[Skip to Content]
[Skip to Content Landing]
Table 1.  Characteristics of the Study Population
Characteristics of the Study Population
Table 2.  Univariate and Multivariate Analyses of Food Intake in the Study Population
Univariate and Multivariate Analyses of Food Intake in the Study Population
Table 3.  Multivariate Analyses of Nutrient Intakes in the Study Population Using a Multinomial Logistic Regression
Multivariate Analyses of Nutrient Intakes in the Study Population Using a Multinomial Logistic Regression
Table 4.  Multivariate Analyses of Dietary Patterns From a Principal Component Analysis of the Study Population Using a Multinomial Logistic Regression
Multivariate Analyses of Dietary Patterns From a Principal Component Analysis of the Study Population Using a Multinomial Logistic Regression
Table 5.  Multivariate Analyses of Dietary Pattern From a Principal Component Analysis of the Subgroup of Women Using a Multinomial Logistic Regression
Multivariate Analyses of Dietary Pattern From a Principal Component Analysis of the Subgroup of Women Using a Multinomial Logistic Regression
1.
Degitz  K, Placzek  M, Borelli  C, Plewig  G.  Pathophysiology of acne.   J Dtsch Dermatol Ges. 2007;5(4):316-323. doi:10.1111/j.1610-0387.2007.06274.x PubMedGoogle Scholar
2.
Gollnick  HP, Zouboulis  CC.  Not all acne is acne vulgaris.   Dtsch Arztebl Int. 2014;111(17):301-312.PubMedGoogle Scholar
3.
Hay  RJ, Johns  NE, Williams  HC,  et al.  The global burden of skin disease in 2010: an analysis of the prevalence and impact of skin conditions.   J Invest Dermatol. 2014;134(6):1527-1534. doi:10.1038/jid.2013.446 PubMedGoogle Scholar
4.
Rademaker  M, Garioch  JJ, Simpson  NB.  Acne in schoolchildren: no longer a concern for dermatologists.   BMJ. 1989;298(6682):1217-1219. doi:10.1136/bmj.298.6682.1217 PubMedGoogle Scholar
5.
Kilkenny  M, Merlin  K, Plunkett  A, Marks  R.  The prevalence of common skin conditions in Australian school students: 3; acne vulgaris.   Br J Dermatol. 1998;139(5):840-845. doi:10.1046/j.1365-2133.1998.02510.x PubMedGoogle Scholar
6.
Perkins  AC, Cheng  CE, Hillebrand  GG, Miyamoto  K, Kimball  AB.  Comparison of the epidemiology of acne vulgaris among Caucasian, Asian, Continental Indian and African American women.   J Eur Acad Dermatol Venereol. 2011;25(9):1054-1060. doi:10.1111/j.1468-3083.2010.03919.x PubMedGoogle Scholar
7.
Cunliffe  WJ, Gould  DJ.  Prevalence of facial acne vulgaris in late adolescence and in adults.   BMJ. 1979;1(6171):1109-1110. doi:10.1136/bmj.1.6171.1109 PubMedGoogle Scholar
8.
Goulden  V, Stables  GI, Cunliffe  WJ.  Prevalence of facial acne in adults.   J Am Acad Dermatol. 1999;41(4):577-580.PubMedGoogle Scholar
9.
Collier  CN, Harper  JC, Cafardi  JA,  et al.  The prevalence of acne in adults 20 years and older [published correction appears in J Am Acad Dermatol. 2008 May;58(5):874. Cafardi, Jennifer A [added]].   J Am Acad Dermatol. 2008;58(1):56-59. doi:10.1016/j.jaad.2007.06.045PubMedGoogle Scholar
10.
Semedo  D, Ladeiro  F, Ruivo  M,  et al.  Adult acne: prevalence and portrayal in primary healthcare patients, in the Greater Porto Area, Portugal.   Acta Med Port. 2016;29(9):507-513. doi:10.20344/amp.6626 PubMedGoogle Scholar
11.
Tan  JK.  Psychosocial impact of acne vulgaris: evaluating the evidence.   Skin Therapy Lett. 2004;9(7):1-3, 9.PubMedGoogle Scholar
12.
Hull  PR, D’Arcy  C.  Acne, depression, and suicide.   Dermatol Clin. 2005;23(4):665-674. doi:10.1016/j.det.2005.05.008 PubMedGoogle Scholar
13.
Mallon  E, Newton  JN, Klassen  A, Stewart-Brown  SL, Ryan  TJ, Finlay  AY.  The quality of life in acne: a comparison with general medical conditions using generic questionnaires.   Br J Dermatol. 1999;140(4):672-676. doi:10.1046/j.1365-2133.1999.02768.x PubMedGoogle Scholar
14.
Di Landro  A, Cazzaniga  S, Parazzini  F,  et al; GISED Acne Study Group.  Family history, body mass index, selected dietary factors, menstrual history, and risk of moderate to severe acne in adolescents and young adults.   J Am Acad Dermatol. 2012;67(6):1129-1135. doi:10.1016/j.jaad.2012.02.018 PubMedGoogle Scholar
15.
Navarini  AA, Simpson  MA, Weale  M,  et al; Acne Genetic Study Group.  Genome-wide association study identifies three novel susceptibility loci for severe acne vulgaris.   Nat Commun. 2014;5:4020. doi:10.1038/ncomms5020 PubMedGoogle Scholar
16.
Lefebvre  MA, Pham  DM, Boussouira  B, Bernard  D, Camus  C, Nguyen  QL.  Evaluation of the impact of urban pollution on the quality of skin: a multicentre study in Mexico.   Int J Cosmet Sci. 2015;37(3):329-338. doi:10.1111/ics.12203 PubMedGoogle Scholar
17.
Wolkenstein  P, Misery  L, Amici  JM,  et al.  Smoking and dietary factors associated with moderate-to-severe acne in French adolescents and young adults: results of a survey using a representative sample.   Dermatology. 2015;230(1):34-39. doi:10.1159/000366195 PubMedGoogle Scholar
18.
Krutmann  J, Moyal  D, Liu  W,  et al.  Pollution and acne: is there a link?   Clin Cosmet Investig Dermatol. 2017;10:199-204. doi:10.2147/CCID.S131323 PubMedGoogle Scholar
19.
Stewart  TJ, Bazergy  C.  Hormonal and dietary factors in acne vulgaris versus controls.   Dermatoendocrinol. 2018;10(1):e1442160. doi:10.1080/19381980.2018.1442160 PubMedGoogle Scholar
20.
Tan  JKL, Vasey  K, Fung  KY.  Beliefs and perceptions of patients with acne.   J Am Acad Dermatol. 2001;44(3):439-445. doi:10.1067/mjd.2001.111340 PubMedGoogle Scholar
21.
El-Akawi  Z, Abdel-Latif Nemr  N, Abdul-Razzak  K, Al-Aboosi  M.  Factors believed by Jordanian acne patients to affect their acne condition.   East Mediterr Health J. 2006;12(6):840-846.PubMedGoogle Scholar
22.
Smith  RN, Mann  NJ, Braue  A, Mäkeläinen  H, Varigos  GA.  A low-glycemic-load diet improves symptoms in acne vulgaris patients: a randomized controlled trial.   Am J Clin Nutr. 2007;86(1):107-115. doi:10.1093/ajcn/86.1.107 PubMedGoogle Scholar
23.
Ismail  NH, Manaf  ZA, Azizan  NZ.  High glycemic load diet, milk and ice cream consumption are related to acne vulgaris in Malaysian young adults: a case control study.   BMC Dermatol. 2012;12:13. doi:10.1186/1471-5945-12-13 PubMedGoogle Scholar
24.
Adebamowo  CA, Spiegelman  D, Danby  FW, Frazier  AL, Willett  WC, Holmes  MD.  High school dietary dairy intake and teenage acne.   J Am Acad Dermatol. 2005;52(2):207-214. doi:10.1016/j.jaad.2004.08.007 PubMedGoogle Scholar
25.
Adebamowo  CA, Spiegelman  D, Berkey  CS,  et al.  Milk consumption and acne in adolescent girls.   Dermatol Online J. 2006;12(4):1.PubMedGoogle Scholar
26.
Adebamowo  CA, Spiegelman  D, Berkey  CS,  et al.  Milk consumption and acne in teenaged boys.   J Am Acad Dermatol. 2008;58(5):787-793. doi:10.1016/j.jaad.2007.08.049 PubMedGoogle Scholar
27.
Juhl  CR, Bergholdt  HKM, Miller  IM, Jemec  GBE, Kanters  JK, Ellervik  C.  Dairy intake and acne vulgaris: a systematic review and meta-analysis of 78,529 children, adolescents, and young adults.   Nutrients. 2018;10(8):E1049. doi:10.3390/nu10081049 PubMedGoogle Scholar
28.
Juhl  CR, Bergholdt  HKM, Miller  IM, Jemec  GBE, Kanters  JK, Ellervik  C.  Lactase persistence, milk intake, and adult acne: a mendelian randomization study of 20,416 Danish adults.   Nutrients. 2018;10(8):1041. doi:10.3390/nu10081041 PubMedGoogle Scholar
29.
Tasli  L, Turgut  S, Kacar  N,  et al.  Insulin-like growth factor-I gene polymorphism in acne vulgaris.   J Eur Acad Dermatol Venereol. 2013;27(2):254-257. doi:10.1111/j.1468-3083.2011.04299.x PubMedGoogle Scholar
30.
Mirdamadi  Y, Thielitz  A, Wiede  A,  et al.  Insulin and insulin-like growth factor-1 can modulate the phosphoinositide-3-kinase/Akt/FoxO1 pathway in SZ95 sebocytes in vitro.   Mol Cell Endocrinol. 2015;415:32-44. doi:10.1016/j.mce.2015.08.001 PubMedGoogle Scholar
31.
Çerman  AA, Aktaş  E, Altunay  İK, Arıcı  JE, Tulunay  A, Ozturk  FY.  Dietary glycemic factors, insulin resistance, and adiponectin levels in acne vulgaris.   J Am Acad Dermatol. 2016;75(1):155-162. doi:10.1016/j.jaad.2016.02.1220 PubMedGoogle Scholar
32.
Rahaman  SMA, De  D, Handa  S,  et al.  Association of insulin-like growth factor (IGF)-1 gene polymorphisms with plasma levels of IGF-1 and acne severity.   J Am Acad Dermatol. 2016;75(4):768-773. doi:10.1016/j.jaad.2016.05.019 PubMedGoogle Scholar
33.
Jung  JY, Kwon  HH, Hong  JS,  et al.  Effect of dietary supplementation with omega-3 fatty acid and gamma-linolenic acid on acne vulgaris: a randomised, double-blind, controlled trial.   Acta Derm Venereol. 2014;94(5):521-525. doi:10.2340/00015555-1802 PubMedGoogle Scholar
34.
Burris  J, Rietkerk  W, Woolf  K.  Relationships of self-reported dietary factors and perceived acne severity in a cohort of New York young adults.   J Acad Nutr Diet. 2014;114(3):384-392. doi:10.1016/j.jand.2013.11.010 PubMedGoogle Scholar
35.
Ulvestad  M, Bjertness  E, Dalgard  F, Halvorsen  JA.  Acne and dairy products in adolescence: results from a Norwegian longitudinal study.   J Eur Acad Dermatol Venereol. 2017;31(3):530-535. doi:10.1111/jdv.13835 PubMedGoogle Scholar
36.
LaRosa  CL, Quach  KA, Koons  K,  et al.  Consumption of dairy in teenagers with and without acne.   J Am Acad Dermatol. 2016;75(2):318-322. doi:10.1016/j.jaad.2016.04.030 PubMedGoogle Scholar
37.
Hercberg  S, Castetbon  K, Czernichow  S,  et al.  The Nutrinet-Santé Study: a web-based prospective study on the relationship between nutrition and health and determinants of dietary patterns and nutritional status.   BMC Public Health. 2010;10:242. doi:10.1186/1471-2458-10-242 PubMedGoogle Scholar
38.
World Medical Association.  World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects.   JAMA. 2013;310(20):2191-2194. doi:10.1001/jama.2013.281053 PubMedGoogle Scholar
39.
von Elm  E, Altman  DG, Egger  M, Pocock  SJ, Gøtzsche  PC, Vandenbroucke  JP; STROBE Initiative.  The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.   Lancet. 2007;370(9596):1453-1457. doi:10.1016/S0140-6736(07)61602-X PubMedGoogle Scholar
40.
Touvier  M, Kesse-Guyot  E, Méjean  C,  et al.  Comparison between an interactive web-based self-administered 24 h dietary record and an interview by a dietitian for large-scale epidemiological studies.   Br J Nutr. 2011;105(7):1055-1064. doi:10.1017/S0007114510004617 PubMedGoogle Scholar
41.
Lassale  C, Castetbon  K, Laporte  F,  et al.  Validation of a Web-based, self-administered, non-consecutive-day dietary record tool against urinary biomarkers.   Br J Nutr. 2015;113(6):953-962. doi:10.1017/S0007114515000057 PubMedGoogle Scholar
42.
Lassale  C, Castetbon  K, Laporte  F,  et al.  Correlations between fruit, vegetables, fish, vitamins, and fatty acids estimated by web-based nonconsecutived dietary records and respective biomarkers of nutritional status.   J Acad Nutr Diet. 2016;116(3):427-438.e5. doi:10.1016/j.jand.2015.09.017 PubMedGoogle Scholar
43.
Le Moullec  N, Deheeger  M, Preziosi  P,  et al.  Validation du manuel-photos utilisé pour l’enquête alimentaire de l’étude SU.VI.MAX. Validation of the photography manual of servings used in dietary collection in the SU.VI.MAX study.   Cah Nutr Diét. 1996;31:158-164.Google Scholar
44.
Vergnaud  A-C, Touvier  M, Méjean  C,  et al.  Agreement between web-based and paper versions of a socio-demographic questionnaire in the NutriNet-Santé study.   Int J Public Health. 2011;56(4):407-417. doi:10.1007/s00038-011-0257-5 PubMedGoogle Scholar
45.
Touvier  M, Méjean  C, Kesse-Guyot  E,  et al.  Comparison between web-based and paper versions of a self-administered anthropometric questionnaire.   Eur J Epidemiol. 2010;25(5):287-296. doi:10.1007/s10654-010-9433-9 PubMedGoogle Scholar
46.
Lassale  C, Péneau  S, Touvier  M,  et al.  Validity of web-based self-reported weight and height: results of the Nutrinet-Santé study.   J Med Internet Res. 2013;15(8):e152. doi:10.2196/jmir.2575 PubMedGoogle Scholar
47.
Craig  CL, Marshall  AL, Sjöström  M,  et al.  International physical activity questionnaire: 12-country reliability and validity.   Med Sci Sports Exerc. 2003;35(8):1381-1395. doi:10.1249/01.MSS.0000078924.61453.FB PubMedGoogle Scholar
48.
Spencer  EH, Ferdowsian  HR, Barnard  ND.  Diet and acne: a review of the evidence.   Int J Dermatol. 2009;48(4):339-347. doi:10.1111/j.1365-4632.2009.04002.x PubMedGoogle Scholar
49.
Cordain  L, Lindeberg  S, Hurtado  M, Hill  K, Eaton  SB, Brand-Miller  J.  Acne vulgaris: a disease of Western civilization.   Arch Dermatol. 2002;138(12):1584-1590. doi:10.1001/archderm.138.12.1584 PubMedGoogle Scholar
50.
Millward  DJ, Layman  DK, Tomé  D, Schaafsma  G.  Protein quality assessment: impact of expanding understanding of protein and amino acid needs for optimal health.   Am J Clin Nutr. 2008;87(5):1576S-1581S. doi:10.1093/ajcn/87.5.1576S PubMedGoogle Scholar
51.
Nicklin  P, Bergman  P, Zhang  B,  et al.  Bidirectional transport of amino acids regulates mTOR and autophagy.   Cell. 2009;136(3):521-534. doi:10.1016/j.cell.2008.11.044 PubMedGoogle Scholar
52.
Zhenyukh  O, Civantos  E, Ruiz-Ortega  M,  et al.  High concentration of branched-chain amino acids promotes oxidative stress, inflammation and migration of human peripheral blood mononuclear cells via mTORC1 activation.   Free Radic Biol Med. 2017;104:165-177. doi:10.1016/j.freeradbiomed.2017.01.009 PubMedGoogle Scholar
53.
Aizawa  H, Niimura  M.  Elevated serum insulin-like growth factor-1 (IGF-1) levels in women with postadolescent acne.   J Dermatol. 1995;22(4):249-252. doi:10.1111/j.1346-8138.1995.tb03381.x PubMedGoogle Scholar
54.
Francis  GL, Upton  FM, Ballard  FJ, McNeil  KA, Wallace  JC.  Insulin-like growth factors 1 and 2 in bovine colostrum: sequences and biological activities compared with those of a potent truncated form.   Biochem J. 1988;251(1):95-103. doi:10.1042/bj2510095 PubMedGoogle Scholar
55.
Melnik  B.  Milk consumption: aggravating factor of acne and promoter of chronic diseases of Western societies.   J Dtsch Dermatol Ges. 2009;7(4):364-370. doi:10.1111/j.1610-0387.2009.07019.x PubMedGoogle Scholar
56.
Costa  A, Lage  D, Moisés  TA.  Acne and diet: truth or myth?   An Bras Dermatol. 2010;85(3):346-353. doi:10.1590/S0365-05962010000300008 PubMedGoogle Scholar
57.
Melnik  BC. Evidence for acne-promoting effects of milk and other insulinotropic dairy products. In: Clemens  RA, Hernell  O, Michaelsen  KF, eds.  Nestlé Nutrition Institute Workshop Series: Pediatric Program. Vol 67. Karger; 2011:131-145. doi:10.1159/000325580
58.
Ben-Amitai  D, Laron  Z.  Effect of insulin-like growth factor-1 deficiency or administration on the occurrence of acne.   J Eur Acad Dermatol Venereol. 2011;25(8):950-954. doi:10.1111/j.1468-3083.2010.03896.x PubMedGoogle Scholar
59.
Guevara-Aguirre  J, Balasubramanian  P, Guevara-Aguirre  M,  et al.  Growth hormone receptor deficiency is associated with a major reduction in pro-aging signaling, cancer, and diabetes in humans.   Sci Transl Med. 2011;3(70):70ra13. doi:10.1126/scitranslmed.3001845 PubMedGoogle Scholar
60.
Berra  B, Rizzo  AM.  Glycemic index, glycemic load: new evidence for a link with acne.   J Am Coll Nutr. 2009;28(suppl):450S-454S. doi:10.1080/07315724.2009.10718111 PubMedGoogle Scholar
61.
Aghasi  M, Golzarand  M, Shab-Bidar  S, Aminianfar  A, Omidian  M, Taheri  F.  Dairy intake and acne development: a meta-analysis of observational studies.   Clin Nutr. 2019;38(3):1067-1075. doi:10.1016/j.clnu.2018.04.015 PubMedGoogle Scholar
62.
Fassier  P, Zelek  L, Lécuyer  L,  et al.  Modifications in dietary and alcohol intakes between before and after cancer diagnosis: results from the prospective population-based NutriNet-Santé cohort.   Int J Cancer. 2017;141(3):457-470. doi:10.1002/ijc.30704 PubMedGoogle Scholar
63.
Andreeva  VA, Deschamps  V, Salanave  B,  et al.  Comparison of dietary intakes between a large online cohort study (Etude NutriNet-Santé) and a nationally representative cross-sectional study (Etude Nationale Nutrition Santé) in France: addressing the issue of generalizability in E-epidemiology.   Am J Epidemiol. 2016;184(9):660-669. doi:10.1093/aje/kww016 PubMedGoogle Scholar
64.
Méjean  C, Si Hassen  W, Gojard  S,  et al.  Social disparities in food preparation behaviours: a DEDIPAC study.   Nutr J. 2017;16(1):62. doi:10.1186/s12937-017-0281-2 PubMedGoogle Scholar
65.
Rosenfield  RL.  What every physician should know about polycystic ovary syndrome.   Dermatol Ther. 2008;21(5):354-361. doi:10.1111/j.1529-8019.2008.00217.x PubMedGoogle Scholar
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    1 Comment for this article
    EXPAND ALL
    Request for Comment on Potential Confounders
    Nicolette Gonzales, MD and MPH Candidate | George Washington University: Milken Institute of Public Health
    Confirmation of the association between diet and acne is sought out by many, and with conflicting studies, it becomes murky. Several confounding factors have been controlled for and it appears the participants go through somewhat extensive questionnaires, with the number of uncompensated steps required in participation in this study, what is the impact, if any, of self-selection bias on the study. Also, what, if any, controls have been put in place to mitigate the effect of self-selected participants?
    Mentioned within the study limitations portion of this study is the possibility for incorrect self-diagnosis of acne, would this same phenomenon possibly
    impact any of the 11-question medical history survey questions? It does not appear the administered surveys are available for viewing.
    Next, it seems age at menarche, pregnancy, and menopause are taken into account to assess any hormone-related factors. However, it is not mentioned if whether the participant utilizes an oral or topical hormone-based therapy such as contraceptives. If this was assessed, does use of exogenous hormones also prove to have little influence over acne? Some oral contraceptives, such as Yaz (drospirenone/ethinyl estradiol), have been FDA approved to treat acne. Spirinolactone, a common diretic, can also impact endogenous hormones (Al-Natour, 2017) If any of the female participants were taking such a therapy, was this taken into account as a confounder of acne?
    Along the same vein, and possibly noted within the medical history questionnaire, was there any consideration for any affect oral anti-inflammatories could have on acne, such as any tetracyclines like doxycycline or minocycline (Rosso, 2015). While not always prescribed for acne, it could reduce breakouts if prescribed for other reasons such as infection. Would prescriptions like this be required to be reported for the study?
    Also, would use of any past drugs be reported in the study such as isotretinoin which reportedly “cures” acne in around half of those who take it (Azoulay, Oraichi, Berard, 2007)? A participant who may report positive for past acne but negative for acne currently, could be adhering to a high glycemic diet and not experience breakouts to the degree of their peers due to past adherence to an isotretinoin treatment. There are also topical treatments for acne which did not appear to be reported or described. It is not clear whether participants are to adhere to similar cleansing habits and whether this would have an effect.
    Lastly, in regard to hygiene, was there any consideration for lifestyle differences such as differences in sleep hygiene, picking of lesions, or number of times the participant touches their face. Spreading of Propionibacterium acnes through poor hygiene could contribute to prolonged breakouts and may mask an effectiveness (or ineffectiveness) of the participants diet (Dreno, 2018).

    Al-Natour, S. H. (2017). Acne Vulgaris: Perceptions and Beliefs of Saudi Adolescent Males. Journal of Family & Community Medicine, 24(1), 34.
    Azoulay, L., Oraichi, D., & Bérard, A. (2007). Isotretinoin Therapy and the Incidence of Acne Relapse: A Nested Case–Control Study. British Journal of Dermatology, 157(6), 1240-1248.
    Del Rosso, J. Q. (2015). Oral Doxycycline in The Management of Acne Vulgaris: Current Perspectives on Clinical Use and Recent Findings with a New Double-Scored Small Tablet Formulation. The Journal of Clinical and Aesthetic Dermatology, 8(5), 19.
    Dreno, B., Bagatin, E., Blume‐Peytavi, U., Rocha, M., & Gollnick, H. (2018). Female Type of Adult Acne: Physiological
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Views 14,443
    Citations 0
    Original Investigation
    June 10, 2020

    Association Between Adult Acne and Dietary Behaviors: Findings From the NutriNet-Santé Prospective Cohort Study

    Author Affiliations
    • 1Paris 13 University, Institut National de la Santé et de la Recherche Médicale, Institut National de la Recherche Agronomique, Conservatoire National Des Arts et Métiers, Nutritional Epidemiology Research Team, Epidemiology and Statistics Research Centre, University of Paris, F-93022 Bobigny, France
    • 2Epidemiology in Dermatology and Evaluation of Therapeutics, EA7379, Paris-Est University, Paris Est Créteil University, Département Infectieux/Immuno/Vaccin, F-94000 Créteil, France
    • 3Department of Dermatology, Mondor Hospital (Assistance Publique, Hôpitaux de Paris), Paris Est Créteil University, F-94000 Créteil, France
    • 4Clinical Investigation Center 1430, Institut National de la Santé et de la Recherche Médicale, F-94000 Créteil, France
    JAMA Dermatol. Published online June 10, 2020. doi:10.1001/jamadermatol.2020.1602
    Key Points

    Question  Is dietary behavior associated with acne in adults?

    Findings  In this cross-sectional study of 24 452 participants in the French NutriNet-Santé study, the consumption of fatty and sugary products, sugary beverages, and milk was associated with current acne in adults. This association was noted after adjustment for sociodemographic variables and confounding factors, including daily energy intake, the number of dietary records completed, and depressive symptoms.

    Meaning  These findings suggest that a Western diet (ie, rich in animal products and fatty and sugary foods) is associated with the presence of acne in adults.

    Abstract

    Importance  Acne is a chronic, multifactorial inflammatory disease. The association between consumption of dairy products and fatty and sugary foods and occurrence and progression of acne remains unclear.

    Objective  To assess the association between dietary behavior and current acne in adults.

    Design, Setting, and Participants  A cross-sectional study was performed as part of the NutriNet-Santé study, which is an ongoing observational, web-based cohort study that was launched in France in May 2009. The present study was conducted from November 14, 2018, to July 8, 2019. A total of 24 452 participants completed an online self-questionnaire to categorize their acne status: never acne, past acne, or current acne. Associations between dietary behavior (food intake, nutrient intake, and the dietary pattern derived from a principal component analysis) and current or past acne were studied in multinomial logistic regression models adjusted for potential confounding variables (age, sex, physical activity, smoking status, educational level, daily energy intake, number of dietary records completed, and depressive symptoms).

    Results  The 24 452 participants (mean [SD] age, 57 [14] years; 18 327 women [75%]) completed at least 3 dietary records. Of these, 11 324 individuals (46%) reported past or current acne. After adjustment, there was a significant association between current acne and the consumption of fatty and sugary products (adjusted odds ratio [aOR], 1.54; 95% CI, 1.09-2.16), sugary beverages (aOR, 1.18; 95% CI, 1.01-1.38), and milk (aOR, 1.12; 95% CI, 1.00-1.25). An energy-dense dietary pattern (high consumption of fatty and sugary products) was associated with current acne (aOR, 1.13; 95% CI, 1.05-1.18).

    Conclusions and Relevance  In this study, consumption of milk, sugary beverages, and fatty and sugary products appeared to be associated with current acne in adults. Further large-scale studies are warranted to investigate more closely the associations between diet and adult acne.

    Introduction

    Acne has been reported to be the most common chronic inflammatory skin disease worldwide,1-3 occurring mostly in the 15- to 17-year age group.4-6 Epidemiologic data from Western countries suggest that the prevalence of acne in adults older than 25 years is approximately 50%, with female predominance.7-10 In this so-called adult acne group, there are 2 distinct populations: patients who developed acne during adolescence and have persistent acne and those who developed de novo acne during adulthood.

    Adult acne has various consequences; one of these is psychological harm associated with low self-esteem, poor perception of one’s body, social isolation, and depressive symptoms.11,12 Acne is reported to have the same emotional, social, and psychological consequences as chronic diseases, such as asthma, arthrosis, epilepsy, and diabetes.13

    Acne appears to be a multifactorial disease in which both genetic and environmental factors have pivotal roles. Endocrine disorders and genetic predispositions can lead to the development of acne; in addition, cosmetic products, tobacco use, stress, exposure to pollution, and dietary behavior may be associated with the development and severity of acne.14-19

    People with acne have been reported to believe that consumption of foods affects their condition. Although chocolate, fatty foods, and milk are frequently thought to be responsible,20,21 data on the role of nutrition in acne are scarce. It has been hypothesized that a glycemic diet22,23 or the consumption of dairy products (particularly milk)24-28 is associated with the pathophysiologic mechanism of acne via androgens and insulinlike growth factor-1 (IGF-1).29-32 However, published studies presented several limitations. Randomized trials could not investigate multiple food exposition within the same time period and might be limited by a small population sample.22,33,34 Observational studies frequently focus on teenage acne24,35 and are based on frequency questionnaires17,24,35 for previous food exposure, which lead to both a lack of precision in food records and a recall bias without taking into account various potential confounding factors, such as depression, energy intake (kilocalories per joule), and smoking.23,24,36

    Thus, the objective of the present study was to assess the association between dietary behavior and current acne using a large cohort of French adults with accurate and timely dietary intake data.

    Methods
    Study Population and Design

    The present study was performed as part of the NutriNet-Santé study. This ongoing, observational, web-based cohort study of adults was initiated in France in May 2009. Participants are extensively phenotyped via questionnaires on the dedicated NutriNet-Santé website (https://www.etude-nutrinet-sante.fr/). Details of the NutriNet-Santé study’s rationale, design, and procedures have been published elsewhere37 (eMethods in the Supplement). The NutriNet-Santé study is conducted according to the tenets of the Declaration of Helsinki.38 It was approved by the French Institute for Health and Medical Research’s institutional review board; the present study is included in that approval. All participants provided electronic informed consent; data are deidentified. Participants do not receive financial compensation. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cross-sectional studies.39

    Case Ascertainment and Data Collection

    A specific, optional questionnaire on acne was developed for the purposes of the present study and was distributed to NutriNet-Santé participants on November 14, 2018 (eTable 1 in the Supplement). The present study was conducted from November 14, 2018, to July 8, 2019. The questionnaire comprised 11 items related to the occurrence and diagnosis of acne and the participant’s medical history; this information enabled us to determine whether the participant reportedly had acne at the present time and/or in the past. All participants who answered the questionnaire were eligible for the study. Each participant’s acne status was classified as never acne, past acne (ie, acne at some time in their life but not at present), or current acne.

    The participants’ usual dietary intake was assessed at baseline and every 6 months after enrollment via a series of 3 nonconsecutive, validated, 24-hour dietary records40-42 randomly assigned over a 2-week period (on 2 weekdays and 1 weekend day). In these records, participants were instructed to report all foods and beverages consumed from midnight to midnight. Participants estimated portion sizes from validated photographs,43 using standard containers, or directly in grams or liters. Participants who provided at least 3 dietary records were included in this study. More details about dietary records are shown in the eFigure in the Supplement.

    For each participant, we calculated the mean intakes across all dietary records of each food group (in grams per day: fruit, vegetables, meat, fish, milk, dark chocolate, milk chocolate, refined cereals, snacks and fast foods, and fatty and sugary products) and each type of nutrient (in milligrams or grams per day: vitamins, zinc, fibers, carbohydrates, lipids, proteins, and saturated fatty acids) using the published NutriNet-Santé food composition database.37 The latter database currently comprises nutritional values (eg, energy, alcohol, macronutrient, and micronutrient contents) for more than 3500 food items.

    At baseline, participants were invited to complete questionnaires related to sociodemographic characteristics (eg, sex and educational level),44 anthropometric data (eg, weight and height),45,46 lifestyle (eg, smoking status and alcohol use), physical activity (assessed using the International Physical Activity Questionnaire),47 health status (eg, any history and diagnosis of cardiovascular diseases, diabetes, and cancer), and, for women, reproductive health (age at menarche, pregnancy, and menopause). Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale; a score greater than or equal to 16 corresponds to the presence of depressive symptoms.

    Statistical Analysis

    Qualitative variables are reported as the number (percentage) of participants. Food consumption and nutrient intakes were considered as continuous variables. In light of the literature results, we chose to assess 12 different food groups: fruit, vegetables, meats, fish, milk, sugary beverages, dark chocolate, milk chocolate, refined cereals, snacks and fast foods, fatty and sugary products, and delicatessen meats.17,20,24,48 The following variables were considered in classes: age (in 4 classes); body mass index (BMI), calculated as weight in kilograms divided by height in meters squared (3 classes); educational status (3 classes); smoking status (3 classes); physical activity (3 classes); sex (male or female); and medical history (presence or absence).

    The characteristics of participants in the current acne and past acne vs never acne groups were compared using an unadjusted χ2 test for qualitative variables or the Kruskal-Wallis test for quantitative variables. The strength of correlations between pairs of food intakes was determined by calculating Pearson coefficient r values; food intakes with r<0.80 were included in a multinomial analysis. Multinomial logistic regressions were performed to assess the association between food intakes and past (lifetime) acne or current adult acne; the results are expressed as the adjusted odds ratio (aOR) (95% CI) vs never acne. After using a backward selection, the regressions were adjusted for energy intake, the number of dietary records completed, sex, age, smoking status, physical activity, educational level, and depressive symptoms. Adjustments for BMI and a history of cardiovascular disease, cancer, type 1 diabetes, or type 2 diabetes were also tested. The same analyses (univariate analyses, Pearson test, and adjusted multinomial logistic regressions) were performed for the various types of nutrients.

    Furthermore, because this was a post hoc analysis, dietary patterns were produced from principal components analysis based on 12 predefined food groups (fruit, vegetables, meat, fish, milk, sugary beverages, dark chocolate, milk chocolate, delicatessen meats, refined cereals, snacks and fast foods, and fatty and sugary products) using the SAS Proc Factor procedure (SAS Institute Inc). This factor analysis forms linear combinations of the original food groups, thereby grouping correlated variables. Coefficients defining these linear combinations are termed factor loadings. A positive factor loading means that the food group is positively associated with the factor, whereas a negative loading reflects an inverse association with the factor. For interpreting the data, we considered foods with a loading coefficient lower than −0.3 or higher than 0.3. We rotated factors by orthogonal transformation, using the SAS Varimax option to maximize the independence (orthogonality) of retained factors and obtain a simpler structure for easier interpretation. In determining the number of factors to retain, we considered eigenvalues greater than 1, the scree test (with values being retained at the break point between components with large eigenvalues and those with small eigenvalues on the scree plot), and the interpretability of the factors. For each participant, we calculated the factor score for each pattern by summing the reported consumption from all food groups weighted by the food group factor loadings. The factor score measures the conformity of an individual’s diet to the given pattern. In addition, the dietary patterns noted in a principal component analysis were assessed in univariate and adjusted multinomial logistic analyses. Owing to a small number of missing values, we used complete-case analyses.

    To limit the influence of hormonal factors linked to acne, we analyzed the subpopulation of women. In addition to the factors considered for the total population, multinomial analyses in women were adjusted for age at menarche, pregnancy, and menopause.

    The threshold for statistical significance was set at P < .05. All analyses were performed with SAS Enterprise Guide software, version 7.1 (SAS Institute Inc).

    Results
    Study Population

    Of the 31 539 individuals who completed the questionnaire, 24 452 (78%) were included in the study because they had (1) completed at least 3 dietary records, (2) reported a normal calorie intake, and (3) reported their acne status (items 1 and 8 from the acne questionnaire reported in eTable 1 in the Supplement). The study population included 18 327 women (75%), and the mean (SD) age was 57 (14) years. A total of 11 324 individuals (46%) indicated that they had acne at the time of the study or in the past; of these, 3576 individuals (32%) believed that diet was a factor in their acne, 3503 individuals (31%) believed that diet was not a factor in their acne, and 4195 individuals (37%) were unsure of whether diet was a factor. Data on comorbidities are summarized in Table 1, and data on the diagnosis of acne, age at onset, age at resolution, and treatments are summarized in eTable 2 in the Supplement.

    There were 13 128 participants (54%) in the never acne group, 9562 participants (39%) in the past acne group, and 1762 participants (7%) in the current acne group. Compared with the never acne and past acne groups, participants in the current acne group were younger (eg, 25-39 years: never, 9%; past, 17%; and current, 48%); had a higher educational level (never, 60%; past, 72%; and current, 78%); had a higher proportion of smokers (never, 12%; past, 12%; and current, 16%); had a lower level of physical activity (never, 20%; past, 23%; and current, 27%); had a lower BMI (<25: never, 66%; past, 70%; and current, 75%); had a lower frequency of cardiovascular disease (never, 18%; past, 14%; and current, 9%), type 2 diabetes (never, 2%; past, 1%; and current, 0.4%), and cancer (never, 7%; past, 6%; and current, 2%); and had a higher frequency of depressive symptoms (never, 16%; past, 17%; and current, 23%) (Table 1).

    The Role of Diet

    The results of the unadjusted and multiadjusted analyses of associations between food intakes and the presence of acne are summarized in Table 2. Unadjusted univariate analyses showed that, compared with participants in the never acne group, participants with current acne consumed significantly more milk (OR, 1.28; 95% CI, 1.18-1.39), sugary beverages (OR, 2.19; 95% CI, 1.94-2.48), milk chocolate (OR, 1.28; 95% CI, 1.19-1.38), snacks and fast foods (OR, 3.83; 95% CI, 3.34-4.40), and fatty and sugary products (OR, 4.35; 95% CI, 3.50-5.41) and significantly less meat (OR, 0.39; 95% CI, 0.31-0.48), fish (OR, 0.17; 95% CI, 0.13-0.23), vegetables (OR, 0.71; 95% CI, 0.66-0.76), fruit (OR, 0.71; 95% CI, 0.67-0.74), and dark chocolate (OR, 0.90; 95% CI, 0.84-0.96). After testing the correlation between the different pairs of foods, all food groups were included (r<0.4).

    After adjustment, the consumption of milk (per glass, aOR, 1.12; 95% CI, 1.00-1.25; P = .04), sugary beverages (per glass, aOR, 1.18; 95% CI, 1.01-1.38; P = .04), and fatty and sugary products (per portion, aOR, 1.54; 95% CI, 1.09-2.16; P = .01) were found to be independently associated with current acne. Results were aOR, 1.76 (95% CI, 1.00-3.05) for 5 glasses of milk (1 L); aOR, 2.29 (95% CI, 1.05-5.00) for 5 glasses of sugary beverages (1 L), and aOR, 8.38 (95% CI, 1.54-47.02) for a complete meal of fatty and sugary products.

    The results for nutrient levels were in agreement with the above findings. After adjustment, the carbohydrate intake (aOR, 1.43; 95% CI, 1.06-1.93; P = .02) and the saturated fatty acid intake (aOR, 3.90; 95% CI, 1.02-15.00; P = .048) were found to be independently associated with current acne (Table 3).

    Principal Component Analysis

    Three principal components (interpreted as dietary patterns) accounted for 42% of the total variability. Labeling was descriptive based on foods with the greatest association with the dietary patterns. The healthy pattern (explaining 18% of the variance) was characterized by higher intakes of fruit, vegetables, and fish. The fatty and sugary pattern (explaining 13% of the variance) was characterized by higher intakes of fat and sugary products, including chocolate. The third pattern, which explained 11% of the variance, was referred to as animal products and refined cereals in view of the marked consumption of meat, milk, and refined cereals.

    In an unadjusted analysis, the healthy and animal products and refined cereals dietary patterns were negatively associated with current acne (healthy: OR, 0.55; 95% CI, 0.52-0.57; P < .001; animal products and refined cereals: OR, 0.92; 95% CI, 0.88-0.97; P = .002), whereas the fatty and sugary dietary pattern was positively associated (OR, 1.25; 95% CI, 1.20-1.30; P<.001) (eTable 3 in the Supplement). After adjustment, adults with current acne were found to be less likely to have a healthy dietary pattern (aOR, 0.88; 95% CI, 0.83-0.94; P = .001) and more likely to have a fatty and sugary dietary pattern (aOR, 1.13; 95% CI, 1.05-1.18; P < .001) (Table 4).

    Further Analyses

    All 18 327 women in the study population were included in the subgroup analyses. The results appeared to support those of the main analyses (eTable 4 in the Supplement). After adjustment, a regression analysis of the dietary patterns from the principal component analysis showed that the healthy pattern was negatively associated with current adult acne in women (aOR, 0.87; 95% CI, 0.80-0.94; P < .001), whereas the fatty and sugary pattern was positively associated (aOR, 1.12; 95% CI, 1.04-1.21; P = .003) (Table 5). The results of the primary and secondary analyses were the same after adjustment for BMI and a history of cancer, types 1 and 2 diabetes, or cardiovascular disease.

    Discussion

    The results of this study suggest an association between current acne and, after adjustment for confounding variables, the consumption of fatty and sugary products, sugary beverages, and milk. In a principal component analysis, a fatty, energy-rich diet (ie, high consumption of fatty and sugary products) was consistently found to be associated with the presence of adult acne. Similar results were noted in a subgroup analysis of the women in the study population.

    The results of our study appear to support the hypothesis that the Western diet (rich in animal products and fatty and sugary foods) is associated with the presence of acne in adulthood. There are several possible explanations for this association. First, a high glycemic-load diet causes a rise in circulating levels of IGF-149 and insulin, which stimulates mammalian target of rapamycin 1 activity.50,51 In turn, mechanistic target of rapamycin 1 stimulates cell proliferation and inhibits apoptosis, which increases levels of oxidative stress and inflammation, thus promoting the development of acne.50-52 The elevation in IGF-1 levels also stimulates the production of androgens, which are associated with the production of sebum and thus the development of acne.29,31,32,53 The consumption of milk also generates an increase in IGF-1 production by the liver and an increase in circulating insulin levels. Neither IGF-1 nor insulin is fully inactivated by pasteurization, homogenization, and digestion.54-57 Hence, milk consumption has similar consequences as a high glycemic-load meal. A role of IGF-1 in acne is also suggested by observations of patients with Laron syndrome, who do not produce IGF-1 and do not develop acne unless supplemented with this growth factor.55,58,59

    The possible association between diet and development of acne has been investigated worldwide; conflicting results have been obtained (eTable 5 in the Supplement), perhaps because of interstudy differences in design, methods, case definitions, study populations (ie, eating habits and cultures), and end points. However, our present results appear to be in line with data on the glycemic load and exposure to dairy products. For example, a study of 44 acne cases and 44 controls by Ismail et al23 noted that the glycemic load, according to 24-hour dietary records, was higher in the acne group than in the control group. Other studies have also reported an association between a high glycemic load (high carbohydrate consumption) and the presence of acne.22,31,60 Our present results showed an apparent association between milk consumption and current acne, as also reported in the literature.24,27,31,61 For example, Adebamowo et al24-26 noted that the consumption of milk, particularly skimmed milk, was associated with the presence of acne in women after adjustment for age, age at menarche, BMI, and energy intake. Juhl et al27,28 reported the same results for adolescent boys and all adults.

    Strengths and Limitations

    Our study’s strengths included the large sample of adults in the NutriNet-Santé cohort, the large number of variables documented via self-questionnaires, and the accuracy of the food records. Food consumption was evaluated using at least three 24-hour dietary records linked to a large (3500-item) food composition database. The 24-hour dietary records linked to a large food composition database enabled us to take account of intraindividual variability and obtain what appeared to be precise, accurate estimates of usual dietary intakes. Furthermore, it has been reported that 24-hour dietary records obtained on several occasions, as used in the NutriNet-Santé cohort study, are more reliable than frequency questionnaires.62

    One of the study’s main limitations is that, relative to the French general population, the study population was younger, with a higher proportion of women, a higher educational level, and healthier dietary habits.63,64 The low proportion of participants with current acne and the fact that the study population has healthier dietary habits than the French general population might have led us to underestimate the level of the associations.

    Another limitation was the relatively high proportion (33%) of participants having self-diagnosed current acne; this subjective report may have introduced classification bias. Nonetheless, the fact that only the presence of acne was evaluated (ie, not the severity) minimized the risk of incorrect self-diagnosis.

    The association between diet and current acne was consistent after adjustment for known and potential confounding factors, which thus minimized confounding bias. The sensitivity analysis of the subgroup of women enabled us to take hormone-related factors into account. The fact that the study variables were collected, analyzed, and validated in the same way in each of the 3 acne groups is likely to have minimized any differential classification bias. Our database did not include information on polycystic ovary syndrome—a condition known to induce acne in women.65 However, other hormonal factors (eg, age at menarche, pregnancy, and menopause) were taken into account and did not appear to change the results of the main analysis. Thus, temporality in the association found cannot be discussed. Rather, we can only note a possible association with current acne—not with the appearance or development of current acne (adult acne). In that context, we chose an adjusted multinomial regression design rather than a propensity score design. Our findings for participants in the past acne group must be interpreted with caution since these individuals may have changed their dietary habits since the time when they had acne. In addition, our study’s cross-sectional, observational design is not able to determine direct, causal associations between diet and the presence of acne in adulthood.

    Conclusions

    The consumption of fatty and sugary products, sugary beverages, and milk appears to be associated with current acne. Our results may support the hypothesis that the Western diet (rich in animal products and fatty and sugary foods) is associated with the presence of acne in adulthood. Our findings provide data on the prevalence of adult acne; however, further large-scale studies are needed to investigate more closely the association between diet and acne that might be of value in the prevention and management of acne.

    Back to top
    Article Information

    Accepted for Publication: April 18, 2020.

    Corresponding Authors: Emilie Sbidian, MD, PhD, (emilie.sbidian@aphp.fr), and Khaled Ezzedine, MD, PhD (khaled.ezzedine@aphp.fr), Department of Dermatology, Mondor Hospital (Assistance Publique, Hôpitaux de Paris), Paris Est Creteil University, 51 Ave du Maréchal de Lattre de Tassigny, F-94010 Créteil cedex, France.

    Published Online: June 10, 2020. doi:10.1001/jamadermatol.2020.1602

    Author Contributions: Ms Penso had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Touvier, Ezzedine, Sbidian.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: Penso, Sbidian.

    Critical revision of the manuscript for important intellectual content: Touvier, Deschasaux, Szabo de edelenyi, Hercberg, Ezzedine, Sbidian.

    Statistical analysis: Penso.

    Obtained funding: Touvier.

    Administrative, technical, or material support: Szabo de edelenyi, Hercberg.

    Supervision: Touvier, Hercberg, Ezzedine, Sbidian.

    Conflict of Interest Disclosures: None reported.

    Additional Contributions: Technical contributions to the NutriNet-Santé study were provided by Younes Esseddik, MSc, Thi Hong Van Duong, MSc, Régis Gatibelza, MSc, Jagatjit Mohinder, MSc, and Aladi Timera, MSc (computer scientists); Cédric Agaesse, MSc (dietitian); Fabien Szabo de Edelenyi, PhD, Nathalie Arnault, MSc, Julien Allegre, MSc, and Laurent Bourhis, MSc (data manager/statisticians); Fatoumata Diallo, MD, and Roland Andrianasolo, MD; and Nathalie Druesne-Pecollo, MSc (operational coordinator). We thank all of the volunteers in the NutriNet-Santé cohort for their participation. David Fraser reviewed the manuscript.

    References
    1.
    Degitz  K, Placzek  M, Borelli  C, Plewig  G.  Pathophysiology of acne.   J Dtsch Dermatol Ges. 2007;5(4):316-323. doi:10.1111/j.1610-0387.2007.06274.x PubMedGoogle Scholar
    2.
    Gollnick  HP, Zouboulis  CC.  Not all acne is acne vulgaris.   Dtsch Arztebl Int. 2014;111(17):301-312.PubMedGoogle Scholar
    3.
    Hay  RJ, Johns  NE, Williams  HC,  et al.  The global burden of skin disease in 2010: an analysis of the prevalence and impact of skin conditions.   J Invest Dermatol. 2014;134(6):1527-1534. doi:10.1038/jid.2013.446 PubMedGoogle Scholar
    4.
    Rademaker  M, Garioch  JJ, Simpson  NB.  Acne in schoolchildren: no longer a concern for dermatologists.   BMJ. 1989;298(6682):1217-1219. doi:10.1136/bmj.298.6682.1217 PubMedGoogle Scholar
    5.
    Kilkenny  M, Merlin  K, Plunkett  A, Marks  R.  The prevalence of common skin conditions in Australian school students: 3; acne vulgaris.   Br J Dermatol. 1998;139(5):840-845. doi:10.1046/j.1365-2133.1998.02510.x PubMedGoogle Scholar
    6.
    Perkins  AC, Cheng  CE, Hillebrand  GG, Miyamoto  K, Kimball  AB.  Comparison of the epidemiology of acne vulgaris among Caucasian, Asian, Continental Indian and African American women.   J Eur Acad Dermatol Venereol. 2011;25(9):1054-1060. doi:10.1111/j.1468-3083.2010.03919.x PubMedGoogle Scholar
    7.
    Cunliffe  WJ, Gould  DJ.  Prevalence of facial acne vulgaris in late adolescence and in adults.   BMJ. 1979;1(6171):1109-1110. doi:10.1136/bmj.1.6171.1109 PubMedGoogle Scholar
    8.
    Goulden  V, Stables  GI, Cunliffe  WJ.  Prevalence of facial acne in adults.   J Am Acad Dermatol. 1999;41(4):577-580.PubMedGoogle Scholar
    9.
    Collier  CN, Harper  JC, Cafardi  JA,  et al.  The prevalence of acne in adults 20 years and older [published correction appears in J Am Acad Dermatol. 2008 May;58(5):874. Cafardi, Jennifer A [added]].   J Am Acad Dermatol. 2008;58(1):56-59. doi:10.1016/j.jaad.2007.06.045PubMedGoogle Scholar
    10.
    Semedo  D, Ladeiro  F, Ruivo  M,  et al.  Adult acne: prevalence and portrayal in primary healthcare patients, in the Greater Porto Area, Portugal.   Acta Med Port. 2016;29(9):507-513. doi:10.20344/amp.6626 PubMedGoogle Scholar
    11.
    Tan  JK.  Psychosocial impact of acne vulgaris: evaluating the evidence.   Skin Therapy Lett. 2004;9(7):1-3, 9.PubMedGoogle Scholar
    12.
    Hull  PR, D’Arcy  C.  Acne, depression, and suicide.   Dermatol Clin. 2005;23(4):665-674. doi:10.1016/j.det.2005.05.008 PubMedGoogle Scholar
    13.
    Mallon  E, Newton  JN, Klassen  A, Stewart-Brown  SL, Ryan  TJ, Finlay  AY.  The quality of life in acne: a comparison with general medical conditions using generic questionnaires.   Br J Dermatol. 1999;140(4):672-676. doi:10.1046/j.1365-2133.1999.02768.x PubMedGoogle Scholar
    14.
    Di Landro  A, Cazzaniga  S, Parazzini  F,  et al; GISED Acne Study Group.  Family history, body mass index, selected dietary factors, menstrual history, and risk of moderate to severe acne in adolescents and young adults.   J Am Acad Dermatol. 2012;67(6):1129-1135. doi:10.1016/j.jaad.2012.02.018 PubMedGoogle Scholar
    15.
    Navarini  AA, Simpson  MA, Weale  M,  et al; Acne Genetic Study Group.  Genome-wide association study identifies three novel susceptibility loci for severe acne vulgaris.   Nat Commun. 2014;5:4020. doi:10.1038/ncomms5020 PubMedGoogle Scholar
    16.
    Lefebvre  MA, Pham  DM, Boussouira  B, Bernard  D, Camus  C, Nguyen  QL.  Evaluation of the impact of urban pollution on the quality of skin: a multicentre study in Mexico.   Int J Cosmet Sci. 2015;37(3):329-338. doi:10.1111/ics.12203 PubMedGoogle Scholar
    17.
    Wolkenstein  P, Misery  L, Amici  JM,  et al.  Smoking and dietary factors associated with moderate-to-severe acne in French adolescents and young adults: results of a survey using a representative sample.   Dermatology. 2015;230(1):34-39. doi:10.1159/000366195 PubMedGoogle Scholar
    18.
    Krutmann  J, Moyal  D, Liu  W,  et al.  Pollution and acne: is there a link?   Clin Cosmet Investig Dermatol. 2017;10:199-204. doi:10.2147/CCID.S131323 PubMedGoogle Scholar
    19.
    Stewart  TJ, Bazergy  C.  Hormonal and dietary factors in acne vulgaris versus controls.   Dermatoendocrinol. 2018;10(1):e1442160. doi:10.1080/19381980.2018.1442160 PubMedGoogle Scholar
    20.
    Tan  JKL, Vasey  K, Fung  KY.  Beliefs and perceptions of patients with acne.   J Am Acad Dermatol. 2001;44(3):439-445. doi:10.1067/mjd.2001.111340 PubMedGoogle Scholar
    21.
    El-Akawi  Z, Abdel-Latif Nemr  N, Abdul-Razzak  K, Al-Aboosi  M.  Factors believed by Jordanian acne patients to affect their acne condition.   East Mediterr Health J. 2006;12(6):840-846.PubMedGoogle Scholar
    22.
    Smith  RN, Mann  NJ, Braue  A, Mäkeläinen  H, Varigos  GA.  A low-glycemic-load diet improves symptoms in acne vulgaris patients: a randomized controlled trial.   Am J Clin Nutr. 2007;86(1):107-115. doi:10.1093/ajcn/86.1.107 PubMedGoogle Scholar
    23.
    Ismail  NH, Manaf  ZA, Azizan  NZ.  High glycemic load diet, milk and ice cream consumption are related to acne vulgaris in Malaysian young adults: a case control study.   BMC Dermatol. 2012;12:13. doi:10.1186/1471-5945-12-13 PubMedGoogle Scholar
    24.
    Adebamowo  CA, Spiegelman  D, Danby  FW, Frazier  AL, Willett  WC, Holmes  MD.  High school dietary dairy intake and teenage acne.   J Am Acad Dermatol. 2005;52(2):207-214. doi:10.1016/j.jaad.2004.08.007 PubMedGoogle Scholar
    25.
    Adebamowo  CA, Spiegelman  D, Berkey  CS,  et al.  Milk consumption and acne in adolescent girls.   Dermatol Online J. 2006;12(4):1.PubMedGoogle Scholar
    26.
    Adebamowo  CA, Spiegelman  D, Berkey  CS,  et al.  Milk consumption and acne in teenaged boys.   J Am Acad Dermatol. 2008;58(5):787-793. doi:10.1016/j.jaad.2007.08.049 PubMedGoogle Scholar
    27.
    Juhl  CR, Bergholdt  HKM, Miller  IM, Jemec  GBE, Kanters  JK, Ellervik  C.  Dairy intake and acne vulgaris: a systematic review and meta-analysis of 78,529 children, adolescents, and young adults.   Nutrients. 2018;10(8):E1049. doi:10.3390/nu10081049 PubMedGoogle Scholar
    28.
    Juhl  CR, Bergholdt  HKM, Miller  IM, Jemec  GBE, Kanters  JK, Ellervik  C.  Lactase persistence, milk intake, and adult acne: a mendelian randomization study of 20,416 Danish adults.   Nutrients. 2018;10(8):1041. doi:10.3390/nu10081041 PubMedGoogle Scholar
    29.
    Tasli  L, Turgut  S, Kacar  N,  et al.  Insulin-like growth factor-I gene polymorphism in acne vulgaris.   J Eur Acad Dermatol Venereol. 2013;27(2):254-257. doi:10.1111/j.1468-3083.2011.04299.x PubMedGoogle Scholar
    30.
    Mirdamadi  Y, Thielitz  A, Wiede  A,  et al.  Insulin and insulin-like growth factor-1 can modulate the phosphoinositide-3-kinase/Akt/FoxO1 pathway in SZ95 sebocytes in vitro.   Mol Cell Endocrinol. 2015;415:32-44. doi:10.1016/j.mce.2015.08.001 PubMedGoogle Scholar
    31.
    Çerman  AA, Aktaş  E, Altunay  İK, Arıcı  JE, Tulunay  A, Ozturk  FY.  Dietary glycemic factors, insulin resistance, and adiponectin levels in acne vulgaris.   J Am Acad Dermatol. 2016;75(1):155-162. doi:10.1016/j.jaad.2016.02.1220 PubMedGoogle Scholar
    32.
    Rahaman  SMA, De  D, Handa  S,  et al.  Association of insulin-like growth factor (IGF)-1 gene polymorphisms with plasma levels of IGF-1 and acne severity.   J Am Acad Dermatol. 2016;75(4):768-773. doi:10.1016/j.jaad.2016.05.019 PubMedGoogle Scholar
    33.
    Jung  JY, Kwon  HH, Hong  JS,  et al.  Effect of dietary supplementation with omega-3 fatty acid and gamma-linolenic acid on acne vulgaris: a randomised, double-blind, controlled trial.   Acta Derm Venereol. 2014;94(5):521-525. doi:10.2340/00015555-1802 PubMedGoogle Scholar
    34.
    Burris  J, Rietkerk  W, Woolf  K.  Relationships of self-reported dietary factors and perceived acne severity in a cohort of New York young adults.   J Acad Nutr Diet. 2014;114(3):384-392. doi:10.1016/j.jand.2013.11.010 PubMedGoogle Scholar
    35.
    Ulvestad  M, Bjertness  E, Dalgard  F, Halvorsen  JA.  Acne and dairy products in adolescence: results from a Norwegian longitudinal study.   J Eur Acad Dermatol Venereol. 2017;31(3):530-535. doi:10.1111/jdv.13835 PubMedGoogle Scholar
    36.
    LaRosa  CL, Quach  KA, Koons  K,  et al.  Consumption of dairy in teenagers with and without acne.   J Am Acad Dermatol. 2016;75(2):318-322. doi:10.1016/j.jaad.2016.04.030 PubMedGoogle Scholar
    37.
    Hercberg  S, Castetbon  K, Czernichow  S,  et al.  The Nutrinet-Santé Study: a web-based prospective study on the relationship between nutrition and health and determinants of dietary patterns and nutritional status.   BMC Public Health. 2010;10:242. doi:10.1186/1471-2458-10-242 PubMedGoogle Scholar
    38.
    World Medical Association.  World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects.   JAMA. 2013;310(20):2191-2194. doi:10.1001/jama.2013.281053 PubMedGoogle Scholar
    39.
    von Elm  E, Altman  DG, Egger  M, Pocock  SJ, Gøtzsche  PC, Vandenbroucke  JP; STROBE Initiative.  The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.   Lancet. 2007;370(9596):1453-1457. doi:10.1016/S0140-6736(07)61602-X PubMedGoogle Scholar
    40.
    Touvier  M, Kesse-Guyot  E, Méjean  C,  et al.  Comparison between an interactive web-based self-administered 24 h dietary record and an interview by a dietitian for large-scale epidemiological studies.   Br J Nutr. 2011;105(7):1055-1064. doi:10.1017/S0007114510004617 PubMedGoogle Scholar
    41.
    Lassale  C, Castetbon  K, Laporte  F,  et al.  Validation of a Web-based, self-administered, non-consecutive-day dietary record tool against urinary biomarkers.   Br J Nutr. 2015;113(6):953-962. doi:10.1017/S0007114515000057 PubMedGoogle Scholar
    42.
    Lassale  C, Castetbon  K, Laporte  F,  et al.  Correlations between fruit, vegetables, fish, vitamins, and fatty acids estimated by web-based nonconsecutived dietary records and respective biomarkers of nutritional status.   J Acad Nutr Diet. 2016;116(3):427-438.e5. doi:10.1016/j.jand.2015.09.017 PubMedGoogle Scholar
    43.
    Le Moullec  N, Deheeger  M, Preziosi  P,  et al.  Validation du manuel-photos utilisé pour l’enquête alimentaire de l’étude SU.VI.MAX. Validation of the photography manual of servings used in dietary collection in the SU.VI.MAX study.   Cah Nutr Diét. 1996;31:158-164.Google Scholar
    44.
    Vergnaud  A-C, Touvier  M, Méjean  C,  et al.  Agreement between web-based and paper versions of a socio-demographic questionnaire in the NutriNet-Santé study.   Int J Public Health. 2011;56(4):407-417. doi:10.1007/s00038-011-0257-5 PubMedGoogle Scholar
    45.
    Touvier  M, Méjean  C, Kesse-Guyot  E,  et al.  Comparison between web-based and paper versions of a self-administered anthropometric questionnaire.   Eur J Epidemiol. 2010;25(5):287-296. doi:10.1007/s10654-010-9433-9 PubMedGoogle Scholar
    46.
    Lassale  C, Péneau  S, Touvier  M,  et al.  Validity of web-based self-reported weight and height: results of the Nutrinet-Santé study.   J Med Internet Res. 2013;15(8):e152. doi:10.2196/jmir.2575 PubMedGoogle Scholar
    47.
    Craig  CL, Marshall  AL, Sjöström  M,  et al.  International physical activity questionnaire: 12-country reliability and validity.   Med Sci Sports Exerc. 2003;35(8):1381-1395. doi:10.1249/01.MSS.0000078924.61453.FB PubMedGoogle Scholar
    48.
    Spencer  EH, Ferdowsian  HR, Barnard  ND.  Diet and acne: a review of the evidence.   Int J Dermatol. 2009;48(4):339-347. doi:10.1111/j.1365-4632.2009.04002.x PubMedGoogle Scholar
    49.
    Cordain  L, Lindeberg  S, Hurtado  M, Hill  K, Eaton  SB, Brand-Miller  J.  Acne vulgaris: a disease of Western civilization.   Arch Dermatol. 2002;138(12):1584-1590. doi:10.1001/archderm.138.12.1584 PubMedGoogle Scholar
    50.
    Millward  DJ, Layman  DK, Tomé  D, Schaafsma  G.  Protein quality assessment: impact of expanding understanding of protein and amino acid needs for optimal health.   Am J Clin Nutr. 2008;87(5):1576S-1581S. doi:10.1093/ajcn/87.5.1576S PubMedGoogle Scholar
    51.
    Nicklin  P, Bergman  P, Zhang  B,  et al.  Bidirectional transport of amino acids regulates mTOR and autophagy.   Cell. 2009;136(3):521-534. doi:10.1016/j.cell.2008.11.044 PubMedGoogle Scholar
    52.
    Zhenyukh  O, Civantos  E, Ruiz-Ortega  M,  et al.  High concentration of branched-chain amino acids promotes oxidative stress, inflammation and migration of human peripheral blood mononuclear cells via mTORC1 activation.   Free Radic Biol Med. 2017;104:165-177. doi:10.1016/j.freeradbiomed.2017.01.009 PubMedGoogle Scholar
    53.
    Aizawa  H, Niimura  M.  Elevated serum insulin-like growth factor-1 (IGF-1) levels in women with postadolescent acne.   J Dermatol. 1995;22(4):249-252. doi:10.1111/j.1346-8138.1995.tb03381.x PubMedGoogle Scholar
    54.
    Francis  GL, Upton  FM, Ballard  FJ, McNeil  KA, Wallace  JC.  Insulin-like growth factors 1 and 2 in bovine colostrum: sequences and biological activities compared with those of a potent truncated form.   Biochem J. 1988;251(1):95-103. doi:10.1042/bj2510095 PubMedGoogle Scholar
    55.
    Melnik  B.  Milk consumption: aggravating factor of acne and promoter of chronic diseases of Western societies.   J Dtsch Dermatol Ges. 2009;7(4):364-370. doi:10.1111/j.1610-0387.2009.07019.x PubMedGoogle Scholar
    56.
    Costa  A, Lage  D, Moisés  TA.  Acne and diet: truth or myth?   An Bras Dermatol. 2010;85(3):346-353. doi:10.1590/S0365-05962010000300008 PubMedGoogle Scholar
    57.
    Melnik  BC. Evidence for acne-promoting effects of milk and other insulinotropic dairy products. In: Clemens  RA, Hernell  O, Michaelsen  KF, eds.  Nestlé Nutrition Institute Workshop Series: Pediatric Program. Vol 67. Karger; 2011:131-145. doi:10.1159/000325580
    58.
    Ben-Amitai  D, Laron  Z.  Effect of insulin-like growth factor-1 deficiency or administration on the occurrence of acne.   J Eur Acad Dermatol Venereol. 2011;25(8):950-954. doi:10.1111/j.1468-3083.2010.03896.x PubMedGoogle Scholar
    59.
    Guevara-Aguirre  J, Balasubramanian  P, Guevara-Aguirre  M,  et al.  Growth hormone receptor deficiency is associated with a major reduction in pro-aging signaling, cancer, and diabetes in humans.   Sci Transl Med. 2011;3(70):70ra13. doi:10.1126/scitranslmed.3001845 PubMedGoogle Scholar
    60.
    Berra  B, Rizzo  AM.  Glycemic index, glycemic load: new evidence for a link with acne.   J Am Coll Nutr. 2009;28(suppl):450S-454S. doi:10.1080/07315724.2009.10718111 PubMedGoogle Scholar
    61.
    Aghasi  M, Golzarand  M, Shab-Bidar  S, Aminianfar  A, Omidian  M, Taheri  F.  Dairy intake and acne development: a meta-analysis of observational studies.   Clin Nutr. 2019;38(3):1067-1075. doi:10.1016/j.clnu.2018.04.015 PubMedGoogle Scholar
    62.
    Fassier  P, Zelek  L, Lécuyer  L,  et al.  Modifications in dietary and alcohol intakes between before and after cancer diagnosis: results from the prospective population-based NutriNet-Santé cohort.   Int J Cancer. 2017;141(3):457-470. doi:10.1002/ijc.30704 PubMedGoogle Scholar
    63.
    Andreeva  VA, Deschamps  V, Salanave  B,  et al.  Comparison of dietary intakes between a large online cohort study (Etude NutriNet-Santé) and a nationally representative cross-sectional study (Etude Nationale Nutrition Santé) in France: addressing the issue of generalizability in E-epidemiology.   Am J Epidemiol. 2016;184(9):660-669. doi:10.1093/aje/kww016 PubMedGoogle Scholar
    64.
    Méjean  C, Si Hassen  W, Gojard  S,  et al.  Social disparities in food preparation behaviours: a DEDIPAC study.   Nutr J. 2017;16(1):62. doi:10.1186/s12937-017-0281-2 PubMedGoogle Scholar
    65.
    Rosenfield  RL.  What every physician should know about polycystic ovary syndrome.   Dermatol Ther. 2008;21(5):354-361. doi:10.1111/j.1529-8019.2008.00217.x PubMedGoogle Scholar
    ×