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Acne, Inflammation & the Gut-Skin Axis

Acne, Inflammation & the Gut-Skin Axis

The link between the robustness of the human gut and skin health has been studied for decades. Once understood, the obscure connection is beneficial for those with skin conditions such as acne because it provides easy avenues for a number of powerful treatments. 

What is Acne?

One of the most prevalent skin conditions, acne vulgaris, affects the roots of hair (hair follicles) and the tiny sacs of oil that moisturize skin and hair, called sebaceous glands. When sebaceous glands become blocked, pimples and cysts may form. Acne is so common that it affects every race and age group, and "most people in the US between 11 and 30 years old will be affected by it” (1). Teenagers are especially likely to suffer acne due to hormonal changes that increase the oil production of the sebaceous glands (1), but so are women as they head into menopause.

Many different body processes and environmental factors can also directly cause acne or create an environment that allows it to occur. Having multiple causes can make acne challenging to treat, so many people go years without a satisfactory resolution. Quickly healing the condition is preferable to prevent scarring and loss of self-confidence. Fortunately, integrative medicine is well-suited for diagnosing and treating conditions that can drive acne!


Acne breaches or stretches the top layers of the skin, appearing in a variety of forms (1, 2):

  • Whiteheads - a clogged pore that is closed 

  • Blackheads - a clogged pore that is open

  • Papules - small bumps that may be tender and red 

  • Pimples (also called pustules) - the same as papules, but with pus trapped at the top

  • Nodules - larger, more solid bumps under the skin that may also be painful

  • Cystic lesions - lumps created by pus under the skin; typically painful. 

These small lumps and bumps appear where there is a heavy concentration of sebaceous glands: on the face, chest, upper back, shoulders, and neck. 

Multiple Causes of Acne

Diagnosing the cause of acne can be complicated because there may often be more than one cause. Additionally, a particular physical expression can be both a cause and a result of acne (for example, inflammation), which complicates a diagnosis. Below are a few identified causes of acne (1, 3, 4), but this is not a complete list. More causes of acne are being discovered as technology progresses.

  • Oil and grease from the scalp, mineral or cooking oil, and certain cosmetics 

  • Various medications

  • Elements of the diet 

  • Hormones, including beginning or quitting birth control pills 

  • Gut health or gastrointestinal disorders 

  • Inflammation or inflammatory diseases  

Gut Health's Role in Acne

Of particular interest to integrative medicine doctors are the last two causes on the list above - gut health and inflammation. While many doctors attempt to balance hormones or use medications to control acne, very few Western medicine doctors look into acne driven by a gut breakdown or compromised skin barriers.

Anyone of any age, any sex, and any race can have acne, which seems to indicate there is something very fundamental driving it. Over the years, researchers have correlated certain skin conditions with underlying diseases and conditions of the gut.

The Gut-Skin Axis

The "gut-skin axis" is the concept of a bidirectional communication between the skin and the gut. The gut is primarily composed of the small and large intestines but is also supported by organs (the stomach, liver, gallbladder, and pancreas).

Like the skin, the gut's lining is composed of layers that provide a barrier between the inside and outside of the body. The body must selectively allow safe and usable food particles to pass through its barrier layers into its interior, allowing (unabsorbed) unsafe or unusable food particles to move through the gut to be expelled from the body.

Both the gut and skin barriers can be breached, causing the immune system to become involved in a process known as inflammation. Inflammation is a normal and natural process that uses heat and naturally produced internal chemicals to heal tissue. Unfortunately, the mechanism that initiates inflammation can sometimes get stuck in a loop, creating a chronic state of inflammation. Chronic inflammation is a known driver of many illnesses - directly causing disease or aiding and abetting illness.

An example of a compromised gut barrier is "leaky gut." Gut barriers are naturally permeable because they must allow food particles to come through them—that's how we are nourished. However, when the avenues that allow particles through controlled gates lose their gate-keeping abilities, undigested food particles can pass through the gut lining into the body's interior. These larger food particles trigger the immune system and sometimes trigger skin irritation from the inside. This mechanism is one of the pathways of the gut-skin axis.

Inflammatory bowel disease (IBD) is another example of a compromised gut barrier. In this case, the first line of defense in the gut's tube develops a malfunction due to responses to imbalanced microbial life (4). This imbalance among bacteria and other microbes triggers the immune cells buried in these layers, causing a perpetual state of inflammation. Inflammation then travels around the body, affecting other things, even reaching remote skin surfaces.

When the skin barrier is compromised, as in psoriasis, it is often due to a similar situation as IBD - an imbalance in the makeup of bacteria on the surface of the skin (4). This combination of factors results in redness, irritation, and a high increase in cell turnover. Cell turnover contributes to the plaques and flaking skin that characterizes psoriasis. High cell turnover is also thought to contribute to clogged pores that result in acne.

Gut-Related Drivers of Acne 

What are the most common culprits that cause the gut to become compromised, eventually affecting the skin?

  • Stress can cause inflammation (5), disrupt digestion, affect sleep, and create many adverse reactions in the human body.

  • A poor diet (foods low in nutrition but high in chemicals and preservatives) (5) can cause immune reactions and inflammation, as well as irritate skin.

  • Excessive consumption of alcohol creates increased permeability of the intestine (6), allowing food particles to enter the bloodstream and trigger the immune system.

  • Over-use of antibiotics reduces certain bacteria in the gut, causing imbalances in bacterial and fungal counts that can erode linings, increase the permeability of the gut barrier, and create inflammation (5). 

  • Overuse of aspirin, acetaminophen, and NSAIDs (non-steroidal anti-inflammatories) compromises the slimy mucosal layer that protects underlying linings of the gut, contributing to increased permeability and lowered absorption of necessary nutrients (5).

  • Birth control pills contribute to the growth of candida (a fungus) in the gastrointestinal tract and a reduction of vitamin B6 (which is essential to gut barrier health) (7).

  • Anything that causes inflammation (food allergies, food sensitivities, inflammatory diet, smoking (8), and vaping (9) can increase the severity of many health conditions.

  • An overburdened or damaged liver allows toxins to continue circulating instead of being broken down and expelled. The liver becomes inflamed and releases inflammatory substances (10), which can then affect remote body parts, including the skin. One sign of a damaged liver is itchy skin (11).

Anecdotally, doctors' offices around the US often see the "perfect storm" of multiple inflammatory and gut-degrading combinations. For example, any combination of stress, estrogen-based birth control pills (BCPs), alcohol, antibiotics, and NSAIDs is particularly harsh on the body. Stress, alcohol, and BCPs deplete B vitamins that help keep the gut lining healthy. NSAIDs and some antibiotics can alter the composition of bacteria in the gut and contribute to the breakdown of the gut lining. Furthermore, pesticides in non organic foods can directly damage the gut lining and kill off microbes in the gut that are critical to a healthy gut barrier.

Is My Acne Due to Gut Health? What Tests Can I Take?

One strength of integrative medicine is that it makes use of advanced testing. Many different types of tests can be used to diagnose gut conditions that can contribute to acne. At a check-up, the doctor may order one or more of these tests:

1. Status of the gut barrier - There are numerous blood or urine tests to choose from that can indicate increased gut permeability. There are also breath tests for the presence of Small Intestine Bacterial Overgrowth (SIBO), a condition that slowly erodes the barrier in the small intestine.

2. Status of microbial balance - Blood, stool, and urine tests can indicate a healthy balance of microbes in the gut or an unhealthy balance (called dysbiosis).

3. Status of liver and kidneys - Inefficient detoxifying capabilities can show up as elevated liver enzymes on blood tests. Indications that the kidneys are not properly filtering out specific metabolites can be reflected in certain blood or urine test results.

4. Inflammation markers - Various blood tests can indicate different types of inflammation in the body, such as C-reactive Protein (CRP), and the Erythrocyte Sedimentation Rate (ESR) test. 

5. Food sensitivity or gastrointestinal tests - Various blood, stool, and urine tests can indicate immune reactions to foods and positively identify gastrointestinal diseases such as Inflammatory Bowel Disease, Ulcerative Colitis, and Celiac Disease.

Potential Treatments for Gut-Related Acne

Many potential treatments for acne exist for conditions originating in the gut. People can try the treatments below, many of which can be done in the comfort of their homes. However, ideally, some of the tests above have been run, and there is a diagnosis to work with. A TCIM doctor can help determine the proper tests to take and customize a treatment depending on the results. 

1. Manage stress - The foundation for health can be found in the daily practice of the "5 pillars of health," outlined in Part I of the series "How to Strengthen Your Immune System."  Preventing stress and maintaining low stress levels helps the body focus on healing.

2. Address known conditions - For example, positive identification of SIBO through testing could require specific antibiotics and diet to knock down bacteria in the small intestine. Likewise, there are particular treatments for Celiac Disease, Inflammatory bowel diseasea, dysbiosis, yeast overgrowth, digestive enzyme insufficiency, leaky gut and other gastrointestinal conditions.

3. Try an elimination diet - Food sensitivity tests can help pinpoint immune reactions to specific foods. Eliminating these particular foods can help repair a compromised gut barrier. Many people are surprised to find that foods they eat daily or weekly are causing reactions in their immune systems. In the absence of test results telling you what foods to eliminate, try eliminating sugar, dairy, wheat/gluten, nuts, soy, and eggs for several weeks  and see if your symptoms are reduced. Our team can help with these steps.

4. Switch to an anti-inflammatory diet with gut-healing supplements - An overly permeable intestine benefits from a diet that will not inflame the gut lining. Typically, this means returning to a whole foods diet free of processed, chemically-laden foods. Additional supplements that contain antioxidant or inflammation-soothing substances such as aloe, l-glutamine, glutathione, probiotics, Omega 3s, turmeric, or ginger can be taken. Some vitamins and minerals, such as zinc, selenium, B vitamins, and vitamin E, and butyrate can help maintain a robust gut lining. We can help you identify and eliminate foods that inflame and irritate the gut lining and suggest appropriate nutritional supplements.

5. Consider liver detoxification - Diet protocols with specific nutritional supplements can help an overburdened liver process and eliminate toxins. Ten and 28 day routines can be followed to cleanse and nourish the liver gently. 

6. Employ IV therapy - In cases where a gut is severely damaged, IV therapies can come to the rescue, delivering gut-healing and inflammation-reducing substances directly to the bloodstream. This method of administration through the blood instead of the digestive system allows gut healing to begin immediately without taxing the system it attempts to fix. Glutathione is a super antioxidant that can be administered through IV, which helps reduce inflammation in the gut.

7. Try acupuncture - The ancient art of acupuncture is an effective way to reduce the effects of stress, help balance the immune system, and balance hormones. Because this therapy does not use the very system it is attempting to heal, it can be beneficial in cases of advanced gut lining damage.

Evaluation is Vital

Since there are many causes of acne, and different skin issues can sometimes resemble each other, a physical exam is necessary to diagnose the condition properly. An exam will help determine the next step, which may include taking some tests to determine the level of gut involvement. Upon evaluating the results, a customized plan can be crafted to address toxins, nutrition deficiencies, inflammation, or other concerns. As mentioned above, we have a large number of potential treatments to offer those who have suffered from the effects of acne for too long. If you have never tried to resolve your acne by healing your gut, it's worth a try. TCIM practitioners can be your team of specialists to bring calm and balance to your skin by repairing your gut health.


Jonathan Vellinga, M.D.

Jonathan Vellinga, MD is an Internal Medicine practitioner with a broad interest in medicine. He graduated Summa cum laude from Weber State University in Clinical Laboratory Sciences and completed his medical degree from the Medical College of Wisconsin.​

Upon graduation from medical school, he completed his Internal Medicine residency at the University of Michigan. Dr. Vellinga is board-certified with the American Board of Internal Medicine and a member of the Institute for Functional Medicine.




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