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Dr Anjali Mahto is a consultant dermatologist and author of The Skincare Bible: Your No-Nonsense Guide To Great Skin.
I have been seeing patients with skin conditions for well over a decade and acne is one of my main areas of interest. Over the past few years, there are some observations I have made which are causing me concern. With the rise of 'wellness' and its stubborn persistence, my increasing worry is how it is affecting our relationship with food in the context of managing skin problems.
Let me give you a bit of background. I am aware that I see a self-selecting group of patients in my private clinics. Many suffer with a longstanding history of acne, most are female and from an affluent background — that is the nature of working in exclusive areas of London. Like many of us, they are intelligent, clued-up women who care not only about their skin health, but also their general health. By the time many of them are sitting opposite me in clinic for their acne, they have already exhausted numerous avenues of treatment. This includes changing their skincare — often having spent thousands trying to find the right product — as well as manipulating their diet, often with little success.
This is a trend that I am finding hard to ignore. Patients are telling me firsthand how they are cutting out dairy, gluten and sugar in an attempt to clear their spots. Many are actively restricting food to the point where it is clear to me it has become an unhealthy obsession. Finding excuses not to go to dinner with friends, refusing to eat a slice of birthday cake that has been lovingly made by a family member, skipping meals when out and about as there is no 'clean' café that can provide 'acceptable' or 'allowed' food. What I am dealing with is not just the acne itself, but also a very real fear of certain foods.
But let’s look at the evidence. What is the relationship with acne and diet? Well, the link has been discussed for decades and remains controversial. Doing good quality dietary studies is difficult and many rely on people's memory of what they ate in the past. Can you accurately recall what you ate last week, let alone 10 years ago? What we do know is that there is a growing relationship between acne development and food that has a high glycaemic index (GI) so, potentially, sugar has some part to play. The way I would translate this, however, is not to cut out sugar altogether but be mindful of consumption. This isn’t just good for your skin but also for your general wellbeing.
Labelling food as the problem is too simplistic and fails to take account of the multi-factorial nature of acne.
The link with dairy is actually much weaker but it may have a role in acne in a small, select group of people — not everyone! For reasons that are not fully understood, low fat dairy seems to be worse than full fat. There is no acne guideline in the UK or the US which recommends cutting out dairy for the treatment of acne. There are plenty of people I see following a vegan diet who still have spots. Likewise, I have lots of patients on my books who have cut out whole food groups but their spots persist. Labelling food as the problem is too simplistic and fails to take account of the multi-factorial nature of acne, which includes variations in hormones and genetics.
Taking things a step further, if food restriction isn't bad enough, the second thing I can’t ignore is food shaming. This is where people think it is socially acceptable to pass unsolicited advice or judgement on someone’s eating habits, blaming them for their skin disease. I can speak about this firsthand as it has happened to me. The stranger in the street who tells you that you have acne because you’re eating ice cream on a hot summer’s day. The concerned relative who tells you to put the chocolate down as it’s obviously giving you spots. The troll on social media who tells you that it’s not surprising you have bad skin because you posted a picture of a slice of pizza.
We are living in a world of information overload. Everyone has a voice and a platform and social media allows us to reach a wider audience that would not have been possible 20 years ago. But is this a good thing? How does one sort out the scientifically credible voices from the charlatans? If you’re feeling desperate because of your spots and your self-esteem is in your boots, it is totally understandable why you would turn to the internet for advice. The difficulty is that not all advice is created equal, and there is a lot of conflicting information — sometimes even coming from health professionals themselves. And just because something works for one person, it doesn't mean it will work for you. We are all individuals, after all, with our unique DNA, environment and gut and skin microbiome.
Acne has already been linked to a number of mental health concerns such as anxiety, depression, social isolation and poor body image. Telling people who are already vulnerable to developing mental health issues to then restrict their diet is a worry but it is happening all over social media, where people — bloggers, via naturopaths and functional medicine — promise to get to the 'root of the problem'.
No one is denying that good nutrition is important for your skin. Food has multiple roles in skin health and disease. But this is not the same as making people feel bad about their dietary choices by offering uninvited advice that is not rooted in science. This creates an unfair blame culture, criticising people who are already struggling. Patients are telling me that comments like this are affecting their mental health or creating disordered eating patterns. Many worry much more about what they eat or think twice about eating that sugary food in public. Friends who work in nutrition and psychology tell me that I’m not alone, and that they are seeing the same thing in their clinics.
So what is the solution? Well, if you are suffering with acne and any of this resonates then it is important to seek medical help. Likewise, if you are noticing a loved one becoming wary around food because of their spots, please encourage them to talk to someone. Be open with your GP or dermatologist about your concerns around food. It can be really helpful to work with a team of people such as a dietitian and psychologist alongside having your skin treated. Food does not have to be 'good' or 'bad' — the labels are too binary. Eating well for your skin is about sustained eating patterns over time, not just that packet of sweets you ate today.