The Causes Of Acne

If you search the net for side-effects of anabolic androgenic Steroids (AAS) you will find many different opinions on the cause. And mostly you’ll find the pictures of this young (21) bodybuilder. Mostly used by offenders of steroid use.

In the countless threads on the discussion boards you can find a lot of bro-science. Like: “Acne is primarily genetically based -- some get it on back and shoulders, some get on the face, some don’t get anything -- you don't just get acne from aas -- I have never had so much as a pimple from taking anything. Yet my back was covered at one point in high school when I was 100% drug free--Your reading too much about the dangers of aas --I've never gotten acne, lost hair, gyno -- Never had any of that and the vast majority of users I know don't really either give or take some occasional acne. “

There also exist many discussions on pro-bodybuilders using enormous amounts of gear without any acne. Visible acne that is. Well most guys know that pictures a modified. Not only those of models and Playboy bunnies, but also the pictures of bodybuilders in the magazine, PhotoShop, you know.. Still it’s not hard to find pics of pro-bodybuilders covered with acne. Here I posted a picture of Dennis Wolf, but also Dorian Yates and others are not too hard to find.

Beside PhotoShop the contestpreps like the spray tan etc etc, makes a lovely picture. Above you see Trey Brewer compared. Most know that the use of androgens has an effect on the pores of the skin, just like the tanning, the increase and decrease takes its toll on the elasticity of the skin. Do I need to mention “Palumboism” which of course also has to do with skin aging. On the threads you hear people discuss Accutane and antibiotics as means of use for advanced bodybuilders.

Accutane - Roaccutane - Isotretinoin

The Swiss drugmaker Roche was the manufacturer of Accutane, it is called Accutane in America and Roaccutane in other countries. Roche has spent a enormous amount in court defending itself against lawsuits from people whose health has been irreparably damaged by this menacing drug.

Roche stopped selling the drug in June 2009.

However, the generic form of Accutane (isotretinoin) is no less deadly and remains available on the marketplace under the names Claravis, Sotret and Amnesteem. Aside from its links to inflammatory bowel disease, Accutane has been implicated as a cause of depression and suicide.

Us bodybuilders like to talk about synergism, one and one makes three. But sadly enough this also goes for side-effects. Doctors are wary of giving accutane to anabolic steroids users because the side effects of the one can exacerbate the other. And don’t even want to go into the effects on the liver.

More on that later in this blog-post.

Genes

Studies have shown that acne responds to androgens (male sex hormones), this is due to genetics. Many studies show higher androgen levels in acne patients than in healthy controls, and suppressing androgen receptors in the skin reduces both sebum production and acne. An enzyme known as 5-alpha reductase (5-AR) plays a part in this puzzle. The enzyme converts testosterone to DHT, which stimulates sebum production and skin cell growth more than other androgen hormones. At least some studies show that 5-AR is overactive in acne patients. I should also note that the conversion of testosterone to DHT happens in the skin.

By inhibiting 5-AR enzyme we can also inhibit the conversion of testosterone to DHT and thus reduce sebum production, skin cell growth and eventually also acne. Several substances inhibit 5-AR, such as EGCG in green tea, certain fatty acids, zinc and saw palmetto.

We can’t say for sure, but 5-AR inhibition is the most likely explanation for the results in the studies below. There’s a good case to be made for DHT as one of the causes of acne and inhibiting it as a way to treat acne. These studies add further support to it. Acne-prone skin is a bit too overenthusiastic in converting testosterone to DHT. This increase sebum production, skin cell growth and keratin levels in the skin cells (which causes them to lump together), all of which conspire to make a mess of your skin.

Several substances can inhibit the conversion, and studies show this can drastically drop sebum production. One study on green tea showed 70% reduction, sea buckthorn 45% reduction and a cream combining saw palmetto, argan oil and sesame seed extracts 42% reduction. Impressive results from all-natural products with little to no side-effects.

Multiple Studies Link Dairy to Acne

Several recent studies have noticed a strong link between dairy and acne. I have paraphrased the abstracts below. The actual abstracts are far more technical. Even a study published by nutritional company Nestle came out and stated this, which is shocking considering how much dairy they use in their products. Nestle has a keen interest on this topic. Smart people as they are, they figured that if their products give people acne sales are likely to drop. So in a paper published in Nestle Nutrition Workshop Series they concluded with this.

The elimination of the whey protein-based insulinotropic mechanisms of milk will be the most important future challenge for nutrition research.

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Evidence for acne-promoting effects of milk and other dairy products. Melnik 2011

In the paper they reviewed the ways milk aggravates acne and placed a special emphasis on insulin (and IGF-1) spiking effects of whey. The paper recommended that Nestle research ways to eliminate the insulin spiking effect of milk, because: “When the insulinemic index of milk has been adjusted to a level corresponding only to its carbohydrate moiety, we will look again into acne-free faces of less obese young people.” So cute.

There you have it, straight from the horse’s mouth, whey aggravates acne. This is already pretty damning evidence, but doesn’t directly address the use of whey protein powders

Acne vulgaris, the most common skin disease of western civilization, has evolved to an epidemic affecting more than 85% of adolescents. Acne can be regarded as an indicator disease of exaggerated insulinotropic western nutrition. Especially milk and whey protein-based products contribute to elevations of postprandial insulin and basal insulin-like growth factor-I (IGF-I) plasma levels. Both, restriction of milk consumption or generation of less insulinotropic milk will have an enormous impact on the prevention of epidemic western diseases like obesity, diabetes mellitus, cancer, neurodegenerative diseases and acne.


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Acne and whey protein supplementation among bodybuilders. Simonart 2012

Accumulative evidence supports the role of nutritional factors in acne. I report here 5 healthy male adult patients developing acne after the consumption of whey protein, a favorite supplement of those engaged in bodybuilding. These observations are in line with biochemical and epidemiological data supporting the effects of milk and dairy products as enhancers of insulin/insulin-like growth factor 1 signaling and acne aggravation.

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Whey protein precipitating moderate to severe acne flares in 5 teenaged athletes. Silverberg 2012

Acne vulgaris has been linked to milk ingestion, both whole and skim milk. The milk fraction that promotes acne is unknown. Five case reports are presented of male patients aged 14 to 18 years who experienced onset of acne shortly after initiation of whey protein supplementation; Whey protein may be the fraction of dairy products that promote acne formation.

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Dietary intervention in acne: Attenuation of increased mTORC1 signaling promoted by Western diet. Melnik 2012

The purpose of this paper is to highlight the Western diet, a fundamental factor involved in the pathogenesis of epidemic acne. Western nutrition is characterized by high calorie uptake, high glycemic load, high fat and meat intake. Epidemic acne has to be recognized as disease of civilization like obesity, type 2 diabetes, cancer and neurodegenerative diseases. These new insights provide a rational basis for dietary intervention in acne by reducing (1) total energy intake, (2) hyperglycemic carbohydrates, (3) dairy proteins and (4) leucine-rich meat and dairy proteins. The necessary dietary changes are opposed to the evolution of industrialized food and fast food distribution of Westernized countries. An attenuation of [acne] is only possible by increasing the consumption of vegetables and fruit, the major components of vegan or Paleolithic diets. The dermatologist bears a tremendous responsibility for his young acne patients who should be advised to modify their dietary habits in order to not only to improve acne but to prevent the harmful and expensive march to other related chronic diseases later in life.

Did you know? The same hormones that stimulate muscle growth can also cause acne?

Research on protein powders has focused more on the effect on muscle growth and strength, understandably. Unfortunately, that leaves us with only a handful of relevant studies to look at.

One study put 19 untrained males into 10 week resistance training program. One group got protein supplement (PRO) with 20g of protein (14g whey and casein and 6g of free amino acids. The other group got a placebo supplement that contained 20g of dextrose (CHO). After 10 weeks the PRO group showed higher IGF-1 levels.

This was confirmed by another study that found combined protein and carbohydrate supplement (42g PRO, 24g of CHO and 2g of FAT) increased IGF-1 levels more than 70g carbohydrate only (CHO) supplement. The supplement was taken twice a day. The study went on for 6 months and the IGF-1 graph shows the difference increased over time. Estimating from the graph IGF-1 levels were up by about 20% at the 6-month mark, compared to slight decline in the CHO group. The study didn’t specify the type of protein used, other than that it was Myoplex.

Finally, we have this short-term study on experienced bodybuilders. The study just looked a single bout of 2-hour weight training session, and found no effect on IGF-1 levels with any supplement (PRO, CHO or CHO/PRO). Given that these are experienced bodybuilders they’ve probably already ‘maxed’ out their IGF-1 and thus the supplement showed no effect.

Those are the only studies that compare protein supplements to other supplements. Protein powders, in general, increase IGF-1 levels more than carbohydrate supplements. This is good for muscle growth but bad for acne.

There was also one study on postmenopausal women. Not exactly the best match when we talk about bodybuilders, but I’ll mention it because it eliminates the effect of resistance training as confounding variable. Those who took 30g of whey protein per day had 8% higher IGF-1 levels than those taking a placebo with identical caloric content.

Protein powders and mass building supplements in general

Quite a few studies looked at protein powders and mass building supplements in general. Usually they are a combination protein and carbohydrates and vitamins, free amino acids are sometimes added. These shakes are usually pretty heavy, and the caloric load alone is enough to spike insulin and IGF-1 levels. That’s why they are not relevant if we want to focus on whey protein.

But they are relevant if you want to know whether protein powders and mass building shakes in general can cause acne. Taking supplements increases IGF-1 and insulin levels after exercise more than exercise alone. Long-term, these supplements also increase baseline IGF-1 levels. Both of these effects are bad for acne, but good for muscle growth.

Adding branched chain amino acids (BCAA) to the supplements makes them even worse for your skin. That’s because BCAA (and especially leucine) activates the mTor pathway, which is sort of a mastermind protein behind acne.

What about soy protein

Several studies have compared whey, casein and soy protein on muscle growth and strength, but none that I saw mentioned IGF-1 levels. Whey protein might stimulate muscle growth a bit better, but in the big picture the differences are quite small.

Soy protein has been studied in non-bodybuilding population, and it’s been shown to increase IGF-1 levels in both young and old men and in postmenopausal women.

So given all that we’ve covered so far I think it’s safe to say soy protein has similar effect on IGF-1 levels (and acne) than the other types of protein powders. It might be a bit better choice for acne-prone bodybuilders than whey protein, but whether that makes any practical differences, I can’t say. On the other hand, if you look at the comments below you’ll see several people commenting that their skin got a lot better after they switched from whey to soy protein.

Not a problem for everybody

We can say that whey protein increases the risk of getting acne, but it’s obviously not going to give acne to everybody.

IGF-1/insulin pathway is just one way to get acne. For some people acne is more inflammatory and more tied to gut issues and food sensitivities. For these people whey protein may not cause any problems.

Here’s a (not comprehensive) checklist of things that put you into high-risk group as far as whey and other protein powders are concerned:

* You have oily skin. This means you either already have elevated insulin and IGF-1 levels or that your skin is very sensitive to these hormones.

* You are insulin resistant with elevated post-meal and fasting blood sugar levels.

* Your acne is aggravated by eating sugar and simple carbohydrates.

Conclusions

Studies consistently show that protein powders work. They stimulate muscle growth and strength more than weight training alone. But this boost comes with a cost. Protein powders increase IGF-1 and insulin levels, both of which are linked to hormonal acne. Protein-rich supplements lead to higher increase than pure carbohydrate powders.

While there are no formal studies on whey protein on acne, it’s highly likely they cause acne at least to some people. Things that put you into high-risk group are: oily skin, insulin resistance, and acne that is aggravated by sugar and simple carbohydrates.

Unfortunately skin’s sensitivity to androgens and IGF-1 is determined by genetics, so there’s no simple way to fix this. Topical remedies can, to some degree, reduce sensitivity and mitigate the problem. But increasing muscle growth with protein powders and clear skin are inherently opposing goals, both depend on the same hormones.

Case study: steroids zits made worse by roaccutane

The protagonist in the German study is a 22 year-old bodybuilder who had been using steroids for a year. He’d been using, among other things, the testosterone-based Sustanon. Five weeks into a course he developed masses of pustules on his chest, and subcutaneous inflammation as well. The bodybuilder, who knew he was susceptible to acne, stopped injecting but the problem didn’t go away. He went to the doctor, who prescribed doxycycline. The bodybuilder took this antibiotic for 4 weeks, but it didn’t help.

So the doctor then gave him isotretinoin, 50 mg a day. Isotretinoin is a strong drug. It has side effects, but usually provides immediate relief – but not in the case of the bodybuilder. His acne, the doctor confirmed after 5 weeks, continued to get worse.

The bodybuilder developed scars and inflammations on his chest and shoulders, which were painful to the touch and bled easily. He developed patches of pink skin growths, that looked like pyogenic granuloma. They contained the notorious skin bacteria Staphylococcus aureus.

A piece of this pink tissue is shown in the inset below left.

The doctors continued with the isotretoin for a couple of months in the hope that it would help. After 7 weeks nothing had changed, so they decided to adopt more drastic measures. The bodybuilder was given 2 g of the antibiotic cefotiam three times a day intravenously, and his spots were treated with a cream containing betamethasone. This treatment helped, and after two weeks his skin had cleared up.

Extreme acne scars chemical bodybuilder (21) for life

The dermatologists at the Heinrich-Heine University in Dusseldorf, Germany, scratched their heads in amazement when they saw the skin of the 21-year-old amateur bodybuilder. The young man’s torso was covered with zits of the worst imaginable sort.

The guy was suffering from acne conglobata. His sebaceous glands were inflamed, causing painful lumps. It’s almost impossible to resist the urge to squeeze and scratch. As you can see in the photo below, the bodybuilder had abscesses and open wounds all over his upper back, chest, shoulders and upper arms. Some of the inflamed areas extended centimetres below the surface of his skin.

Only after the doctors kept on questioning him did the bodybuilder confess that he was using anabolic steroids: 30 mg dianabol a day and twice a week 250 mg testosterone-enanthate. [In fact the guy probably took much more, if you ask us] The photo below shows how the bodybuilder looked not too long ago, when he had the body he had dreamed of.

But an examination of his testes also revealed the effects of anabolic steroids use: they had shrunk and the sperm quality was also low.

The doctors got the bodybuilder to give up his anabolic steroids regime and gave him medicines to kill the micro-organisms. The bacteria Proprionibacterium acnes, which lives on the skin, plays an important role in the development of acne. The bacteria form colonies in the zits, but if you kill the bacteria the acne disappears.

And after six weeks the bodybuilder’s spots were gone too. But, as you can see in the photo below, the guy’s upper body is still covered with scars. They are so serious that the doctor who treated the bodybuilder, Peter Arne Gerber, is not sure whether the bodybuilder will ever be able to train again. "It is questionable whether he will be able to start building muscle mass again - he may not be able to perform the exercises due to the scarring", Gerber said in a BBC interview. [BBC 21 August 2008]

That you can get acne from anabolic steroids is not new. You can read it in all underground handbooks and in the medical textbooks. And everyone in the steroids world will tell you too. But not everyone knows that acne caused by steroids can be so extreme, and that you may have to live with the damage for the rest of your life. That’s why Peter Arne Gerber decided to discuss the case in an article in The Lancet.

One out of ten anabolic steroids users has a serious acne problem, researchers estimate. Acne is the second most common side effect of anabolic steroids use, after the psychological side effects, like irritation, aggression and sleeplessness.

According to scientists, the sunbathing, so loved by chemical bodybuilders, does not help against anabolic acne.

The vitamin A-based accutane and anti-bacterial agents do help, but doctors are wary of giving accutane to anabolic steroids users because the side effects of the one can exacerbate the other. Both anabolic steroids and accutane can lead to depression. Another, non-medical way to reduce acne is to eliminate refined carbohydrates such as sugar and white bread from the diet.

What can we do to treat acne. There are many topical products available, adapting your eating habits as described above.

The use of anti-oxidants and much more, I’ll address in a later blog post.

 Silymarin (Milk thistle) is very well known by us bodybuilders as a supplement to help the liver cope with oral steroids and severe alcohol (ab)use.