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SKEPTOID BLOG:

Does eating chocolate give you acne?

by Stephen Propatier

April 24, 2013

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Donate Cytokine "The Official journal of the International Cytokine Society" published a small study suggesting a link between consuming chocolate and Adult/Adolescent Acne. The MyHealthNewsDaily published an article based on the study,"Bittersweet News: Chocolate May Trigger Acne". It is a compelling narrative. The actual research is not. It has been picked up by the news media and spread without skepticism. No big surprise that the title is misleading and not supported by the actual research. News writers often fail to recognize the difference between a proposed link, and one based upon solid evidence. The actual study has a much different title "Chocolate consumption modulates cytokine production in healthy individuals". Acne is a complicated disease and there are many factors involved. Despite common lay person perception, diet plays a small role. So... don't start a battle with your child or significant other over acne and chocolate just yet.

The significance of diet in the development of acne is an issue long debated. Parents and their affected children often ask if foods are a culprit; recent surveys of adolescents found that as many as 62-72% believe that diet is a contributing factor. Despite strong lay beliefs, the predominant teaching in medicine is that diet plays a minimal role in acne. This is based on small trials conducted in the 1960s and 1970s that found that prepared-chocolate bars, peanuts, and other blamed foods did not cause flares of acne.These studies have since received criticism for their design and short follow-up. In recent years, the increased emphasis on nutrition and health has prompted investigators to again tackle this difficult subject.

Research in the field of acne continues on many fronts. Molecular and translational studies may allow targeted therapies in the future in the form of vaccines. Despite improved clinical trials assessing the relationship of dietary components and acne, a direct effect has not been confirmed. Larger studies, hopefully, will help to further determine the interplay of lifestyle factors and acne.

The current consensus opinion of acne/diet is that there are no clear findings. This study has methodological issues and is not likely to change the consensus opinion. I do not agree with the primary investigators statement "epidemiological studies do in fact demonstrate a dietary link with any particular acne correlation". All of the epidemiological studies are dependent on adult recollection of acne flairs and dietary associations. Often years later. This format is plagued by confirmation bias and memory issues. The individual well structured studies do not show a link. This is consistent with no real effect.

This study in particular is of an extremely small size, 7 people. It has minimal controls and relies on the weak foundation of cytokine mediated acne. Although inflammation response is part of acne, it is more complicated than that. In short I am not convinced that this study says anything about acne. It does not carry enough weight to stand on its own and certainly does not overturn current consensus. A large study with better controls and a dose dependent cytokine response could be convincing. Still it would not convince me of a causal effect on acne. That would require a secondary study showing a dose dependent acne response to differing amounts of chocolate with different % of cocoa.

Like many other singular studies, interesting not convincing. In the media information is portrayed as the "New Answer". In a"this changes everything" format. This is just plain not true.

Here is the Up to Date treatment consensus.

General approach to treatment — Four key factors promote the development of acne lesions (figure 1). These factors are targeted during therapy, and include [7]:

Follicular hyperproliferation and abnormal desquamation
Increased sebum production
Propionibacterium acnes (P. acnes) proliferation
Inflammation
Follicular hyperkeratinization and abnormal corneocyte desquamation lead to follicular obstruction. This, in combination with the androgen-stimulated increase in sebum production, promotes the formation of the microcomedo, the earliest lesion of acne. The microcomedo enlarges to form a comedo as lipids, bacteria, and desquamated corneocytes accumulate (picture 1A-B). P. acnes can proliferate in this environment. Follicular rupture may occur, leading to a host inflammatory response, with the appearance of papules and pustules consistent with inflammatory acne (picture 2). (See "Pathogenesis, clinical manifestations, and diagnosis of acne vulgaris".)

Effective management of acne involves the use of therapeutic agents that combat these factors (table 1). A global panel of experts has recommended a comprehensive treatment plan for patients with acne vulgaris (algorithm 1) [8]. Patients should be given realistic expectations regarding timelines for improvement. It takes approximately eight weeks for a microcomedo to mature. Thus, therapy must be continued beyond this duration in order to assess efficacy.

Topical retinoids are effective in the treatment of comedonal acne due to their ability to normalize follicular hyperkeratosis and prevent formation of the microcomedo [9]. Topical retinoids also improve inflammatory acne [8,10]. This may be due to a combination of intrinsic anti-inflammatory properties of topical retinoids and their ability to prevent the formation of microcomedones. (See 'Topical retinoids' below.)

Topical retinoids can be used as monotherapy in individuals with exclusively comedonal acne. However, patients with an inflammatory component often benefit from the addition of concomitant antimicrobial therapies (eg, benzoyl peroxide or topical antibiotics) that reduce the number of proinflammatory P. acnes colonizing the skin. (See 'Topical antimicrobials' below.)

Patients with moderate to severe inflammatory acne often warrant more aggressive treatment with oral antibiotics [7]. Antibiotics in the tetracycline class are most frequently used, and appear to have both antibacterial and anti-inflammatory properties. The use of benzoyl peroxide with topical or oral antibiotics decreases the emergence of antibiotic resistant bacteria.

No dietary modification, of any kind.

You can tell by the amount of available research on this subject that there is strong evidence behind the consensus opinion. That is why I am not swayed by one study. Media reports do not equal good science. You should base medical care on what your doctor knows, not what your news anchor reads off a teleprompter.

General rule, when the news media says something dietary is either "good" or "bad" you have good reason to be skeptical.

References:

Al-Hoqail IA. Knowledge, beliefs and perception of youth toward acne
vulgaris. Saudi Med J 2003; 24:765-768.

Rigopoulos D, Gregoriou S, Ifandi A, et al. Coping with acne: beliefs and
perceptions in a sample of secondary school Greek pupils. J Eur Acad Dermatol
Venereol 2007; 21:806-810. Bibliographic Links

12 Fulton JE Jr, Plewig G, Kligman AM. Effect of chocolate on acne vulgaris.
JAMA 1969; 210:2071-2074. Lifespan Print Journals Bibliographic Links

Anderson PC. Foods as the cause of acne. Am Fam Phys 1971; 3:102-103.
Bibliographic Links

Adebamowo CA, Spiegelman D, Danby F, et al. High school dietary dairy intake
and teenage acne. J Am Acad Dermatol 2005; 52:207-214. Lifespan Full Text
Lifespan Print Journals Bibliographic Links

Adebamowo CA, Spiegelman D, Berkey CS, et al. Milk consumption and acne in
adolescent girls. Dermatol Online J 2006; 12:1. Bibliographic Links

Adebamowo CA, Spiegelman D, Berkey CS, et al. Milk consumption and acne in
teenaged boys. J Am Acad Dermatol 2008; 58:787-793. Lifespan Full Text Lifespan
Print Journals Bibliographic Links This study looks at the relationship of milk
consumption and development of acne in a male teenage population. This is one of
the more recent attempts to answer the question of whether diet is related to
the development of acne.

Cordain L. Implications for the role of diet in acne. Semin Cutan Med Surg
2005; 24:84-91. Bibliographic Links

Cordain L, Lindeberg S, Hurtado M, et al. Acne vulgaris: a disease of Western
civilization. Arch Dermatol 2002; 138:1584-1590. Lifespan Full Text Bibliographic
Links

Smith RN, Man NJ, Braue A, et al. The effect of a high-protein, low
glycemic-load diet versus a conventional, high-glycemic-load diet on biochemical
parameters associated with acne vulgaris: a randomized, investigator-masked,
controlled trial. J Am Acad Dermatol 2007; 57:247-256. Lifespan Full Text
Lifespan Print Journals Bibliographic Links This is the first randomized,
controlled trial of the effects of dietary glycemic load on acne.

Smith RN, Mann NJ, Braue A, et al. A low-glycemic-load diet improves symptoms
in acne vulgaris patients: a randomized controlled trial. Am J Clin Nutr 2007;
86:107-115. Lifespan Print Journals Bibliographic Links

Klassen AF, Newton JN, Mallon E. Measuring quality of life in people referred for specialist care of acne: comparing generic and disease-specific measures. J Am Acad Dermatol 2000; 43:229.
Dalgard F, Gieler U, Holm J, et al. Self-esteem and body satisfaction among late adolescents with acne: results from a population survey. J Am Acad Dermatol 2008; 59:746.
Yazici K, Baz K, Yazici AE, et al. Disease-specific quality of life is associated with anxiety and depression in patients with acne. J Eur Acad Dermatol Venereol 2004; 18:435.
Bowe WP, Shalita AR. Effective over-the-counter acne treatments. Semin Cutan Med Surg 2008; 27:170.
Lehmann HP, Robinson KA, Andrews JS, et al. Acne therapy: a methodologic review. J Am Acad Dermatol 2002; 47:231.
Haider A, Shaw JC. Treatment of acne vulgaris. JAMA 2004; 292:726.
Williams HC, Dellavalle RP, Garner S. Acne vulgaris. Lancet 2012; 379:361.
Thielitz A, Gollnick H. Topical retinoids in acne vulgaris: update on efficacy and safety. Am J Clin Dermatol 2008; 9:369.
Gollnick H, Cunliffe W, Berson D, et al. Management of acne: a report from a Global Alliance to Improve Outcomes in Acne. J Am Acad Dermatol 2003; 49:S1.
1Leyden JJ, Shalita A, Thiboutot D, et al. Topical retinoids in inflammatory acne: a retrospective, investigator-blinded, vehicle-controlled, photographic assessment. Clin Ther 2005; 27:216.
Thiboutot D, Gollnick H, Bettoli V, et al. New insights into the management of acne: an update from the Global Alliance to Improve Outcomes in Acne group. J Am Acad Dermatol 2009; 60:S1.

by Stephen Propatier

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