Integration of the “No Dairy Diet” into Modern Acne Therapy
F. William Danby, MD, FRCPC
Adjunct Assistant Professor of Dermatology
Department of Surgery
Geisel School of Medicine at Dartmouth
***This is based on the text of a poster presented at the October, 2006 meeting of the European Academy of Dermatology and Venereology. There are portions that have been edited and updated January 1, 2015 because new information has become available***
Objective: To optimize the efficiency of acne therapy by minimizing exposure to the acnegens in dairy products.
Materials and Methods:
The acceptance of a “No Dairy Diet” requires that patients and their parents and their physicians understand the blackheads and blemishes develop.
An animation illustrating the concept of comedo production is available at the ACNE ANIMATION tab on this website.
Suggestion: Read the next few paragraphs then take a look at the animation.
The animation illustrates the concept that the hormones that govern reproduction of the cells in the duct are responsible for over-production of these cells.
A working hypothesis is presented and illustrated that suggests that these cells fail to mature, leading to ‘retention hyperkeratosis’ and comedo formation.
This failure of normal terminal differentiation is postulated to be due to impaired nutrition on a cellular level, likely due to hypoxia, produced by internal pressures within the pilosebaceous duct. The presence of anoxia is indicated by the existence of healthy colonies of the anaerobic ‘acne bacillus’ called Propionibacterium acnes or P. acnes.
Featured segments include:
1. The view illustrating the restrictive “glassy membrane” that limits the expansion of the infundibulum, forcing the oil and lining cell debris to the surface.
2. The cross-section of the duct, showing the glassy membrane as colored pink (it is PAS positive) and the concentric production of lining keratinocytes heading to the center of the duct.
3. The overactive metabolic process that results in failed terminal differentiation is represented by the accumulation of lipids instead of production of mature keratohyaline, completion of terminal differentiation, and subsequent separation of one cell from another, allowing desquamation.
4. The central hypoxia, represented by the incremental bluish discoloration, is proposed as the prime cause of the impaired metabolic activity that leads to comedo formation. Recent evidence indicating that hypoxia may directly be the cause of increased proliferation and poor differentiation supports the hypothesis that anoxia may be the ultimate final cause of comedo development.
Suggestion: Take a look at the animation then come back and review the rest of this poster.
Once patients (and their physicians) have an understanding of the dynamics in the duct, they will better appreciate the impact of the various hormones that start the process of plugging of the duct and production of the comedo (blackhead).
The hormones that turn on acne come from three sources:
1. Gonadal hormones.
Young men have no problem with the concept of hormones from the testes/ testicles driving beard hair growth. They must simply relate the same stimulation process to the overproduction of the cells that line the follicular portion of the folliculopilosebaceous unit (FPSU). Regrettably, no acceptable therapy is in general use to counteract this.
Young women will very often have already made the link between monthly cyclic ovarian hormonal activity and flares of their acne. This provides a basis for discussion of the wisdom of using hormone control to achieve complete acne control, and also for the wisdom of using a non-androgenic (non-male type) progestin (progestagen), available as drospirenone in the oral contraceptive Yasmin or Yaz. I explain to them that almost all other progestins in birth control pills have a male influence, although the amount of maleness varies. Drospirenone, on the other hand, has no maleness, and blocks the action of some other male hormones from the ovaries and from the adrenal glands. Norgestimate is a less effective but acceptable option.
Patients need to know that six months is a minimum time to try oral contraceptive therapy, and they may wish to be on this therapy indefinitely. It is emphasized that this is treatment for a medical condition, and although it has the side effect of being a contraceptive, that is not the main reason for using it. Patients also need to know that the acne may recur if and when they stop taking this medication. The usual precautions (including the use of second contraceptive methods, if warranted) and warnings (especially smoking avoidance) and a thorough family history (for evidence of clotting disorders) must apply.
2. Adrenal hormones.
Most teens know that the adrenal glands make adrenaline, which is part of the acute stress response, but very few know about the other activities of adrenal glands. They need to know that these glands respond to the chronic stresses of daily life. I usually list homework, school, dating, money, appearance, parents, and siblings as the most common stresses. Most readily understand and relate to this picture.
I warn them that the major risk of a flare in the late teens is due to the first semester of college. The hormones from the adrenal glands are at fault. For the females, I point out that drospirenone also blocks these hormones, so they get a “2-for-1” effect. Unfortunately, except for drospirenone and its cousin spironolactone, no safe specific way of blocking these stress hormones is available. For young men, no blockade is currently available.
3. Dairy hormones and other hormones from outside the body.
By the time the subject of hormones in dairy products is introduced, the thought pattern linking hormones and acne is usually established and understood. The study of 47,355 nurses linking acne and dairy is introduced, along with the fact that there are numerous hormones and growth factors in milk and other dairy products. Patients and their parents are invited to review the original scientific work, available on the Internet at http://www.acnehelp.org.uk/dairy.htm#Dairy2
I tell my patients that I expect total avoidance of all dairy products as an essential part of their acne therapy, no matter what additional therapy is used. Dairy avoidance is the foundation of all forms of acne therapy.
The list includes cheese, butter, ice cream, cottage cheese, cream cheese, cream and all forms of fluid milk, dried milk, organic milk, Lactaid milk, processed cheese spreads and protein powder supplements containing whey and casein.
Patients are given the option of either simply avoiding all dairy products and eating other foods, or stopping all dairy products and supplementing those they miss with nondairy substitutes, whether from soy, rice, or other sources. A superb list of 2500 dairy-free foods has recently been completed by the organization that supports the “Go Dairy Free” website at http://www.godairyfree.org/.
Integration of the “No Dairy Diet”
The need to avoid all dairy products is explained as the baseline therapy for all acne management programs.
Three options are provided.
1. The Natural “No Therapy” Therapy
The most natural acne therapy is achieved by simply stopping all dairy products and waiting for the unnatural process of acne to resolve. This choice is welcomed by a small but important and committed minority. The major problem is that this approach appeals to those who are already being careful with their diet and are usually following a modified vegan lifestyle, which often means that they have chosen dairy products as a major source of protein or for protein supplementation, and the additional restriction on calories is difficult, though not impossible. If this choice is made, then great care must be taken to choose a balanced diet. A nutritionist’s assistance is suggested, and the use of supplemental vitamins is recommended. These individuals usually need no calcium supplementation because of its availability in their diet.
2. The Standard “Routine Acne Care” Therapy
Some will choose to remain faithful to their previous standard anti-acne regimens. Most dermatologists will find it necessary to provide some fine tuning, whether this be explanation of the value of comedolytics such as the retinoids, addition of combined therapy of the benzoyl peroxides with topical antibiotics, or judicious selection and administration of oral antibiotics. Many patients who come to dermatologists from primary care physicians or are self-referred have little idea of the fine points of the use of these various products, and an educational session is warranted. They need to know that the plugged pores in their acne-prone areas are already populated with bacteria and yeast, and that there really are three jobs to be performed:
1. Eliminate all the yeast and bacteria in the follicles. They are the antigens that cause most of the inflammation.
2. Eliminate all present lesions.
3. Prevent a whole new crop of plugged pores.
3. “Full Speed Ahead – I Want To Get Better As Soon As Possible” Therapy
It is impossible to shrink sebaceous glands down to pre-pubertal size with standard topical therapy. This must be explained by the dermatologist and understood by the patient. Isotretinoin is routinely offered as the best option available to empty out the present plugged pores, calm the fires of active acne, miniaturize the oil glands themselves, and decrease the size of the hormone manufacturing apparatus in the sebaceous ducts and the sebaceous glands themselves.
Patients need to know that getting rid of acne is rather like fighting a forest fire. First, one must apply the most aggressive therapy possible to put the fire out, and then it is essential to avoid lighting any more matches. Point out that, yes, forest fires do burn out naturally, but they leave ugly scars, just like acne.
The patient must understand that only total clearance of the pores, totally ‘putting out the fires’ and total control of the hormones will give the best long term results. These results are seen first as clearance of the present acne and secondly as freedom from, or minimization of the risk of, recurrences.
Isotretinoin therapy, supplemented in young women with hormone control using drospirenone if possible and other minimally androgenic oral contraceptives (plus spironolactone if necessary), and with concurrent total dairy avoidance, is suggested for control and is continued until all lesions are settled.
It would be wonderful if simply stopping all dairy would cure all acne, but it is essential to remember milk is only one source of the hormones that trigger acne.
Patients must understand that the hormones from different sources ‘stack up’ on each other. There is nothing one can do to reduce the hormones from male testes; the acnegenic hormones from the adrenals cannot be controlled with any medicines; the ovarian hormones can only be controlled to a certain degree; and only time will allow a gradual decrease in the growth hormone that acts through IGF-1, usually after age 20.
This means that maintenance, following discontinuation of the isotretinoin, is essential.
1. Dairy avoidance must become a part of everyday life.
2. The same is true for oral contraceptives, when possible and acceptable.
3. Topical comedolytics are standard for long term acne prophylaxis, preference being given to the less irritating and anti-inflammatory products such as adapalene and low-potency over-the-counter salicylic acid and benzoyl peroxide products.
4. Antibacterial prophylaxis is best accomplished without antibiotics if possible. Benzoyl peroxide is doubly useful here.
5. Anti-Malassezia prophylaxis is worth considering as well, using low dose pulses of oral ketoconazole, or shampoos containing ciclopirox, ketoconazole 1% or selenium sulfide 1%. The shampoo is used for 5 minutes weekly
Questions and Answers
Patients (and their parents) have multiple concerns about stopping dairy intake. Suggesting that milk may present significant risks to health flies in the face of a massive and long-standing milk-promoting advertising campaign. But there are numerous negatives about milk that are gradually being realized.
Why avoid milk products?
The most reasonable explanation that links milk products and acne is that milk contains hormones that “turn on” oil glands. The cows are milked very shortly after their first calf, they are made pregnant again as soon as possible, while still milking, and the cycle is such that they produce milk during most of their lives. Roughly half of all marketed milk (and so milk products) comes from these pregnant cows. The hormones are not injected into the cows – they are natural hormones that cows make during every “menstrual” cycle, but during pregnancy these hormones are produced constantly at high levels and so are found in all cows’ milk and all marketed milk and milk products.
How do the cow hormones make acne?
Oil gland pores (the follicular portion of the folliculopilosebaceous unit or FPSU) are plugged by the overproduction of the cells that line the pore – basically a “traffic jam” happens in the pore. Take another look at the animation to see how this happens. It is generally understood that this overproduction of ‘lining cells’ is caused by hormones and there are three sources of these hormones. The first is the ovaries or testicles, the second is the adrenal (stress) glands and the third is dairy products or other ‘outside sources’ like birth control hormones in pills, patches, rings, IUDs and shots.
These three sources “stack up” on each other and, when the amount of hormone present is enough to plug up the pore, acne is started.
The effect of the male hormone (testosterone) that turns on acne may also be magnified by foods other than dairy. Milk causes a quick rise in insulin levels and insulin-like growth factor-1 (IGF-1) that in turn causes androgen receptors to open so that the circulating testosterone, dihydrotestosterion and other androgenic substances can reach them much more easily. This increased level of insulin can also be stimulated by the over-processed foods that are part of our modern (Western) diet, so a return to a more ‘caveman’ type of diet would actually help acne. Early experiments conducted to prove this did not differentiate between the impact of dairy alone versus variations in dietary glycemic load. When the effects of milk and the effects of high glycemic load diet were separated during later clinical trials, there was very little differentiation between high and low glycemic diet, not statistically significant in a dairy-oriented culture with significant ‘background’ diary (Australia) and just barely significany in a culture with much less ‘background’ dairy in the diet (South Korea). On the other hand, comparison of high versus low intake of dairy in two cultures with less background dairy (Italy and Malaysia) gave highly significant relative risks of acne in the high dairy consumers (and that was with as little as 3 x 250 mL portions of milk per week.
Why do I get acne when some of my milk-drinking friends never have a blemish?
Everybody has a different level of hormone where acne happens (this is the acne “threshold.”). Some of your friends are lucky and may never reach the threshold, so they never will have any acne. Paris Hilton’s complexion is just as hereditary as her income. She ‘lucked out bigtime’. But many young women pass this threshold just before their period every month; others stay above the threshold for years, and have acne for years, because of milk and milk products; others cross the threshold with stress (first year college is the most common stressor in late teens). By removing dairy from your diet, you will usually be able to get down below your personal threshold, making your acne much less with time. This threshold is also influenced by your family history so if one or both of your parents had acne, your threshold will likely be lower, making acne risk higher.
What about cheese?
The production of cheese usually involves a process called fermentation. Some of the hormones in milk that can turn into dihydrotestosterone, or DHT, the strongest acne producing hormone, are actually turned from precursor status into active DHT during the making of the cheese. The result is that cheese is actually a worse cause of acne than the milk it is made from. While our consumption of milk has gradually decreased over the past 30 years in America, the amount of cheese being consumed has tripled.
What about hormone-free milk?
There is no such thing as “hormone-free” milk. The confusion is caused by a company that sells a hormone called bovine somatotropin (BST) or recombinant bovine growth hormone (rBGH). It is given by injection into cows to make them produce more milk. Some milk producers have made the point that they do not use this injection. They are advertising that the milk is “hormone-free”. It obviously does not contain the injected hormone but all the cows’ natural hormones are still in the milk. We do not know yet what the injected hormones do to the levels of natural hormones in milk. And we do not know yet how to get the hormones out of the milk.
Is lactose-free milk okay?
No. Lactose intolerance has nothing to do with acne. Putting lactase enzyme into milk will make it easier for a lactose-intolerant person to handle the lactose in the milk but it will do nothing to reduce the steroid sex hormone levels or the whey / casein / insulin / IGF-1problem.
Is “organic” milk okay?
No. “Organic” simply means that the pesticides and insecticides the cows are exposed to in their food are less toxic than usual. Actually recent studies show that the organic cows are healthier and have even higher levels of hormones in their milk.
Does this mean I’m allergic to milk?
No. Milk allergy produces all sorts of other problems, but not acne. There have been a few cases described of patients who were allergic to milk, and when they stopped their milk their acne cleared up. Stopping the milk actually cured both diseases but the acne was not caused by the allergy. There is more to this story but that is in the book.
What are my options in moving to a dairy free diet?
There are two ways to handle dairy restriction.
1. The first (and simplest) is to just stop consuming all milk, cream, cheese, ice cream, butter, sour cream, cheeseburgers, pizza, processed cheese and spreads, protein supplements containing casein or whey – anything that contains or is made mainly from milk. I tell my patients that it is best to avoid “anything that comes from the south end of the cow”. Usually it is enough simply to avoid the easily identified products listed above. An organization called “Go Dairy Free” publishes a list of over 2500 foods available in America that are completely dairy-free. Many of them are available in the European Community. It is not necessary to avoid milk as a minor ingredient, at least for managing acne, but the list provides a broad spectrum of substitutes for the usual dairy products. The published list covers everything from soy milk to dairy-free chocolate bars.
2. The second way is to find dairy-like substitutes for whatever you are missing. Soy products are the most convenient and most easily available. They include substitutes for milk, creamer, chocolate milk, ice cream, cheeses of various types, including cream cheese and even butter substitutes. Goat milk and goat cheese are suggested alternatives, but also are not hormone-free and should be avoided. We have no idea what hormones and how much hormone they contain. The “Go Dairy Free” list is very valuable here. See http://www.godairyfree.org
How long do I need to do this?
The “No Milk” diet has three phases.
First is the total restriction phase. It is essential to minimize the production of new plugs in the pores, and this lasts at least six months. In studies done many years ago, it took ‘several months’ for acne in a group of males to clear after castration.
Second is the maintenance phase, and it lasts through all the teen years into the early 20s. During this phase, zero dairy intake is best.
Third is the cautious reintroduction phase, usually possible in the early 20s. But, depending on individual thresholds, some acne patients can never return to dairy. One of my early patients, a heavy ice cream consumer all his life, had terrible acne on his back at age 61. Another patient, a lovely 28 year-old woman who had never had acne in her teens spent three months tasting and researching cheese all over Europe before opening a delicatessen in America. She presented with cystic acne along the entire jaw line and upper neck. She cleared after six months of no treatment other than full dairy avoidance.
What else can I do for my hormones?
For males there is no generally accepted anti-hormone therapy. Young men can be told that there is almost nothing to be done about their stress hormones, but that they have a choice on the other two sources of hormones: “We can cut off your dairy products or consider a more radical option.” It’s a joke, but it helps them understand.
Young women have the option of controlling their hormones with oral contraceptive (birth-control) pills. We prefer to call these “hormone control” or “acne control” pills, but they are all the same as birth control pills, really, and are given for medical reasons. The product we prefer is not only the least likely of all “birth-control” pills to make new acne, but it also blocks acne-making hormones from other sources (like the stress glands). Most young women with previous acne have almost no acne after six to 12 months on this “pill”, especially if they stop their dairy intake at the same time. The preferred BCPs contain drospirenone (norgestimate is second best). Both may be supplemented with spironolactone.
What about my calcium intake?
Remember first of all that there are hundreds of thousands of growing teens in America, and millions in the world, who are either lactose intolerant or allergic to milk. They grow up just fine. It also helps to realize that cows have big strong bones, healthy teeth, produce milk during most of their lives, and also produce a calf every year (with its own new set of bones) – yet they drink no milk and take no calcium supplements in nature (although when they are being ‘factory-milked’ they do get supplements).
It is far more important for maintenance of bone health to make sure you have an adequate intake of vitamin D, regular bone-stressing exercise, an otherwise healthy diet containing sources of calcium, and to be sure you have a normal amount of estrogen in your body if you are female. Vitamin D supplements in the range of 2000 IU per day are cheap insurance, at minimal risk. This is far more important than drinking extra milk or taking calcium supplements. Indeed taking both Vitamin D in the new recommended higher doses and taking calcium supplements can cause kidney stones.
But won’t I be at increased risk of osteoporosis?
There is evidence that the opposite is true. There is a Harvard study that strongly suggests that milk-consuming populations have a higher risk of osteoporosis than those populations that do not consume high levels of dairy product.
What else does dairy hormone do?
There are studies that suggest that consuming dairy products may be associated with breast cancer and prostate cancer. And a recent study of lactose-intolerant persons who had significantly less breast and ovarian and lung cancer. Further studies are necessary, but if you have a family history of either kind of cancer you should consider avoiding dairy intake.
I’ve heard of lots of other diseases caused by milk. Where can I learn more?
Many disorders have been attributed to milk. There is some science behind some of the claims. Although it is not an accepted or orthodox medical web site, www.notmilk.com contains a generally well-referenced catalog of milk-related disorders.