Botanical, alternative treatments show promise in acne vulgaris treatment
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Key takeaways:
- Acne vulgaris may be driven by underlying systemic, immune-inflammatory pathways.
- Addressing those underlying causes with lifestyle changes may mitigate disease severity.
Utilizing alternative, botanical treatments for acne may target the underlying causes of disease and improve severity, according to a study.
“A growing trend in acne management is for a more integrative systemic approach, driven by both patients and providers,” Cheryl Burgess, MD, medical director at Center for Dermatology and Dermatologic Surgery in Washington, D.C., and member of the board of directors of the American Academy of Dermatology and the Skin of Color Society, and colleagues wrote. “In addition to the local inflammation at the pilosebaceous unit, there is now a growing body of evidence that suggests that acne vulgaris may be driven by underlying systemic, immune-inflammatory pathways.”
According to the authors, some of these underlying causes may include psycho-emotional stress, diet and metabolism, hormonal fluctuations, the skin and gut microbiome, oxidative stress and dysregulated immune function.
While conventional acne medicines only address the pathophysiology at the pilosebaceous unit, Burgess and her colleagues propose that natural compounds and dietary supplements, including nutraceuticals, may address these underlying ailments.
In this study, the researchers compiled the current evidence for the use of various supplements in addressing these six systemic underlying drivers of acne.
Psycho-emotional stress
“Psycho-emotional stress leads to a neuroendocrine response and the release of inflammatory cytokines in the skin,” the researchers explained. “Clinically, higher reported stress levels have been associated with an increased acne grade in adult women.”
“While these data confirm the anecdotal reports of the impact of systemic stress on acne in adult females, there is a lack of therapeutics available to address psycho-emotional stress in the acne patient,” the researchers added.
While lifestyle additions such as yoga, meditation and exercise are recommended to reduce stress, not every patient has the bandwidth to implement these changes. However, there are a few botanicals that may do the trick.
The shrub ashwagandha found in Asia and Africa is an “adaptogen” that may stop detrimental fluctuations of cortisol and other stress hormones.
Ocimum tenuiflorum, more commonly known as holy basil, can also be used to combat stress. According to a double-blind, placebo-controlled study published in 2022 in Frontiers of Nutrition, adult participants who received holy basil reported a significant decrease in stress as well as salivary and hair cortisol levels. Holy basil may also offer antioxidant, analgesic and anti-inflammatory benefits that improve acne.
Diet and metabolism
“Sugar consumption and insulin fluctuation have been directly implicated in the development of acne vulgaris,” the researchers wrote. “As such, acne management also includes recommendation for consuming a low glycemic diet and maintaining balanced blood insulin levels.”
Certain botanic treatments, specifically berberine and ginger, have been shown to balance out the negative effects of glucose and insulin fluctuations.
Used in Chinese traditional medicine to treat hypercholesterolemia, type 2 diabetes and infections, berberine improves blood glucose and insulin sensitivity through direct effects on low-density lipoprotein receptors and glucose absorption and uptake.
As far as outcomes in acne go, according to a 2020 study published in European Heart Journal, berberine performed equally to minocycline for the treatment of patients with acne. Another study published in 2022 in Pharmaceuticals also found that women with PCOS who received berberine reported a 61% decrease on the Global Acne Grading System and a 71% decrease on the Cardiff Acne Disability Index.
Ginger, on the other hand, can address inflammation and oxidation that occurs in patients with acne. Additionally, patients with acne often have lower levels of vitamin A, D and selenium. According to the authors, there is growing evidence that once these deficiencies are corrected, acne may improve.
Zinc has also shown to decrease inflammatory acne scores and improve acne severity in patients. When formulated with other ingredients, niacinamide, also known as vitamin B3, has been shown to reduce inflammatory papules due to its ability to reduce oxidation reactions in the body.
“All of this evidence suggests there may be an overlap of underlying whole-body drivers of acne vulgaris and a necessity to balance them to manage acne vulgaris and promote general skin health,” the authors wrote.
Gut and skin microbiome
Research has suggested that patients with vs. without acne have a less diverse gut microbiome, containing a higher ratio of Bacteroides to Firmicutes. Since the gut microbiome has been shown to interact with the pathogenesis of acne, the researchers believe that “improved biodiversity of the skin and gut microbiome is essential for epithelial health.”
Treating acne with antibiotics is a mainstay of acne treatment; however, this type of treatment can cause an imbalance in the gut microbiome. Therefore, the researchers recommend supplementing with probiotics, commensals and/or heat-killed postbiotic L-137.
Lastly, research shows that patients with acne have an underrepresentation of two primary producers of butyrate, a short-chain fatty acid that helps maintain the health of the epithelial defense barrier, improve oxidative status and relieve mucosal inflammation. Therefore, increasing butyrate in patients with acne may be an important factoring for alleviating disease severity.
Hormones
Hormonal acne is driven by an excess of androgen levels. Balancing these levels is important for the treatment of acne; however, current methods, such as oral contraceptives and spironolactone, may not be viable options for women who are trying to conceive or who have experienced unwanted side effects during treatment.
Alternatively, there are botanical options that can balance androgen levels while removing the risk for side effects. Maca, a Peruvian root used to improve energy levels, infertility and menstrual irregularities, may be one such option.
According to a double-blind, randomized, placebo-controlled study published in 2000 in the Journal of the American Academy of Dermatology, Maca tablets significantly increased E2 production and suppressed high density lipoprotein levels among women with menopause.
“All of this suggests that Maca could be a useful botanical supplement for addressing the underlying hormonal component of acne vulgaris,” the researchers wrote.
Selenium supplementation is another alternative treatment for acne, seeing as patients with acne have reported lower selenium levels vs. the general population. In fact, according to 2012 study published in the Journal of Drugs in Dermatology, women with polycystic ovary syndrome who supplemented with selenium for 8 weeks exhibited significant improvements in their acne. Selenium supplementation also decreased DHEA-S levels, which is known to elevate androgen levels in patients with acne.
Oxidative Stress
“With the strong indications for UV damage and its role in acne vulgaris development and epidermal integrity, antioxidants may be useful in the mitigation of this damage, which could improve skin health,” the authors said.
Excellent sources of antioxidants include Sicilian red oranges (also known as blood oranges), tomatoes, olive oil and ginger. Sicilian red oranges in particular contain high levels of antioxidants that, when consumed, reduce UV-induced skin redness, malondialdehyde levels and lipoperoxide levels.
Immune Function
“Targeting and attenuating components of an irregular immune system could improve acne vulgaris outcomes,” the authors wrote in making a case for curcumin, the golden component of turmeric. “It has been used for centuries for its anti-inflammatory properties and is now being investigated for its use in inflammatory bowel disease, colon cancer, psoriasis, rheumatoid arthritis and a multitude of other inflammatory conditions.”
In addition to improving general immune function, curcumin has been shown to have antimicrobial properties against Staphylococcus epidermis and Cutibacterium acnes. With this, curcumin can suppress bacterial proliferation, making it a promising alternative for acne treatment.
Conclusion
Physicians have experienced a paucity of scientific evidence and a lack of clinical data supporting the use of complementary and alternative medicine, according to the authors. However, scientific literature is beginning to bridge the gap, showing that these botanical options are indeed viable for the treatment of various inflammatory diseases, including acne.
“The approach does not reject the established, effective therapeutics that are available to us,” the researchers emphasized, “rather it proposes an expanded consideration using evidence-based studies to provide a more comprehensive approach to acne management.”
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Burgess C, et al. J Drugs Dermatol. 2024;doi:10.36849/JDD.8138.
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