Ian Spohn, ND, is a staff naturopathic doctor for Energique who enjoys challenging the dogmas of both conventional and alternative medicine. He is a passionate supporter of the paleo diet and classical homeopathy.
Acne is one of the most common skin problems prompting visits to dermatologists and also one of the most stubbornly difficult medical conditions to treat. Its pathogenesis is considered to be completely understood, and yet no good treatments seem to be available. Could it be that there is more to this common skin ailment than is conventionally supposed? According to a fairly recent hypothesis, acne is not a hormonal disorder at all but rather a metabolic disorder, more specifically a disorder of fat metabolism resulting from a deficiency of pantothenic acid (vitamin B5). Acne is a disease of civilization insofar as it is absent among indigenous peoples, so how could it be a vitamin deficiency disease when such are thought to have been eradicated in the Western world? Especially a deficiency of vitamin B5, which is apparently unique among vitamins in that it has no known deficiency syndrome and is thought to be the most easily obtainable. Yet any theory to explain acne must account for all the phenomena associated with that disease, and no other theory seems to fit the picture better than B5 deficiency.
The conventional theory of acne is fairly simple and blames the sex hormones which your body is naturally supposed to have. Androgen hormones are known to stimulate the activity of the skin’s sebaceous glands. Overactivity of the sebaceous glands causes too much oil secretion, which clogs pores, and then a commensal organism called Propionibacterium acnes begins to thrive in the anaerobic environment created, metabolizing the skin oils into inflammatory byproducts which trigger an inflammatory response within the pore causing acne. Everything can be traced back to “too much” sex hormone, specifically too much male sex hormone. This makes it seem like acne is an inevitable part of going through puberty, and yet it is virtually absent among indigenous peoples living in traditional cultures when they go through puberty, even among some “lucky” Western children when they go through puberty. It also, more and more commonly in the Western world, continues to afflict people into adulthood, after hormone levels are supposed to have stabilized.
The androgen theory of acne has three main pieces of supporting evidence. One, it always begins during puberty, when sex hormone levels dramatically rise. Two, androgens increase the oiliness of the skin by directly stimulating the production of sebum in the sebaceous glands. And three, it has long been noted that male eunuchs do not get acne, implying that a lack of testosterone makes one immune to developing acne. There are, however, numerous problems with this theory; the most glaringly obvious one, which makes it almost embarrassing that doctors would actually blame acne on androgen activity, is the disease’s strikingly equal sex distribution. In other words, acne affects women and girls with more or less the same prevalence as men. Unlike testosterone, the female hormones estrogen and progesterone do not increase the activity of the sebaceous glands, so if excess androgens were the cause, one would expect acne to be either ten times more prevalent or else ten times more severe in males than in females, who of course have at least ten times the amount of androgen coursing through their bloodstreams, yet this is not at all the case. An easy way to prove (or disprove) the androgen theory would be to simply test the androgen levels of boys with and without acne, to see if there’s a difference. Surprisingly, this research has actually been done, and it was found that people with and without acne have no difference in testosterone levels.[iii] Yet, the fact remains that castration apparently cures acne. To reconcile these phenomena, a new theory is needed and a deficiency of vitamin B5 would actually seem to explain everything.
Vitamin B5 is unusual in that unlike most of the other vitamins, it has no known deficiency syndrome. In fact, B5 deficiency is so poorly characterized that there aren’t even any clear-cut symptoms to associate with it, other than general fatigue. The problem with studying B5 deficiency is that it is nearly impossible to actually become deficient in vitamin B5 without becoming deficient in most of the other B vitamins as well, making it difficult to ascertain the symptoms of B5 deficiency in isolation. In fact, B5 is so easily obtained from food that its chemical name, pantothenic acid, refers to its universal availability. Since every plant and animal cell contains pantothenic acid, it would seem the only way to become truly deficient would be starvation, or perhaps parenteral feeding if someone forgot to add some B5. Eat just about anything from the plant or animal kingdom, and you’re sure to get some B5 with your meal. Yet despite having no known deficiency syndrome, B5 is undeniably a vitamin in the sense that the body needs it to function, yet is unable to make it. B5 is a necessary constituent of the all-important coenzyme A, a molecule composed of B5, the amino acid cysteine, and a molecule of adenosine triphosphate (ATP). B5 is therefore necessary to obtain energy from food via the Krebs cycle, as food metabolites cannot enter the Krebs cycle without being first bound to coenzyme A, to form acetyl coenzyme A. Vitamin B5 is also required to catalyze the synthesis of new fats in the body, including cholesterol (the body typically makes four times more cholesterol than the diet provides) and all the steroid hormones derived from cholesterol. This is where vitamin B5’s relation to acne becomes apparent: it is required to burn fats as energy, as well as to synthesize sex hormones. It is, in fact, required to synthesize all the steroid hormones, not just the androgens on which acne is blamed.
Most sources of nutritional information will tell you not to worry about getting enough vitamin B5 because it’s universally found in food, and so merely getting enough to eat in general will probably take care of your B5 requirements. This is theoretically true, but there is one important scenario for which this may not be the case: processed foods, especially very high-calorie processed foods (that is, most of them). Because vitamin B5 is required to turn food calories into energy, calorie-containing foods therefore need to contain vitamin B5 to make enough coenzyme A to metabolize those calories. There must be a healthy balance between consumption of calories and consumption of the vitamins required to burn those calories. Simply obtaining calories from whole foods in their natural state seems to solve this problem without much effort, but now consider the consumption of so-called empty calories, highly processed foods which provide plenty of energy to the body with virtually no vitamins. When calories are obtained from refined sugar, highly processed seed oils, or the starch of refined grains, the B5 content of the plant cells from which these empty calories were originally derived does not make it into the finished food. You’re consuming purified energy stripped of the factors required to utilize that energy, like buying a toy without batteries. This forces the body to draw upon its own batteries that it meant to use to power something else, meaning that eventually something has to give. Unless these empty-calorie junk foods are consumed in concert with other foods that are comparatively rich in B5 while being comparatively low in calories, it will create an enormous imbalance between energy consumed and B5 provided, preventing the body from utilizing that excess energy. What then happens to all of that excess energy?
Possibly it is simply stored as unusable fat, which could potentially explain the role of processed foods in the obesity epidemic. Another theory is that excess fats and oils, or excess sugar that the body has converted into fats and oils, that cannot be used for energy can “spill out” through the sebaceous glands to be eliminated through the skin, similar to how excess blood sugar can spill into the urine. Is acne basically the diabetes of fat? Consumption of high-calorie foods in the absence of B5 or the other vitamins required to fully metabolize those calories leads to elimination of the excess oils through the sebaceous glands, clogging pores and, in fact, being the true cause of acne. That acne can result from eating too much processed junk food, especially fried foods (providing high quantities of processed seed oil) and sweets (the refined sugar in which is quickly converted to fat in the body), is colloquially known and considered a piece of well-established conventional wisdom. However, scientific research on the link between diet and acne remains controversial, since studies usually fail to show a clear association between acne and any one food culprit used as the subject of the study. This may be because scientific studies typically look at only one broad type of food, such as “dairy” or “dietary fat,” without any regard for whether the foods consumed were whole or processed. If the true dietary culprit is processed empty calories causing a relative deficiency of vitamin B5, this would be difficult to precisely quantify for the purposes of scientific research. How would one separate the sugar added to chocolate milk from a glass of unmodified whole milk in a study of acne and dairy consumption or the soybean oil in a plate of French fries from the sour cream on a baked potato in a study of total fat intake? But while science, with its inherent limitations, has failed to definitively link diet to acne, conventional wisdom and experience has made it clear that junk food does play a role. Acne is undeniably a disease of civilization because it is virtually absent among teenagers in indigenous groups consuming a traditional diet free of junk food.
The theory that acne is caused by a vitamin B5 deficiency was first postulated by doctor Lit-Hung Leung, MD in Medical Hypotheses.[vi] His theory goes that vitamin B5 is a crucial cofactor in the synthesis of all steroid hormones, including both male and female sex hormones, so the onset of puberty and consequent increased synthesis of these hormones in girls and boys would dramatically increase their vitamin B5 requirements, straining the body’s B5 pool and unmasking a deficiency if levels were only borderline-adequate to begin with (on a standard American diet, probably the case). Castration, that is permanently removing two glands which synthesize large quantities of steroid hormones daily, would lessen the body’s need for B5 and effectively compensate for such a deficiency. The idea is that the synthesis of sex hormones depletes B5 levels, which then compromises the body’s ability to fully metabolize fats, as this process also requires vitamin B5. These unusable excess fats, since they cannot be broken down into energy, end up being wastefully eliminated through the skin which clogs pores. Bacteria on the skin then begin to metabolize these unused fats instead, creating inflammatory byproducts and triggering an immune response within the pore causing acne. Since additional B5 is required whenever additional steroid hormones are synthesized, this would explain many phenomena related to the onset of acne: why it develops during puberty (increased steroid hormone synthesis), why it tends to flare in women premenstrually (increased hormone synthesis at this time), why acne can also worsen during pregnancy (again, hormones), and even why stress can exacerbate acne: cortisol produced during the stress response is also a steroid hormone. This might also explain why birth control pills can sometimes do wonders with acne: the exogenous steroids in birth control pills replace and suppress the natural production of hormones in the menstrual cycle, easing the demand for B5 and freeing up more for the proper breakdown of fats.
The B5 deficiency theory would also explain why processed junk foods of all types, not just sugar, chocolate, fat, dairy, etc., can cause or worsen acne. Consuming large quantities of calories in processed foods would put heavy demands on the body’s B5 pool without replenishing it to the degree that consuming whole, natural calories would. Empty calories in the form of refined sugar would be the worst, since B5 would be required to convert the sugar into fat and then more B5 would be needed to then turn that fat into energy, whereas turning processed fats into energy would only drain B5 levels once. Acne’s known association with sugar has earned it the nickname “diabetes of the skin.” This is believed to be due to sugar increasing sebum production via mTORC1, but the B5 deficiency theory would also fit here. And then there are the case reports of acne developing after vitamin B12 supplementation.[vii]. How would vitamin B12 cause acne according to the conventional theory? It is well known that the B vitamins work together as a complex, and so supplementing too much of one can upregulate certain metabolic processes and consequently deplete the others, which is why B12 can mask a folate deficiency, for instance. So a B5 deficiency induced by excess vitamin B12 could potentially account for this phenomenon too.
There have been two clinical trials of pantothenic acid as an acne therapy: one published by Dr. Leung himself in the journal Medical Hypotheses,[viii] and one published in the journal Dermatology and Therapy.[ix] Both used very high doses of pantothenic acid (10 grams and 2.2 grams per day), but both reported positive results, though in some cases of severe acne, it took up to six months of supplementation to produce a marked effect. This may imply that the body’s B5 pool is something that can be gradually depleted over years of eating junk food and may sometimes need to be gradually replenished by months of high-dose supplementation. B5 is a water-soluble vitamin, and it is conventionally held that the water-soluble vitamins are not stored in the body since no watery storage depot has yet been identified, as in contrast with adipose tissue for storing fat-soluble vitamins. But this isn’t true because the body is known to store up to several years’ worth of vitamin B12 and B12 is a water soluble vitamin. So the theory that water-soluble vitamins cannot be stored in the body could well be completely wrong, just like the theory that acne is caused by excess androgens. Vitamin B5 supplementation is considered safe even in high doses, mostly because the transporters get saturated and limit absorption beyond a certain dose, though there is some concern that too much B5 can induce a biotin deficiency, since these vitamins compete for the same transporters. There are also much older studies reporting vitamin B6 to be the cure for acne,[x] so the problem may not truly be as simple as a deficiency of B5 alone. The good news is that your hormones are probably not to blame for your acne, but rather a lack of nutrients in your diet, which is a problem more easily remedied and over which you have much more control. It should also remind healthcare practitioners of the important role that the B vitamin complex can play in the treatment of skin disorders.
[i] 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
[ii] Hamilton J, Mestler G. Effect of orchiectomy and oophorectomy upon existent and potential acne. Journal of Investigative Dermatology. 41:249-53, Nov. 1963
[iii] Sultan C, Oliel V, Audran F, Meynadier J. Free and total plasma testosterone in men and women with acne. Acta Derm Venereol. 1986;66(4):301-304.
[iv] Hamilton and Mestler 1963
[v] Cordain, Lindeberg, Hurtado, Hill, Eaton, Brand-Miller 2002.
[vi] Leung LH. Pantothenic acid deficiency as the pathogenesis of acne vulgaris. Med Hypotheses. 1995;44(6):490‐492. doi:10.1016/0306-9877(95)90512-x
[vii] Martínez de Espronceda Ezquerro I, Oscoz Jaime S, Yanguas Bayona JI. Vitamin B12-induced acne. Acné inducido por vitamina B12. Med Clin (Barc). 2018;151(3):e15. doi:10.1016/j.medcli.2018.01.002
[viii] Leung 1995.
[ix] Yang M, Moclair B, Hatcher V, et al. A randomized, double-blind, placebo-controlled study of a novel pantothenic Acid-based dietary supplement in subjects with mild to moderate facial acne. Dermatol Ther (Heidelb). 2014;4(1):93‐101. doi:10.1007/s13555-014-0052-3
[x] Jolliffe N, Rosenblum L, Sawhill J. The effects of pyridoxine (vitamin B6) on persistent adolescent acne. Journal of Investigative Dermatology. Feb. 16 1942. Accessed online 5/28/2020 at https://core.ac.uk/download/pdf/82274731.pdf
Any homeopathic claims are based on traditional homeopathic practice, not accepted medical evidence. Not FDA evaluated.
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