Doctor Logic: “Acne is Caused by Bacteria”

Presumably Dr. Jenny Kim is a good dermatologist because the author of this NPR piece chose to quote her:

UCLA dermatologist Dr. Jenny Kim says many people don’t realize it’s bacteria that cause acne. “Some people say your face is dirty, you need to clean it more, scrub more, don’t eat chocolate, things like that. But really, it’s caused by bacteria and the oil inside the pore allows the bacteria to overpopulate,” Kim says.

If I were to ask Dr. Kim how she knows that acne is “caused by bacteria” I think she’d say “because when you kill the bacteria [with antibiotics] the acne goes away.”  Suppose I then asked: “Is there evidence that the bacteria of people who get acne differ from the bacteria of people who don’t get acne (before the acne)?” What I assume Dr. Kim would answer: “I don’t know.”

There is no such evidence, I’m sure. It is quite plausible that the bacteria of the two groups (with and without acne) are exactly the same, at least before acne. If it turned out, upon investigation, that the bacteria of people who get acne is the same as the bacteria of people who don’t get acne, that would make it much harder to say that acne is caused by bacteria. As far as I can tell, Dr. Kim and apparently all influential dermatologists have not thought even this deeply about it. To do so would be seriously inconvenient, because if acne isn’t caused by bacteria, it would be harder to justify prescribing antibiotics. Which dermatologists have been doing  for decades.

It isn’t just dermatologists. Many doctors believe that H. pylori causes ulcers — wasn’t a Nobel Prize given for discovering that? The evidence for that assertion consisted of: 1. H. pylori found at ulcers. 2. Doctor swallowed billions of H. pylori and didn”t get an ulcer. (Not a typo.) It was enough that he got indigestion or something. 3. Antibiotics cause ulcers to heal. That was enough for the two doctors who made the H. pylori case and the Nobel Prize committee they convinced. The doctors and the committee failed to know or understand that H. pylori infection is very common and almost no one who is infected gets an ulcer. Psychiatric causal reasoning has been even simpler and even more self-serving. We know that depression — a huge problem — is due to “a chemical imbalance”, according to many psychiatrists, because (a) antidepressants work (not very well) and (b) antidepressants change brain chemistry.

Dr. Kim’s false certainty matters because I’m sure most people with acne don’t know what causes it. I didn’t. Dr. Kim’s false certainty and similar statements from other dermatologists make it harder for them to find out.  I wrote about a woman who figured out what caused her acne. It wasn’t easy or obvious.

Thanks to Bryan Castañeda.

10 Responses to “Doctor Logic: “Acne is Caused by Bacteria””

  1. Alex Chernavsky Says:

    Seth, I’ve read your earlier posts about H. pylori, but I’m still unclear about what you think is going on, exactly, when ulcers form — and when they go away following antibiotic use. Can you elaborate?

    Seth: I don’t know why most people with H. pylori infection don’t get ulcers — in other words, the crucial difference between those who get ulcers and those who don’t. Probably it’s nutritional, although I’m not sure. I believe ulcers go away following antibiotic use because bacteria were somehow helping to maintain the ulcers.

  2. Brian Says:

    When I had esophageal ulcers, the gastroenterologist checked to see if they were caused by bacteria, determined that they were not and then prescribed a proton pump inhibitor and something he called a liquid bandaid (I forget the technical name). After a few weeks, my ulcers were gone and I discontinued medical treatment.

  3. Morris Says:

    Seth
    There is a view that holds that acne postules are caused by mucin blockage in lymph vessels. The mucin is a response to bacterial endotoxins. This accords with my experience. Healing periodontal gum disease (known to be microbial) has caused occasional postules to appear in the vicinity. I have experienced some other strange correlations to my acne which ocurred decades ago.

  4. charlie Says:

    Isn’t H. pylori the gold standard for self-expermentation?

    So, if I parse down, antibiotics cure acne. A lot of people don’t want to take anti-biotics and/or accutane. All the poor doctor is saying is don’t take sandpaper to your face because that won’t help.

    (Another thought — people with acne are in some way defective, and the acne is just a visual warning not to reproduce with them)

    Seth: “Poor doctor”? I doubt she is poor. Statements like hers, as I say, block helpful research.

  5. Jenny Says:

    I’ve just read Chris Kresser’s article on the link between gut bacteria imbalance and/or Sibo and acne. Much more plausible, and I am certainly one who ‘lost’ the acne the day I went gluten free.
    http://chriskresser.com/the-gut-skin-connection-how-altered-gut-function-affects-the-skin

  6. Kitty Says:

    I had terrible skin my whole life and tried every cleanser and skin product ever invented (or so it seemed). My skin cleared up almost immediately when I stopped eating wheat, and it has stayed clear.

  7. D Says:

    What about he role of androgens. Take steroids, get backne. I’ve also noticed that women who skew towards the masculine side of the specturm tend to be more likely to have acne problems.

  8. L Says:

    What the he’ll are u doing at tsinghua?? Join me at harvard. Stop qasting ur time teaching chinx who don’t know Spanglish!! What a waste!! They can’t compare to us Americans in Boston!! MIT is nearby if u want to stop a little lower. But tsinghua?? Babe. What a joke!!

  9. Tony Mach Says:

    It took me some awful while to figure out my personal connection between my acne and my diet – we need more pages like yours Seth!

    I can now say with certainty that for me acne is caused by dairy from pasteurized cow milk. Three to six hours after I eat dairy, I get an outbreak of acne.

    Though dairy is clearly the main cause for my acne, I sometimes get very very low level acne, which I haven’t been able to track down: Traces of dairy in my food? Traces of cereal grains? Nuts? A reaction to beef? Bacterias acting up? I simply don’t know (yet), this isn’t so clear cut as dairy=>acne.

    And though I have *not* been able to trigger an acne out-break with cheese from raw milk, I remain suspicious that milk does more harm to my body than just acne. I had spurious “funky” symptoms after raw milk consumption. I had one low blood sugar episode and recently one swollen hard node (lymph node?), both after raw milk cheese consumption (again within the 3 to 6 hours timeframe).

  10. Tony Mach Says:

    So Seth, here is the story how I found out my acne/dairy connection:

    In summer 2010 my health problems got noticeable worse (unrefreshing sleep, strange pains, strange sensations in the skin and other stuff I don’t want to share here :-P ), and I had to do something. Furthermore I was gaining weight, I was suspecting something along the lines of Diabetes, or some other metabolic problem.

    As I was looking into dietary changes, I stumbled over Wolfgang Lutz’s and Robert Atkins’ work. Being engineer by training, I figured that if blood sugar might be the problem (which, as it turned out, wasn’t the case for me), then reducing carbs might be a solution (stop fueling the problematic sub-system) – so both Lutz and Atkins appealed to me and I thought let’s give it a try (I was a bit frightened about such an radical change of diet – you read all kind of BS – but hey, I felt like I was going to die anyway).

    Before the change, I ate a lots of white bread, some milk-chocolate and drank lots of milk. First I reduced carbs – like Lutz suggested, I tried to aim for 6 bread units – but within days I noticed that some problems (like the strange pain and skin sensations) diminished right away. The acne cleared up noticeable. So I thought why bother with low-carb, let’s go full no-carb (like Atkins suggests for some month).

    And voila, with no-carb everything go better, and I started to feel healthy for the first time in my life. I lost over 30 pounds, all health problems either went away or were almost gone, and life started to become enjoyable. This was a period of about two months over with most problems went away, some fast, some slower.

    So for over half a year I was focused on the carbs=evil scheme, started eating cheese again (hey, no carbs!), when slowly some of the health problems returned, my weight started to rise again.

    At that point I panicked a bit and made a huge mistake: I thought I can figure this one out too, I have to do something right away. So I trusted what some doctors had written about an pathogen (which I tested for with borderline results), how to cure it (with over the counter medication like Vitamin D and NAC and other stuff) and I thought let’s try this too! The things I took made me worse, but as it was supposed to be a “die off”/”herx” reaction, I wasn’t too alarmed. Turned out that experiment cost me almost an year until I got better again. So for about a year I was not in the mood for big experiments and personal stuff like moving to another city kept me busy.

    But slowly I introduced “safe starches” into my diet (like plantains), because kept reading one should not go too much low-carb. I tried out self-made sourdough rye bread (makes me enormously hungry, so I stopped again) and at one point I thought: What the heck, I’m going to eat ice-cream today – 3 hours later I got slightly noticable pimples and local inflammation (I think they are called nodules), and after another roughly 3 hours the acne was prominent.

    After that, my suspicion was that milk might be bad for me, but maybe some properly “ripe” cheese like hard cheese (properly digested by bacteria) might be OK. So I waited for the acne inflammation to go back and tried again with an parmesan. Bingo, acne again, and again on the 3 to 6 hours timeframe.

    So I didn’t touch milk or dairy again, but now I looked for raw milk cheese, as I read something about it being possibly better. After a while I found raw-milk-cheese, tried it – and got no acne. Tried again, after some time, with another brand – again no acne. Tried cheese from pasteurized milk – acne.

    As I still have health problems, I am still in the process of figuring out things. Next up for me is trying to get rid of beef for a week or two, to see if that might be a problem for me.

    In summary:
    - I was not very systematic in my experiments, and had some lucky moments.
    - All the macro-nutrient ratio paradigms are IMHO BS and not applicable for the majority (might make sense if someone has real/major metabolic problems like T1DM, etc.)
    - Having said that, in my view some carb foods come with baggage: e.g. cereal grains and (pasteurized) milk
    - A quickly reacting, non-dangerous, clearly visible (objective) surrogate health marker (in my case acne) is worth its weight in gold
    - With such a marker, one should completely eliminate suspicious foods (in my case *ALL* dairy) and then introduce it again (two or three challenges)
    - For me, pasteruized-milk-dairy=acne, raw-milk-dairy=no-acne
    - Milk-chocolate is dairy
    - Some surrogate health markers (e.g. weight) reacted “funky” for me: I changed my diet to no-carb, my weight went down, and without any big chances my weight started to climb again.
    - I still have some residual health problems
    - For most of the health problems that went away, I don’t know exactly what food (Cereal grains? Dairy? Vegetable oils? etc.) caused what problem
    - As I felt like I was going to die on my old diet, I am not particular keen on going back full scale to my old diet to see if after one or two month all my old symptoms return, to erode which food caused which symptom…
    - Medical science and several MDs helped me diddly squat
    - For me, Paleo blogs were much more helpful than the medical community
    - There are more tidbits I found out, but I lack the energy right now to write them down shortly
    - There is a lot I still don’t know about my health problems

    In closing:
    In my view it is important to get ideas what may (or may not) be a problem, what experiments one can do safely (I had no problem with larger amounts of sat-fat, but two spoons of vegetable oil gave me a weird pressure in the temples…). The time delay between consumption and health effect is interesting to know too, some things act faster, some slower. While I think that I am not alone in that dairy causes acne, I think not everybody seems the same, and by now I wouldn’t be surprised if for some people acne is caused by other things besides dairy.

    So much more to write, I guess …

    P.S.: Some conditions are thought to cause acne (e.g. some adrenal issues) and I wonder if the medical science has the causation wrong, and in fact both the accompanying acne and the “primary” condition have both the same underlying cause (e.g. dairy).