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Naturopathic Causes and Treatment of Acne Vulgaris

See also Carahealth Skin

Symptoms of acne

Comedones, pimples, superficial sebaceous cysts Acne Vulgaris is characterised by the presence of comedones or blackheads, pimples, small superficial sebaceous cysts, and scars. There are over half a dozen types of acne, the most common being blackheads. The areas chiefly affected are the forehead, temples, cheeks, chin, chest and back. In rare cases, almost the entire body may be covered with acne accompanied by extensive scarring.

Naturopathic causes of acne vulgaris

* Insulin resistance

* High insulin like growth factor (ILGF)

* Excess inflammation

* Under functioning of the eliminatory organs

* Bowel toxicity

* Lymphatic congestion

* Poor circulation

* Hyperproliferation (excess production) of skin cells due to vitamin A deficiency

* Excess sebum production due to zinc deficiency

* Hormone imbalance /Testosterone excess

* Sluggish liver

* Nutrtitional deficiencies zinc, vitain A, niacin

* Excess iodine??

Pathophysiology of Acne

Acne develops when;

* The duct of the gland is blocked because of abnormal production of skin cells known as hyperkeratinization due to insulin excess.

* Excess sebum production.

* Proliferation of the acne bacteria, A pyrogens.

* Inflammation

The western diet is high in calories and a large portion of these are derived form high glycemic index (GI) foods. In the USA, 47% of the energy intake is high GI foods. A recent US survey found that 54% of women aged more than 25 years had some degree of acne, while 40% of men in this age group were affected. High GI foods raise blood sugar and this causes the pancreas to release extra insulin. Insulin has direct effects on the sebaceous gland to cause abnormal keratinization and increased sebum production. High GI food

Raised blood sugar

Raised INSULIN Insulin-like growth factor (ILGF) increases SEBACEOUS GLANDS ILGF-binding protein decreases sebum production increases Androgen production increases Promotes cell proliferation TESTES and OVARIES * Insulin has many effects apart from controlling blood sugar. It increases Insulin-like Growth Factor (ILGF).

* ILGF promotes keratinocyte proliferation.

* ILGF stimulates sebum production.

* Insulin decreases ILGF-binding protein

* ILGF-binding protein inhibits keratinocyte proliferation and promotes cell death via apoptosis.

The result of these changes in hormones is the development of obstructions in the outflow duct of the oil gland. Insulin increases oil production in the sebaceous glands directly and indirectly by causing increased androgen production in the ovaries and testes. More amounts of the androgen are available to act inside the sebaceous glands because insulin reduces the amount of sex hormone binding globulin available. This protein binds androgens and prevents them entering cells to act.The result of these changes is more oil production and enlargement of the oil glands.

Acne and Insulin Resistance

Skin with a tendency for acne has been shown to be insulin resistant. Insulin is a hormone that regulates carbohydrate metabolism, as well as playing a role in protein metabolism and fat metabolism. Insulin regulates the way our cells use the available energy in the bloodstream. Insulin has 3 effects on glucose;

1. Glucose is used by the cells for the production of ATP

2. Excess glucose is stored as glycogen in the liver

3. Any excess glucose is stored as fat ie more calories than required.

People with insulin resistance don't respond to the normal amounts of insulin released in the body. Even though there is plenty of glucose in the bloodstream, the cells actually think they are starving as the insulin receptors become "lazy" and the glucose is not allowed in the cell to make ATP for energy. As a result, the pancreas starts producing more and more insulin resulting in a downward spiral. Blood glucose levels can build up and the result is hyperinsulinaemia (lots of insulin) and hyperglycaemia (lots of blood glucose). As we don't make insulin out of thin air (zinc, B vitamins, chromium are cofactors), in the long run this can lead to late onset diabetes, a condition known as pancreatic exhaustion in naturopathic terms. Diabetes of course is a global pandemic that is costing the health service unnecessary amounts of money. Good naturopaths could be saving the government money and should be recruited immediately into mainstream healthcare.

Diet and Acne

Diet, though not a direct cause of acne, does have an indirect effect on acne. That is why so many 'acne cures' recommend dietary change. Although the pathogenesis of acne is currently unknown, recent epidemiological studies suggest that dietary factors, including the glycaemic load, may be involved. A study whose objective was to determine whether a low-glycaemic-load diet improves acne lesion counts in young males found that he improvement in acne and insulin sensitivity after a low-glycaemic-load diet suggests that nutrition-related lifestyle factors may play a role in the pathogenesis of acne.[1]

Although diet may not directly cause acne, high Glycameic Index (GI) carbohydrates can aggravate acne. Insulin and its cousin, insulin-like growth factor I IGF-1 have been found to stimulate human ovarian testosterone production by the thecal cells in the polycystic ovary syndrome.[2] Excess testosterone stimulates excess sebum (oil) production which can in turn block the pores and lead to proliferation of the acne bacterium resulting in acne. Because diet has an indirect effect on acne, individuals will get variable results when changing what they eat as they metabolise food differently.

Acne and Dairy

Data 47,355 women from the Nurses Health Study II was examined to retrospectively evaluate whether intakes of dairy foods during high school were associated with physician-diagnosed severe teenage acne. The study found a positive association with acne for intake of total milk and skim milk. The authors hypothesised that the association with milk may be because of the presence of hormones and bioactive molecules in milk.[3]

In another study, researchers implicate the high levels of refined carbohydrates (such as bread and cereals) in teenage acne. Following a similar rationale, they suggest that high levels of blood sugars increase the levels of insulin and insulin-like growth factor (IGF-1), which leads to excess production of male hormones. These male hormones then trigger acne outbreaks. And as well as that, insulin-like growth factor (IGF-1) encourages certain skin cells (keratinocytes) to increase. Keratinocytes are also implicated in acne.

In order to treat acne with insulin resistance avoid poor quality carbohydrates such as white bread, sugar and pasta and spuds. These types of carbohydrates are digested quickly and enter the blood stream rapidly. This is often referred to as high GI or GL glycaemic index or glycaemic load. See diets the zone diet for information on Low GI foods and recommendations.

Poor Eating Habits and Acne

Irregular hours of eating, excessive starch consumption, too much of sugar, fried and fatty foods are also common causes of acne. Chronic constipation is another cause of acne vulgaris. Chronic constipation leads to toxins being reabsoped and then re-circulated into the bloodstream. The skin is then forced to eliminate them. The extra efforts of the skin to eliminate excess waste results in acne and other forms of skin disease such as eczema and psoriasis.

Poor Elimination via the Skin

Acne is also caused due to a devitalised condition of the skin which is a result of unhygienic living habits, excessive consumption of tea, coffee, alcohol or tobacco, and sedentary habits, which lead to general debility and under functioning of the eliminatory organs.

Insulin Resistance and Testosterone in Men and Women

In healthy men however there is an inverse association between testosterone and insulin. Total plasma testosterone decreases with each decade of age and insulin increases with each decade of age.[4] Another small study's results indicate that insulin resistance (i.e. high insulin) in men is associated with reduced testosterone secretion and may be due to alterations in the hypothalamic Pituitary Gonadal (HPG) axis and to reductions in sex hormone binding globulin (SHBG). Interestinlgy if men have low testosterone level and also low SHBG, the prostate will convert testosterone to a Dihydrotestosterone or DHT will results in male pattern baldness and both Benign Prostatic Hyperplasia BPH and prostate cancer.

In women, excess insulin can cause higher levels of male hormones or androgens. These androgen hormones have long been implicated in acne. They increase the sebum (oil production)of the sebaceous glands, which clogs pores and provides a breeding ground for the acne bacteria, A pyrogens.

Inflammation and Acne

The western diet is high in unsaturated fatty acids that promote inflammation. When the sebaceous glands rupture, the sebum is more irritating and inflammation is more severe. A diet high in arachidonic acid (basically in red meat and dairy) and low in omega 3 (basically fish and flax) promotes inflammation.

Nutritional therapy for acne

Niacin

Nicotinic acid (also generally known as niacin) and niacinamide (also known as nicotinamide) are similarly effective as a vitamin because they can be converted into each other within the organism. The blanket term vitamin B(3) is used for both. In ageing skin, topical application of niacinamide improves the surface structure, smoothes out wrinkles and inhibits photocarcinogenesis. It is possible to demonstrate anti-inflammatory effects in acne, rosacea and nitrogen mustard-induced irritation. Because of its verifiable beneficial effects, niacinamide would be a suitable component in cosmetic products for use in disorders of epidermal barrier function, for ageing skin, for improving pigmentary disorders and for use on skin prone to acne.[5]

Niacin in combination with zinc is being assessed in clinical studies for the treatment of inflammatory skin diseases such as acne vulgaris. The basis for these investigations is the variety of potential mechanisms of action of nicotinamide and zinc, including an anti-inflammatory effect via inhibition of leukocyte chemotaxis, lysosomal enzyme release, lymphocytic transformation, mast cell degranulation, bacteriostatic effect against Propionibacterium acnes, inhibition of vasoactive amines, preservation of intracellular coenzyme homeostasis, and decreased sebum production. Other possible mechanisms involve suppression of vascular permeability and inflammatory cell accumulation, as well as protection against DNA damage.[6] Vitamin therapy should comprise the intake of 100 mg niacin, three times daily. Niacin is contraindicated in acne rosacea unless it is a no flush niacin.

Zinc and Acne

Studies have shown that acne sufferers have lower-than-normal levels of zinc in their bodies.[7] Zinc was found to be superior to Vitamin A in the treatemtn of acne. The effects of oral zinc sulfate (corresponding to 135 mg of zinc daily) alone and in combination with vitamin A (300,000 international units) daily on acne lesions were compared with those of vitamin A alone and of a placebo. The number of comedones, papules, pustules, and infiltrates were counted at each visit. After four weeks, there was a significant decrease in the number of papules, pustules, and infiltrates in the zinc-treated groups. The effect of zinc plus vitamin A was not better than zinc alone. After 12 weeks of treatment, the mean acne score had decreased from 100% to 15%. The mechanism for the effect of zinc therapy in acne, to our knowledge, is not presently known. Howver zinc is a 5 alpha reductase inhibitor and prevents the conversion of testosterone to DHT, thereby lowering sebum production. Zinc also contributes to improving insulin sensitivity.

Zinc gluconate was compared to the antibiotic minocycline in a multicentre randomised double-blind trial. 332 patients received either 30 mg elemental zinc or 100 mg minocycline over 3 months. The clinical success rate was 31.2% for zinc and 63.4% for minocycline. It was concluded that Minocycline and zinc gluconate are both effective in the treatment of inflammatory acne, but minocycline has a superior effect evaluated to be 17% in the study.[8] Caution The use of megadoses of vitamin and mineral supplements has become common. The authors describe a 17-year-old boy who presented with fatigue after taking large daily doses of zinc supplements for 6 to 7 months in an attempt to treat his acne. A zinc-induced hypocupremia developed, causing anemia, leukopenia, and neutropenia. Anemia and neutropenia resolved 6 months after he stopped taking the zinc. Excessive zinc intake can have toxic effects, and questions about patients' use of vitamin and mineral supplements should be asked when medication histories are taken.[9] Common side effects from taking zinc are nausea. Always take zinc on a full stomach. Some zincs such as zinc sulphate are poorly absorbed. Gluconates, citrates and malates are much more assimilable.

Vitamin A

Topical retinal A has long been used to treat acne. A retrospective, investigator-blinded,vehicle-controlled, photographic assessment study was to assess the efficacy of topical retinoids as monotherapy in inflammatory acne. The investigators rated pretreatment and posttreatment photographs of patients who had participated in 12- or 15-week, double-blind comparisons of tazarotene 0.1% gel, adapalene 0.1% gel, tretinoin 0.1% microsponge, tretinoin 0.025% gel, and tazarotene 0.1% cream. Inflammatory acne was improved with all 4 retinoids Results of this study suggest that topical retinoid monotherapy can achieve clinically significant improvements in inflammatory acne.[10] Large quantities of vitamin A-such as 300,000 IU per day for females and 400,000-500,000 IU per day for males-have been used successfully to treat severe acne.11 However, unlike the long-lasting benefits of the synthetic prescription version of vitamin A (isotretinoin as Accutane®), the acne typically returns several months after natural vitamin A is discontinued. In addition, the large amounts of vitamin A needed to control acne can be toxic, resulting in ;liver damage or birth defects and should be used only under careful medical supervision.[11]

Pantothenic acid

For years, the pathogenesis of acne vulgaris has been known to be strongly influenced by hormonal factors. A radically different theory for the pathogenesis od acne is related its basic pathology to a deficiency in pantothenic acid, a vitamin previously not known in medical circles to cause any deficiency syndrome in humans. It was found that the effect of hormonal factors in acne becomes secondary to that of the availability of pantothenic acid. A complete cure of this condition was found to be effected by a very liberal replacement therapy with the vitamin.[12]

Vitamin B5 works by reducing the oil production of the sebaceous glands. This is done by increasing Coenzyme A (Co-A) which increases the metabolic breakdown of oils by normal activity of cell physiology. Pantothenic acid is a major component of Co Enzyme. CoEnzyme A is actually a Pantothenic Acid molecule attached to an ADP molecule. Taking additional B5 increases the amount of Coenzyme A available for use in the cell. The more Co-Enzyme A, the more fatty acids can be metabolized, which means they are oxidized or burned up as energy production.[13]

Iodine in Milk linked to Teenage Acne

Harvey Arbesman, a dermatologist at the University of Buffalo in New York, made the link in a letter published in the Journal of the American Academy of Dermatology. He cited a study published in the Journal last February that suggested hormones and bioactive material in milk may increase teenagers' risk of acne. Arbesman said another cause could be the iodine: "It is well established that iodine can exacerbate acne. Various studies have shown significant levels of iodine in milk in different countries, including the US, Britain, Denmark, Norway and Italy.

"Thus, the observed association of dairy products with acne may be secondary to the iodine content of the dairy products ingested." Arbesman said that giving cows iodine-fortified feed to prevent infection, and using iodine solutions to clean cows' udders and milking equipment, meant there was a lot of iodine in dairy products. [14]

Tea tree

In a single-blind randomly comparative therapeutic clinical trial, a 2% tea lotion was compared with 5% zinc sulphate solution in the treatment of acne vulgaris. Forty-seven patients with acne vulgaris were divided randomly into 2 groups, and were instructed to use the following solutions twice daily for 2 months; group A used 2% tea lotion, group B used 5% zinc sulphate solution. Patients with papulopustular lesions were included in the study, while patients with severe acne were excluded. The clinical improvement was scored by counting the number of inflammatory lesions both before and after treatment. Two percent tea lotion was statistically significant in decreasing the number of the inflammatory lesions in acne vulgaris, while 5% zinc sulphate solution was beneficial, but did not reach statistically significant level as tea lotion.[15]

Home Remedies

Orange Peel Remedy for Acne

Homemade Acne Treatment with orange peel has been found very effective. Pound the orange peel with water on a piece stone and apply on acne affected areas.

Lemon Cure for Acne A simple remedy at home for acne: Apply lemon juice regularly to reduce pimples and acne. This has proven beneficial results Garlic Remedy for Acne Garlic has been used successfully to cure acne. Rub with raw garlic several times a day.

Garlic is known to cure the toughest of acne problems. The external use of garlic helps to clear the skin of spots, pimples and boils. To cure acne further, eat three seeds of raw garlic once daily for a month. This purifies the blood stream and ensures basic cleansing of blood & keeps acne away.

Coriander and Mint Juice Therapy for Acne A teaspoon of coriander juice, mixed with a pinch of turmeric powder, is another effective home remedy for pimples and blackheads. Apply mixture on the face after thoroughly washing it every night before retiring.Use mint juice in a similar manner as coriander juice. Acne Fenugreek Treatment

Fenugreek is another useful remedy for acne. Make a paste of fenugreek leaves and apply over the face every night before going to bed. Wash off with warm water in the morning. This prevents pimples and blackheads.

Cucumber Treatment Grated cucumber applied over the face, eyes, and neck for fifteen to twenty minutes has been found effective. It is the best tonic for your complexion. Its regular use prevents pimples and blackheads.

Well-balanced Acne diet

After the one-week, all-fruit diet, the patient can gradually adopt a well-balanced diet with emphasis on raw foods, especially fresh fruit and vegetables, sprouted seeds, raw nuts, and wholegrain cereals, particularly millet and brown rice. Avoid strong tea/coffee, soft drinks and processed foods Meats, sugar, strong tea or coffee, condiments, pickles, soft drinks, candies, ice cream, refined and processed foods should be avoided as far as possible.

Herbal actions required

Alteratives

Circulatory stimulants

Diuretics

Nervines

Carahealth Skin

This tincture is designed to treat skin diseases such as acne, acne rosaceae, eczema, psoriasis, even skin lesions and ulcers. The tincture functions to improve toxic elimination via the liver and bowel, improve circulation and elimination via the skin and to improve lymphatic functioning so as to decrease lymphatic congestion. It is a general liver and lymphatic tonic and can be used to improve digestive secretions to assist weight loss and increase health and vitality. This tincture is even useful as a general cancer preventative. Not suitable in pregnancy.

Poke root Phytolacca decandra – Phytolacca is an alterative, emetic and purgative. As an alterative herb it will gradually restore the proper function of the body and increase health and vitality. Poke root is a potent lymphatic alterative, useful in combination for skin problems due to lymphatic congestion with associated swollen lymph glands and other signs of lymphatic congestion. According to Mrs. Grieves, “A slow emetic and purgative with narcotic properties. As an alterative it is used in chronic rheumatism and granular conjunctivitis. As an ointment….it is used in psora, tinea capitis, favus and sycosis and other skin diseases….It is used as a cathartic in paralysis of the bowels. Headaches of many sources are benefited by it…. …Authorities differ as to its value in cancer…It is also stated to be of undoubted value as an internal remedy in cancer of the breast.”

Milk thistle Silybum marinarum Milk thistle is astringent, bitter, cholagogue, demulcent, diaphoretic, diuretic, emetic, emmenagogue, galactogogue, hepatic, stimulant, stomachic and tonic. Milk thistle is the trophorestorative of the liver. Milk Thistle can be used to increase the secretion and flow of bile from the liver and gall bladder and contains constituents, which protect liver cells from chemical damage. Silymarin, an extract from the seed, acts on the membranes of the liver cells preventing the entry of virus toxins and other toxic compounds and thus preventing damage to the cells from toxic chemicals and medications. It is used internally in the treatment of liver and gall bladder diseases, jaundice, cirrhosis, hepatitis and poisoning. It is indicated in skin complaints associated with a sluggish liver. As a galactogogue it specifically stimulates the flow of breast milk. Milk thistle also lowers cholesterol levels, reducing insulin resistance and reduces the growth of cancer cells in breast, cervical and prostate cancers. Regeneration of the liver is particularly important in the treatment of cancer since this disease is always characterised by a severely compromised and often partially destroyed liver.

Nettle leaf Urtica dioica – Nettle is astringent, haemostatic, dermatological agent, mild diuretic, tonic; extracts are reported to have hypoglycaemic properties. Nettle is also a natural anti-histamine. It is indicated for rheumatic conditions, uterine haemorrhage, cutaneous eruptions, infantile and psychogenic eczema, epistaxis, melaena. Nettel is specifically indicated in nervous eczema. Nettles are rich in vitamins A, C, D, iron, potassium, manganese, and calcium and chlorophyll making nettle an excellent blood tonic and remedy in anaemia and other debilitated states. They strengthen and support the whole body. Throughout Europe they are used as a spring tonic and general detoxifying remedy. They are specific for rheumatism, arthritis and eczema especially associated with blood deficiency. The herb has an important effect on the kidney and on fluid and uric acid excretion, so is of benefit in gout and other arthritic conditions, particularly if there is an element of anaemia. Urtica is also of benefit in chronic skin conditions such as eczema, helping to cleanse the body of accumulated toxins. Urtica is known to stimulate milk flow in nursing mothers, and is often used in this way by farmers for their stock. It has been shown experimentally to have both hypoglycaemic and hyperglycaemic properties, the hypoglycaemic component being ‘urticin’. Nettle leaf extract contains active compounds that reduce TNF-α and other inflammatory cytokines.

Red clover Trifolium pratense – Red clover is alterative, anti-inflammatory, dermatological agent, expectorant, mildly antispasmodic, relaxant sedative, diuretic and oestrogenic. Red clover is one of the most useful remedies for children with skin problems. It may be used with complete safety in any case of childhood eczema and chronic skin conditions such as psoriasis and acne. It is of particular benefit for children with eczema/asthma syndrome. It is antineoplastic and has been used in the treatment of cancers, especially of the breasts and ovaries.

Burdock root Arctium lappa – Burdock is an alterative, antibacterial, antifungal, antiphlogistic, aperient, blood purifier, carminative, cholagogue, depurative, diaphoretic, diuretic, hypoglycaemic and stomachic. Burdock is one of the foremost detoxifying herbs in both Chinese and Western herbal medicine. It is used to treat conditions caused by an 'overload' of toxins, such as throat and other infections, boils, rashes and other skin problems. The root is thought to be particularly good at helping to eliminate heavy metals from the body. The plant is also part of a North American formula called Essiac, which is a popular treatment for cancer. The plant is antibacterial, antifungal, carminative and can be used to treat fungal infection such as candida. Recent research has shown that seed extracts lower blood sugar levels. In TCM Burdock is known as Niu Bang Zi. The fruits are used. Burdock fruit is said to be pungent, bitter and cold and enters the stomach and lung meridian. It is said to expel wind-heat and benefits throat and is indicated for fever, cough, sore-red-swollen throat, clears heat and relieve toxicity and is indicated for red swellings, carbuncles, mumps, rashes and moisten the intestines and treat constipation due to wind-heat.

Lifestyle Advice

Epsom Salt Detox

A hot Epsom salts bath once a week is beneficial in all cases of acne. Prepare the bath by adding 1 kg of Epsom salts to 60 litres of water having a temperature of about 37.8° C. The patient should remain in the bath tub for 25-35 minutes until he sweats freely. After the bath, the patient should get into bed and warp a clean light coloured sheet around them. Pull the covers up and allow sweating all night. WARNING this is only for the robust. Avoid if suffering from dizziness or hand sweats or night sweats

Carina is available to lecture for your group or institution on this subject.

Carina Harkin BHSc.Nat.BHSc.Hom.BHSc.Acu. is a practitioner of 11 years, complementary medicine lecturer of 4 years and mother of six in Galway, Ireland who practices what she teaches.

For an appointment call Carina directly on 083 34 66 333.

All products are available through www.carahealth.ie. Remember, we are here for a good time not a long time, enjoy your food life!

Carahealth Galway, Acupuncture, Naturopathy, Homeopathy, Herbal Medicine, Nutrition, Nutritional therapy, Flower essences, Iridology, Short courses, Cosmetic Acupuncture

[1] Robyn N Smith, et al., A low-glycemic-load diet improves symptoms in acne vulgaris patients: a randomized controlled trial, American Journal of Clinical Nutrition, Vol. 86, No. 1, 107-115, July 2007

[2] John E. Nestler et al. Insulin Stimulates Testosterone Biosynthesis by Human Thecal Cells from Women with Polycystic Ovary Syndrome by Activating Its Own Receptor and Using Inositolglycan Mediators as the Signal Transduction System1 The Journal of Clinical Endocrinology & Metabolis, Vol. 83, No. 6 2001-2005, 1998.

[3] Adebamowo CA et al., High school dietary dairy intake and teenage acne. J A Acad Dermatol., 2005 Feb;52(2):207-14.Click here to read

[4] Interrelation between plasma testosterone and plasma insulin in healthy adult men: the Telecom Study Journal Diabetologia Springer Berlin / Heidelberg, Vol 35, Number 3, Feb, 1992.

[5] Gehring W. Nicotinic acid/niacinamide and the skin, J Cosmet Dermatol. 2004 Apr;3(2):88-93.

[6] 1: Cutis. The mechanisms of action of nicotinamide and zinc in inflammatory skin disease. Fivenson DP.2006 Jan;77(1 Suppl):5-10 [7] Pohit J, Saha KC, Pal B. Zinc status of acne vulgaris patients. J Appl Nutr. 1985;37:18-25. [8] Michaelsson G, Juhlin L, Ljunghall K. A double-blind study of the effect of zinc and oxytetracycline in acne vulgaris. Br J Dermatol. 1977;97:561-566.

[9] Salzman MB, Smith EM, Excessive oral zinc supplementation. J Pediatr Hematol Oncol. 2002 Oct;24(7):582-4

[10] Leyden JJ, Shalita A, Thiboutot D, Washenik K, Webster G Topical retinoids in inflammatory acne: a retrospective, investigator-blinded, vehicle-controlled, photographic assessment..lin Ther. 2005 Feb;27(2):216-24

[11] Kligman AM, Mills OH Jr, Leyden JJ, et al. Oral vitamin A in acne vulgaris. Preliminary report. Int J Dermatol 1981;20:278-85.

[12] Leung LH. Pantothenic acid deficiency as the pathogenesis of acne vulgaris., Med Hypotheses, 1995 Jun;44(6):490-2

[13]http://www.zimbio.com/Acne+vulgaris/articles/1691/Pantothenic+Acid+Vitamin+B5+Acne+Dr+Jeffrey

[14] http://www.nutraingredients.com/Research/Iodine-in-milk-linked-to-teenage-acne

[15] Sharquie KE, Noaimi AA, Al-Salih MM. Topical therapy of acne vulgaris using 2% tea lotion in comparison with 5% zinc sulphate solution .Saudi Med J. 2008 Dec;29(12):1757-61

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