Acne

ACNE FROM THE INSIDE OUT

Acne - this one hits home as acne as something I’ve fought with myself. Wakening with a big painful pimple or a patch breakout could crumble my spirit for the day, affecting me personally and professionally. Each time a patient came in for support of acne, my stomach flipped. “Why would they listen to my advice when they see my own blemishes?” I would feel unconfident, ashamed, anxious, embarrassed, and unhealthy. As a Naturopath, I felt I should be able to set an example of being ‘healthy from the inside out’. The truth is, my own negative experiences made me a better doctor. This is because I dig deeper to find solutions through never-ending research, courses, and webinars. Moreover, I empathize with clients who have been impacted in the same way. Although my skin might not always be perfect, it is a lot better than it was, and I have the tools to unravel the layers and manage outbreaks. Most importantly, it has made me realize that nothing is wrong with me but rather, I am just human, learning to deal with life’s challenges and opportunities. It is my goal to empower you to feel the same, to take control of your acne, and to feel confident in your body.

CAUSES / TRIGGERS

I encourage you to circle or list what triggers might apply to you.

Digestive imbalances (e.g., dysbiosis, constipation, excessive bloating, food intolerances). 
Multiple factors can disrupt our gut including our environment, the foods we eat (or don’t eat), medications, food poisoning, environmental toxins, stress, and more. When our gut is inflamed and overloaded, we develop systemic inflammation and are unable to absorb the nutrients we require to heal. Typically, when there is a skin disruption there is also a gut disruption.

Hormone imbalance (e.g., insulin, androgens, estrogen and progesterone). 
Insulin resistance and blood sugar imbalances signal your ovaries and adrenals to produce androgens. High androgens, such as testosterone and dihydrotestosterone (DHT), can increase sebum production, increasing the likelihood of clogged pores and bacterial invasion. Estrogen and progesterone imbalances can also effect oil production in the skin when, in excess, max out the liver’s capacity to detoxify. This creates a greater demand on the skin. Conditions such as polycystic ovary syndrome (PCOS) may incorporate some or all of these imbalances.

Stress. 
Stress can be a root cause of impaired digestion and hormone imbalance, and lead to acne. For example, one study showed a two-day lag period between a stressful event and acne flare-up! Although we cannot always control our stressors, we can control our stress response by giving our body what it needs (see more under ‘treatment’).

Medications (e.g., recurrent antibiotic use, hormonal birth control methods). 
Multiple different medications can disrupt the gut microbiome, increase inflammation and toxic load, and decrease nutrient absorption. An overloaded digestive system will rely on other elimination pathways to detoxify, such as the skin, and the result can be acne. A list of medications that can contribute to acne include anabolic steroids, antibiotics, anti-epileptic drugs, bromine, corticosteroids, cytostatic drugs, halogens, hormones, and hormonal contraceptive options (IUD, pill), immune-modulating or suppressive drugs, iodine, lithium, psychotherapeutic drugs, sirolimus, SSRIs, TCAs, and vitamin B12.

Environmental toxins (e.g., hormone disrupting chemicals in plastic containers, cosmetics, household products, foods with pesticides and herbicides, receipts). 
Environmental toxins are hiding everywhere and it is up to us to make smarter choices to decrease our toxic load.

Nutrition. 
Our skin is impacted by the foods we eat (or don’t eat) and how much we eat (over nutrition). Overeating increases Insulin Like Growth Factor 1 (IGF-1) and appears to worsen acne.

Dehydration. 
Plenty of water is essential to flush out toxins through out sweat, feces, and urine. Hindered detoxification leads to inflammation and acne.

Skin irritants (e.g., hygiene products, picking, drying, sun damage). 
Skin irritants can affect skin barrier function while disrupting the skin’s natural microbiome and leaving it vulnerable to breakout.

Bacterial exposure (e.g., infrequent washing of cellphones, pillowcases, face cloths, masks). 
Just as contaminated food causes food poisoning, constant exposure of your face to bacteria can result in breakout. Cheeks are a common area for bacterial breakouts due to cellphone usage.

Hindered detoxification (e.g., suboptimal liver metabolism, constipation, under-sweating, sedentary): 
When the body is unable to detoxify efficiently through one of the emunctories (skin, kidney, intestines, lungs, liver) the burden is increased for the others (e.g., the skin). The skin detoxifies via sweat, the kidney via urine, intestine via poop, tbe lungs via efficient breathing, and the liver via nutritional and hormonal recycling/elimination.

Inflammation.
A multitude of inflammatory factors contribute to red or pustular breakouts. These include stress, dairy, smoking, constipation, environmental toxins, dehydration and more.

Genetics. 
Family history and genetics can increase the risk of acne. In this case, cutting out dairy can sometimes reduce acne flares.

DO YOU HAVE ANY OF THESE ASSOCIATED SYMPTOMS?
If so, this could help us find the root cause.

• High androgens (DHT, testosterone): hirsutism (abnormal or excess hair growth on the chin, upper lip, abdomen or breasts), alopecia (thinning hair on the head), oily skin

• Insulin resistance / blood sugar imbalance: feeling shaky, irritable, fatigued or light-headed when hungry, weight loss resistance, frequent sugar cravings, frequent infections (e.g., yeast infections, urinary tract infections), frequent urination

• Estrogen and progesterone imbalance: premenstrual syndrome (PMS), heavy or painful periods, fibroids, endometriosis, menstrual clotting and pain, irregular periods

• Polycystic ovarian syndrome (PCOS): infrequent or absent menses, polycystic ovaries (“string of pearl sign”), signs of high androgens, insulin resistance, and/or estrogen and progesterone imbalances

LOCATION CAN GIVE US A CLUE TO THE CAUSE

ACNE TRACKING
I recommend tracking your acne for 1 to 3 months using the acne tracking table below (prior to or upon initiation of treatment). This will help us decipher your primary causes/triggers to develop a more specific treatment plan which, in turn, will lead to more effective results. For example, if your breakouts typically occur before each menstrual cycle we may focus on hormone regulation. This step may not be necessary if you are already aware of your triggers.

OBJECTIVE MEASURES

ESTABLISHING AN BASELINE TO MONITOR PROGRESS

Prior to starting treatment, I recommend (A) performing a lesion count, (B) taking a photo, and/or (C) using the skin scoring table below to grade severity. These should be done during the worst time of the month (if there is one) to create an objective baseline reference point to review once the treatment course is complete. Once treatment has started, I highly suggest avoiding lesion counts, progress photos, and/or grading until the course of treatment is complete. Day-to-day comparisons can be defeating and frustrating since skin healing occurs gradually over time. 

LABS AND TESTING

Labs aren’t always indicated for acne but can be helpful when determining causative factors. Specific labs are generally chosen based on clinical presentation and patient history.

If suspecting hormonal acne, these labs may be helpful:

• Androgens: total testosterone, free testosterone (= active form), DHT; test these in the morning

• Estradiol, progesterone; test around day 21 of menstrual cycle

• Blood sugars: fasting insulin and glucose (use HOMA-IR to determine if insulin resistant), HgA1c, IGF-1; test fasted in the morning

• Thyroid hormones: TSH, fT3, fT4, anti-TPO; test in the morning

• Stress hormones: DHEA-S, cortisol; test in the morning

If suspecting polycystic ovarian syndrome (PCOS):

• Test all of the above with the addition of LH, FSH, SHBG, AMH, androstenedione, 17-OHP, prolactin, HCG (if absent period)

• A pelvic ultrasound may also be warranted 

If suspecting nutrient deficiencies:

• Zinc tally test (especially indicated if have a copper IUD or weak immune system)

• Fatty acid profile (if suspecting inflammation and omega-3 deficiencies)

• Vitamin D (especially indicated in winter, weak immune system, low mood, low sun exposure)

If suspecting concomitant skin conditions:

• Skin scrape

Other comprehensive tests:

• Gut health panel (e.g., GI Maps)

• Comprehensive hormone panel (e.g., DUTCH Complete)

Treatment

When treating acne there is no cookie-cutter approach or magic pill, but rather a multitude of approaches to rebalance. Each treatment plan is individualized to address the root cause(s). A course of treatment, and estimated time to observe improvement, can take 3 to 8 months. Healing takes time so do not give up if results aren’t immediate. Let’s dive in and see which options speak to you!

STEP 1: PRACTICE SELF-CARE AND REDUCE STRESS

• Unfortunately, stress is a trigger. Although we cannot always control our stressors, we can control our stress response by giving our body what it needs. Each day, ask yourself “what do I need to make today great/better?” 

• Self-care looks different for everyone and it should not be something you dread doing (maybe self-care means not doing something). Examples of self-care include naps, rest, exercise, connection, reading, nature-time, meditation, bathing, a nourishing meal, journaling, saving chores for another day, therapy, gratitude, positive intentions, allowing yourself space to feel crummy, monthly massages, acupuncture, etc.

• Think I am “full of it?” Research shows that cognitive behavioural therapy (CBT) alone reduced acne severity and picking scores after two months. It also resulted in faster complete resolution (i.e., 5 months versus 8 months).

STEP 2: SUPPORT NATURAL DETOXIFICATION

• Sweat regularly to improve circulation, reduce bodily inflammation, and support detoxification.

• Hydrate! Adequate hydration is essential for optimal body function since water is the means by which both wastes and nutrients travel. I recommend starting each day with a large glass of lemon water. Prepare the night before by soaking 1/4 lemon (rind included) in 1 to 2 cups of water. It’s also a good idea to filter your water using Stantevia or a high quality water filter.

• Ensure daily bowel movements - fibre, squatty potty, regular toilet times, hydration, magnesium.

• Reduce toxic load - use natural cleansing and hygiene products, choose electronic receipts, store food and water in glass or metal containers, avoid plastics, choose organic or home-grown produce, eat grass-fed meats, refrain from smoking (nicotine increases sebum production and decreases skin vitamin E).

STEP 3: OPTIMIZE NUTRITION AND DIGESTIVE HEALTH

In order to optimize skin repair we need (1) nutrient-dense foods to assist healing, and (2) meal regularity to balance blood sugar. I recommend 3 to 4 meals per day spaced 2 to 3 hours apart and every meal should include protein (fist-sized portion), a healthy fat (1 to 2 tablespoons), a complex carbohydrates (palm-sized portion) and vegetables (1/2 plate). 

Foods to Include

Fruits and Vegetables.

Vegetables are high in nutrients, antioxidants and fibre (all of which contribute to detoxification, blood sugar regulation and repair). I recommend changing it up each week since each colour has different nutritional benefits (i.e., the common saying, “eat the rainbow”). Some great examples include:

• Leafy greens and cruciferous vegetables such as asparagus, arugula, broccoli, broccoli sprouts, cabbage, cauliflower, kale, mustard greens, spinach.

• Onions and garlic (also have an antimicrobial effect).

• Orange foods such as squash, sweet potatoes, carrots, and apricots (high in vitamin A for glowing skin).

• Berries (lowest effect on blood sugar spikes out of all the fruits, tremendous amounts of antioxidants)

Lean Proteins.

Protein stabilizes blood sugar and helps us feel satiated.

• Lean meats: chicken, SMASH fish, turkey, prawns

• Egg whites

• Legumes: beans, chickpeas, lentils, soy

• Seeds: chia, hemp

Healthy Fats.

Skin inflammation, which can trigger acne, can be counteracted with anti-inflammatory fat in the diet. For example, some studies show that people who eat more fish have lower acne scores. Healthy fats are also required to synthesize and balance hormones. These include:

• Avocado, avocado oil (for cooking)

• Olives, extra-virgin olive oil (for salads)

• Seeds (chia, fresh ground flax, hemp, pumpkin, sesame) … and in your smoothie or sprinkle on your salads

• SMASH fish (salmon, mackerel, anchovies, sardines, herring)

• Nuts, unsalted and raw (almonds, Brazil nuts, cashews, hazelnuts, macadamia, pistachios, walnuts)

Complex Carbohydrates.

Carbohydrates give us quick energy, and are divided into complex and simple sugars. Complex carbohydrates take longer to break down and thus are less likely to spike blood sugar. They also contain more nutrients such as B-vitamins. Swap your simples for complex carbs.

• Simple carbohydrates (typically white in colour): white rice, white potatoes, white flour-based pastas, bananas, sugar

• Complex carbohydrates: brown rice. yams, legume-based pastas, berries

Other Acne Supportive Foods.

• High fibre foods (vegetables, nuts, seeds, legumes) to cleanse the bowel, detoxify and balance hormones. Aim for 35 grams per day. 

  Note: 2 tbsp of fresh ground flaxseed is equivalent to half of your daily fibre intake. Simply add it to your smoothie or salad. In addition to its detoxifying effects, flaxseed can also lower circulating testosterone levels to lessen acne.

• Probiotic-rich foods such as coconut yogurt, chickpea and rice miso, kefir, kimchi, pickled vegetables, and sauerkraut. These help diversify our microbiome for optimal digestive health.

• Nutritional yeast. 2 to 3 grams three times daily may reduce insulin sensitivity and acne. Avoid if on MAO inhibitors.

Foods to Reduce (to 1-3 servings/week)

I am not a fan of a restricted approach simply because we want what we cannot have and this takes a toll on our mental health. Instead, I emphasize the importance of adding the ”nutritious and delicious” from above, establishing an intuitive balance that makes our bodies (and skin) feel good, and enjoying the foods below on special occasions (versus regularly) guilt-free.

Dairy.

E.g., cheese, milk, sweetened yogurt, ice-cream, whey protein (less concerned about grass-fed butter)

Research shows overconsumption of dairy can worsen acne by increasing inflammation, IGF-1, DHT, and oil production. Minimize dairy to less than three servings per week with an emphasis on smaller servings and/or organic, whole dairy products. Studies have actually shown that whole milk products contribute less to acne outbreaks than skim milk products (i.e., women who drank two or more glasses of skim milk per day were 44% more likely to have acne). Acne is more likely to worsen with dairy given a positive family history. 

Chocolate

There is strong evidence that chocolate can worsen acne lesions, sometimes in as little as three days. One study even compared chocolate with jelly beans and found the chocolate group to have a significant increase in acne lesions after just 4 weeks. If you suspect chocolate is one of your triggers, try eliminating it and monitor improvement over 2 months.

Saturated fats.

E.g., fried foods (deep fried chicken, fries, burgers, chips), red meat (pork, beef), unhealthy oils (canola, peanut, soy, and vegetable oils)

Generally, I do not recommend eliminating all red meat from the diet, especially good quality grass-fed red meat. Red meats are high in iron, B-vitamins, zinc and thus do have nutritional benefit. However, relying solely on red meats can increase inflammation as they predominately contain omega-6 versus the anti-inflammatory omega-3. Include 1 to 2 portions of red meat per week.

So what oils should we include? (1) Olive oil is my favourite for cool temperatures, such as on a salad or drizzled over legume-based pasta. (2) Coconut oil is great for medium temperatures, such as frying yams in turmeric or baking breakfast muffins. (3) Avocado oil is best for high heats, such as when making a stir-fry.

Sugar and refined carbohydrates.

E.g., muffins and other baked goods, candy, gluten, white bread, white pasta, sweet coffee beverages, soda, juice.

Blood sugar imbalances may be a cause/trigger of acne (and inflammation). Try a monthly sugar cleanse or slowly start swapping simple carbs (e.g., white breads and pastas) for complex carbs (e.g., sweet potato or legume-based pastas) and processed/refined foods (e.g., granola bars) for whole foods (e.g., nuts and seeds).

STEP 4: ESTABLISH GOOD SKIN HYGIENE

• Regularly wash bacteria-exposed surfaces such as pillowcases, make-up brushes, face cloths (if using), and cellphones.

• Do not touch or pick! Not only will this wreak havoc on your skin barrier, but it will also spread bacteria, increase inflammation, and lead to scarring later on.

• Ice! At the first sign or sensation of a pimple, specifically an inflammatory cystic one, ice it! This can reduce inflammation and result in a less severe and painful breakout.

• Enjoy safe sunshine. Excess sun exposure causes inflammation and the production of comedogenic agents in the skin.

• Use natural, fragrance-free products.

An Optimal Cleaning Regime

• Cleanse twice daily. Splash face with warm water in the morning and use a cleanser or mild, natural ingredient soap in the evening. Try cleansing without a cloth but if you want to use one opt for a soft microfibre cloth, ensuring a clean one every day or every other day. Avoid regular use of cleansers/soaps with antimicrobial properties as this can encourage antibiotic resistance and destroy healthy skin. Avoid over-cleansing (an extra-rinse post workout is fine) as this can strip the natural oils from your face and lead to a rebound effect of sebum overproduction.

• Use a toner after cleansing to help close the pores and prevent bacterial invasion. A product example would be Graydon Face Food Mineral Mist.

• Moisturize! This is essential for cell turnover and repair. One of the biggest myths is to dehydrate the blemish. One of my personal favourites is a compounded 4% niacinamide cream which helps reduce sebum production and thus prevent acne. It’s also brightening and can reduce redness.

• Exfoliate one to three times per week with lactic acid (versus abrasive beads that can damage the skin). A product example is Pure + Simple Lactic Acid 5%. Lactic acid is especially good for blackheads, which are essential oxidized pores. It is best to exfoliate in the evenings when make-up doesn’t need to be re-applied.

• Finish with SPF! Sun damage is one of the causes of acne in the first place. Ensure you choose a produce with zinc oxide as the main ingredient (versus harmful chemical such as oxybenzone, avobenzone, homosalate, oxtocrylene, octisalate). A few product examples include Color Science Face Shield SPF, Coola Cucumber Matte Sunscreen, Alumier Clear Shield, Green Beaver Mineral Sunscreen for Face, and Andalou Naturals Clean Skin Sunscreen.

STEP 5: SUPPLEMENTS TO SUPPORT ACNE

Zinc
I highly recommend zinc for most types of acne. Zinc deficiency can be a cause of acne due to its supportive role in the immune system and its ability to inhibit bacteria from growing in sweat glands. It’s also important for vitamin A absorption to promote skin repair. Those with a weak immune system, a copper IUD (copper depletes zinc) or who have persistently used the birth control pill (also depletes zinc) may be at higher risk of zinc deficiency.
Dose: Zinc (citrate, sulphate or picinolate) 15 to 50mg daily with food for 3 months.
Safety: Not to be taken long-term as it can deplete copper. May cause GI upset or nausea.
Food sources: Oysters and pumpkin seeds.

Omega-3
Omega-3 fish (or algae) oils have anti-inflammatory and hormone-balancing effects (and can also improve mood). 
Dose: 1000 mg combined EPA and DHA daily for at least 3-6 months. Choose high quality brands that use ethically caught, low mercury fish (e.g., NutraSea). Once opened, refrigerate your fish oils.
Food sources: SMASH fish, seeds (hemp, chia, flax), olive oil, avocado. (note: I highly suggest omega-3 supplementation unless fish is being consumed at least three times per week.)

Probiotics
Probiotics are shown to control the growth of P. acnes, decrease sebum production, and decrease expression of the gene related to the release of inflammatory cytokines, the inhibition of pathogenic CD8 T-cells and the activation of regulatory T cells. They also play a role in insulin modulation to support acne and are especially indicated while using antibiotics (2 to 3 hours apart) or if there is a history of recurrent antibiotic use.
Dose: Probiotics (containing Lactobacillus rhamnosus GG) daily with food for 3 months. Refrigerate once opened. Recommended brands include Genestra Brands, Nutritional Fundamentals for Health (NFH).
Food sources: Coconut yogurt, kefir, kimchi, pickled vegetables, and sauerkraut.

Vitamin D3
Vitamin D deficiency has been associated with acne and acne inflammation. The more severe the deficiency, the worse the acne. Research shows that two months of adequate supplementation decreased inflammatory lesions.
Dose: Individualized dose based on laboratory results.
Food (and other) sources: Sunshine is our main source, however, SMASH fish, fortified grains, egg yolks and beef also have some vitamin D.

Lactoferrin
Lactoferrin is naturally produced by our mucosal epithelial cells and is present in most biological fluids (tears, saliva, vaginal fluids, semen, nasal and bronchial secretions. bile, GI fluids, urine, milk). It helps regulate the immune response and has antimicrobial, antioxidant, and anti-inflammatory properties. It can also reduce sebum production. Research showed a significant reduction in mean lesion count as fast as two weeks, with maximum reduction occurring around ten weeks.
Dose: 100 mg twice per day or 200 to 300mg daily for 3 months. Example products include Lactoferrin-250 or Advanced Whey by AOR.
Food sources: Whey protein powder.

Vitamin A
Vitamin A helps to speed healing, hydrate the skin, ensure a healthy skin barrier, support the skin’s immune system, and prevent breakouts. Accutane, one of the strongest medications for acne, is a naturally occurring derivative of vitamin A.
Dose: 100 000 IU daily for 2 months followed by 25 000 - 50 000 IU daily for 2 months. Avoid use for longer than 4 months.
Food sources: Orange foods such as carrots, squash, yams, cantaloupe, apricots and tropical fruits.
Safety: Avoid in pregnancy, especially at doses greater than 5000 IU which could be teratogenic. Higher doses of vitamin A may also cause side effects such as dry lips and skin.

Liver Support
I generally recommend liver support (e.g., NAC, milk thistle, B-vitamins) to help boost detoxification and take the elimination load off the skin. This can be taken as a capsule (e.g., LivCo by MediHerb, Liver SAP by NFH), tincture, or tea (e.g., milk thistle from Apotheka Herbal Boutique).
Liver-supporting foods: Bitters such as arugula, bitter melon, black coffee (not too much of it), dandelion greens, artichokes and kale.

Magnesium Bisglycinate
Magnesium supports detoxification via the liver (hormone breakdown/excretion) and bowel (reduces constipation). It is especially indicated if constipation is a factor and/or if having premenstrual acne.
Dose: 300 to 400 mg daily taken in the evening (e.g., with dinner, or keep by your toothbrush or on nightstand). Suggested brands include CanPrev, NFH, Natural Factors, or AOR.
Food sources: Avocados, nuts and seeds, fatty fish, leafy greens, dark chocolate (greater than 65%).

Multivitamin
A multivitamin may be an easy way to get a little dose of multiple skin supporting nutrients (e.g., zinc, selenium, and vitamins A, E and D). It’s also an excellent option if present or previous use of an oral contraceptive, as the pill can deplete vitamin B12, folate, selenium, zinc, magnesium, and vitamin C.

Herbs
Herbs can be individually selected to best suit your needs. Topically, burdock, calendula, chamomile, echinacea, Oregan grape root, and tea tree may be of benefit. Orally, I may suggest a customizable tincture:

• Oregan grape root (10mL): bitter

• Milk thistle (20mL): liver detoxifying

• Echinacea (20mL): antimicrobial

• Licorice (20mL): anti-inflammatory (and tasty)

• White peony (20mL): hormone-balancing

• Holy basil (10mL): stress-reducing and blood sugar balancing

• Dose: 2mL 2 to 3 times daily depending on severity. Continue for 3 months then re-evaluate. Can also use for acute flares only.

STEP 6: ADDITIONAL CONSIDERATIONS FOR HORMONE BALANCE

• Androgen excess: If symptoms of androgen excess (e.g., cystic acne along the jawline, hirsutism, PCOS) consider supplements that block 5-alpha-reductase to reduce DHT and high estrogen in the ovary: 1) zinc 10 to 50 mg daily for 3 months; 2) ECGC 300 to 500 mg caps 1 to 2x daily or 75 mg caps x 4 to 5 daily; 3) Saw palmetto (e.g., Genestra Brand) 200 to 300 mg daily for 3 to 9 months. Spearmint and green tea can also be supportive.

• Insulin resistance: If suspecting insulin dysregulation (e.g., acne on the cheeks, severe bouts of hunger or light-headedness, weight loss resistance) consider: 1) eating the proteins on your plate before the carbohydrates; 2) adding cinnamon to meals and smoothies; 3) focussing on a high protein diet; 4) eating consistent meals, every 3 to 4 hours apart, and avoiding grazing; 5) only having coffee alongside food; 6) blood sugar balancing supplements such as probiotics, berberine, magnesium, inositol, chromium or holy basil tea.

• Estrogen dominance: If suspecting estrogen excess (e.g., heavy periods, painful periods, PMS, clotting, frequent periods then follow these tips: 1) regularly top your soups and salads with a few tablespoons of broccoli sprouts as these are super high in DIM, which can support estrogen detoxification; 2) include 1 to 2 tablespoons of fresh ground flaxseeds daily, grinding a batch weekly to sprinkle on foods or add whole seeds to grind in your daily smoothie; 3) eat 1 to 2 cups per day of cooked cruciferous vegetables (e.g., arugula, asparagus, broccoli, kale) as this can be especially helpful in our luteal phase (= second half of cycle post-ovulation) when we start to breakout; 4) supplement with both DIM (Zymogen, Metagenics) and calcium-d-glucarate (CDG) together as DIM helps assist detoxification in the liver while CDG packages up the toxins and ensures it’s eliminated versus reabsorbed (take 1 cap of each for 3 months straight but not long-term); 5) Vitamin B6 (5 to 10 mg daily), which is especially indicated for premenstrual acne.

REFLECTION AND TOP TAKE-AWAYS

Feeling overwhelmed yet? Lets do a reflection to prioritize and develop a start-up plan.

My top three acne triggers are probably:
E.g., (1) blood sugar imbalance (2) chocolate (3) stress.

Three interventions I feel are most important and can start immediately include:
E.g., (1) SMASH fish three times per week (2) zinc and probiotic supplementation (3) topical niacinamide.

What changes I would like to see after a 3-6 month treatment course:
E.g., Less cystic breakouts on my chin.

How I would like to feel after a 3-6 month treatment course:
E.g., Increased confidence and more control over my breakouts.

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