why some teens struggle with severe acne while others don't. Really a lot of it could be depending on their metabolic responses, which can differ significantly between teens, not only because of just familial predisposition, but also just what is the family eating? What is this teen eating? Now I wanted to dive a little deeper into some of the connections between insulin resistance and hormones, particularly relevant during these teenage years, but even relevant in the adult years. And so I'm going to focus on two. And there are more, but these are the two big ones, namely androgens like testosterone. I want to just, just explain that a little more. And then somatomedins or the insulin like growth factors, IGFs, you've probably heard of IGF1. We're going to talk about both of those now. So firstly, with androgens, high insulin levels will cause the ovaries and the adrenal glands to produce more androgens. This isn't as much an effect that you do see in from the testes, so that's, that's an important difference between the sexes. But androgens such as testosterone, the most famous of them, are known to stimulate the sebaceous glands, increasing the sebum production. Greater sebum results in greater clogging of pores, creating an environment conducive to acne causing bacteria. Further, androgens influence the growth and differentiation of skin cells, which can contribute to the hyperkeratinization or the thickening of the outer layer of the skin, which further can serve to block pores. Okay, so that's a little more detail on androgens. Then what about IGF1, the most famous of the IGFs? Now, just by way of brief background, insulin can stimulate the liver to produce more IGF1. And the liver is the source of these hormones. And IGF1 is a hormone that plays a critical role in growth. Now importantly, we often think of growth hormone as being the main hormone that stimulates growth. And yet in reality it's actually IGF 1 or IGF 2 and 3. So it's these insulin like growth factors that actually promote the growth of the bones, whereas growth hormone primarily actually just mobilizes fuel to fuel the growth. That's a topic for another time. But in the Context of Acne, IGF1 promotes the proliferation of the keratinocytes, the skin cells and the sebaceous glands, once again increasing sebum and skin cell growth. And all of this Once again just contributes to have this perfect storm of promoting high levels of IGF1, this is relevant, are often associated with diets high in refined carbohydrates. And so this further plays into the modern environment, making it even harder for adults, and especially teenagers to keep that skin clean. So by influencing these hormones, again, androgens and the IGFs, particularly IGF1, insulin indirectly creates an environment where acne really can thrive. And it's, I like talking about the, the endocrinology of it because it's so relevant and it's such a beautiful example of the interconnectedness of all of these various systems in the body. Now I'm kind of making the case that unapologetically not kind of, I am making the case that there's a strong metabolic core to acne. What I thought would be interesting would be to highlight some of the ways in which conventionally viewed metabolic drugs have been used off label, if you will, for acne treatment. That as much as I mentioned some drugs earlier, like retinoids or some peroxide, which have been shown to be effective, certainly it's interesting to compare the use of something like say metformin. Now, I highlight metformin specifically because it is the most widely used insulin sensitizing drug and it really does act by improving insulin sensitivity. Now that is not me giving Metformin a free pass. There are considerations to metformin that I've spoken about before. So please do not take this as me giving some approval for the use of this drug. But it is interesting that as opposed to other drugs that are metabolic, this one does actually act to improve insulin sensitivity, albeit with consequences that I've talked about previously. Now, with all of that having been said, in recent years there has been growing interest in the use of metformin for the treatment of acne in that while metformin isn't usually viewed as a first line therapy, it does in fact show some promise, particularly in instances, and this isn't surprising, where there is a known hormonal imbalance like for example, pcos. Now PCOS is very much a consequence of insulin resistance, so it's very much a metabolic problem. In just last year, a meta analysis in 2024 was published in the journal Pharmaceuticals. And remember, you need to be an insider to get access to the show notes and the citations. And they found significant improvement in acne patients that without PCOS but that were treated with metformin, which really does suggest a direct effect of the insulin sensitizing drug. Another study in 2024 this one in a. I think it was a port Portuguese journal. Yeah, and I got the citation in the show notes they report the direct benefit of metformin which resulted in significant improvements in acne lesions on the skin in adolescents and adults, in this case not necessarily those with just pcos, but just generally suggesting a broad use of the drug. And the evidence doesn't stop there actually that there are some studies that have done a comparative analysis looking at how metformin stacks up against some conventional acne treatments. One of the studies I found looked at 70 women with adult or late onset acne, so not just looking at teens. And they compared metformin with isotretinoin. So that's one of the retinoids over six months. And they found that both treatments significantly reduced acne severity. Yes, the retinoid had a better effect, but even still the metformin was significant and it had other improvements related to the skin, like improving hirsutism, which is when women with PCOS get a little more facial hair and things. So some pretty significant evidence suggesting that a metabolic drug like metformin does have a substantial ability to improve acne. Further adding to the view that at least in part acne is, does have metabolic origins. Now I focused on drugs. If insulin sensitizing drugs can work, what about an insulin sensitizing diet? There has been a slow, this, this, a slow progress in this area of research. So there's not a lot that's been done over the years. But over the past decade, ish things have started to accelerate in this regard, particularly scrutinizing a high glycemic load diet. So a diet that is rich in refined starches and sugars and how the evidence suggests that this approach, this diet does exacerbate acne and thus cutting that out is a way to improve acne. So the oldest study, one of the oldest was actually in 2007 and this published in a very good journal, the American Journal of Clinical Nutrition. I've had a lot of study looking at women and I'm going to come to another one. This was one in young men and they just gave them instructions to control carbs. So a low glycemic, low diet and lowering insulin. And they found significant improvements, specifically significantly fewer acne lesions by just controlling carbohydrates. Another study published just last year, again published in the Journal of Translational Medicine, looked at a ketogenic diet in women aged 18 to 30. So young to kind of early aged women who had moderate ACNE and over 45 days, they had a significant improvement. And I actually wanted to cite some of the numbers for you because the improvement was so significant. They looked at a couple different markers and of skin health. One was called the global acne grading system gags. And they found that the lower the score, the better that the score dropped from about 24 to 16. Now, it's hard to appreciate those units. Those are going to be kind of a relative unit, but just appreciate the magnitude of drop that this acne score went from a score of 24 down to 16. Pretty, pretty huge reduction, right? Went down by a third. Another one they looked at was the Dermatology Life Quality Index dlqi, and its degree of improvement was even stronger. It went from a score of 15 down to 7. So it was cut by more than half, again suggesting not only a highly statistically significant change, but a very meaningful change, too. And in that same study, they noted other significant improvements in, in oxidative stress markers, insulin sensitivity markers, and even inflammation markers. So a host of benefits. And you could say, well, which of those specifically resulted in the improvement of acne? My response would be, who cares? I doubt the study subjects were too upset about the significant improvements in their acne. And if they were losing more weight, having lower inflammation, et cetera, well, all the more reason to enjoy it. Okay, so then, what are some of the practical takeaways before we move on to the conclusions of in the lecture? Well, based on the research and general information of endocrinology and physiology, I believe that there are some key steps, some key takeaways, and even some practical steps to improve acne. And I hope you're going to share this with your friends or family members that you're thinking of during this mini lecture. First of all, it's very important. Control carbohydrates. You want to minimize sugary foods like white bread and processed snacks. As I usually say, carbs that come from bags and boxes with barcodes, you need to keep those to a minimum. And that will help reduce insulin levels. This is particularly important for teenagers who are already going to have higher insulin. Yes, contributing to their growth, but potentially also contributing to their acne. We don't want to make that worse. Now, it's not just a matter of cutting that out. You want to replace it. So the usual rules apply. Prioritize protein and don't fear the natural fats that come with that protein. So focus on things like meat and fish and eggs and avocados. That's what the dietary advice was in the papers that I mentioned earlier. So I'm comfortable sharing that with you as your friendly neighborhood scientist. And then all of this lastly is just going to be, you know, fostering or strengthening the view that a low carbohydrate diet as much as, yes, it is definitely a way to improve your metabolic health. The results are obvious that it can is a good way to clear up skin health as well. So, in conclusion, acne is more than just a cosmetic problem. It is potentially a metabolic issue that while the conventional treatments will focus on the surface symptoms, addressing insulin resistance and the hormonal imbalances will really provide a deeper solution in a long term improvement where you know, you're not just masking a symptom, you actually are resolving the problem right from its foundations. And to me, the evidence is quite clear that lowering insulin through dietary changes can significantly reduce acne severity. And as I've noted repeatedly for teenagers, I believe the message is even more relevant. The combination of hormone changes and physiological insulin resistance during adolescence really does create a perfect metabolic storm for acne. And so understanding the metabolic roots of acne can, I hope, empower young people to make these dietary and lifestyle choices that support healthier skin. We all know how reluctant the teenager may be to take advice from a parent, but nothing motivates, I have found, like playing into their ego a little bit. So if you or someone you know struggles with acne, I do think it is time to look a little beyond the conventional topical treatments that just address the surface symptoms and go deeper in asking the question of how metabolic health can influence skin health. Until next time, more knowledge, better health.