The acne-stress connection has long been suspected but most evidence for psychological factors in skin disease have been anecdotal, up until recently.

A study published in 2003 in the Archives of Dermatology found that acne flare-ups were common in college students during exams, compared to less stressful non-exam periods. What’s more, the severity of the acne increased with rising stress levels.

Of course, knowing this could simply mean that you have one more thing to stress about come exam time, namely, that your skin will break out and you’ll want to hide away rather than sit in an exam hall with hundreds of people. What is needed, then, is insight into why exam stress and acne are connected, in order to disrupt the mechanism and restore skin health, naturally.

Acne, Hormones and Stress

One theory was that stress influenced the hormones which influenced the skin cells producing sebum (the oily substance in the skin). Sebum excess clogs the pores and can cause pimples and acne cysts as it clings onto dead skin cells and harbours bacteria.

The theory goes that stress was linked with increased acne through the mechanism of upregulated sebum production. However, a later study, in 2007, found that high school students did have worse acne during exam time but that there was no indication that psychological stress caused significant increases in sebum production.

Gastrointestinal Distress and Acne

Other theories have now been taken up by researchers with more promising results in terms of bettering our understanding of the stress-acne connection. One such hypothesis is based on the findings that acne patients are at a higher risk of gastrointestinal distress and symptoms including constipation, halitosis and gastric reflux.

Abdominal bloating was significantly correlated with acne in the adolescents surveyed in this study (some 13,000 students). Way back in the 1930s when Stokes and Pillsbury first proposed a unified gut-brain-skin theory, the researchers cited prior studies showing that some 40% of those with acne had low stomach acid levels (hypochlorhydria).

Low stomach acid would then allow for dysbiosis to occur (an overgrowth of bad bacteria and sub-optimal beneficial bacteria levels), causing an increase in intestinal permeability.

Food Allergies, Leaky Gut and Acne

When the gut becomes leaky it means that an important barrier to antigens and potential antigens is taken away. Foods that were previously unproblematic may now cause symptoms of food sensitivities and even acute allergic reactions.

This brain-gut connection is a key reason why adults develop sudden allergies to foods that they have eaten their entire lives without problems. An increased antigenic load in the bloodstream causes systemic inflammation, creating a whole host of problems, including skin flare-ups.

Seventy years ago, these two researchers proposed the use of what we now refer to as probiotics and omega 3 in order to help counteract the stress-induced dysbiosis and inflammation. Specifically, they recommended Lactobacillus acidophilus for skin health.

Low Stomach Acid Levels and Skin Problems

Low levels of stomach acid have also been reported as a possible exacerbating factor in rosacea as well as in acne and mental health disorders. Hypochlorhydria is a significant risk factor for small intestinal bacterial overgrowth (SIBO), which is also found in around half of patients on proton pump inhibitor treatment long-term.

Low levels of stomach acid can cause symptoms similar in some cases to excess acid production and some naturopaths express concern that many of those medicated with antacids are actually in need, instead, of additional stomach acid, namely betaine hydrochloride, to help their malabsorption issues.

Intestinal Dysbiosis and Malabsorption

Intestinal dysbiosis can prevent proper absorption of nutrients such as proteins, fats, carbohydrates, B vitamins and other micronutrients. As these are needed for skin health it is unsurprising that long-term problems of intestinal dysbiosis lead to acne and other skin disorders. Dysbiosis also means an increased toxin load as the bacteria produce metabolic waste.

Treating the Gut to Heal the Skin

Correcting the intestinal dysbiosis using probiotics and antimicrobial treatment has been found to aid restoration of the intestinal barrier and this, in turn, has been seen to improve emotional health (see studies by Pimentel, et al, 2000, and Addolorato, et al, 2008).

SIBO slows down transit time in the small intestine, encouraging the overgrowth of undesirable bacteria and causing increased gut permeability. Correcting SIBO has been seen to significantly improve rosacea in patients (Parodi, et al, 2008) and a recent report suggests that SIBO is ten times more prevalent in those with acne rosacea, which could mean that this skin condition would also benefit from restored intestinal biosis.

E. coli and Skin Flare-Ups

Acne vulgaris patients have also been found to have a higher level of reactivity to bacterial endotoxins found in the stool (such as E. coli lipopolysaccharide endotoxin) than those without the skin condition, as well as having more of these toxins in their blood.

This suggests that bacterial toxins are passing through the compromised intestinal barrier to trigger immune system responses in the blood of these patients. What’s more, this systemic E. coli endotoxin has been seen to produce depression-like behavior in animals (Viana, et al, 2010) and those with irritable bowel syndrome who were highly anxious had increased reactivity to the endotoxin in one study (Liebregts, et al, 2007).

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Managing Acne Linked to Stress

Acne appears, then, to be more likely to flare up when a person is under excessive stress and when digestive health is compromised. Unfortunately, the stress connection doesn’t end there. Picking at pimples is frowned upon by dermatologists everywhere but these skin specialists also know that they cannot simply prescribe ‘leaving your pimples alone’ as an acne remedy, despite it being sage advice.

Stress makes us fidgety and makes us fiddle with things, be it pulling at the hair, twiddling pens, chewing pencils, tapping our feet or picking at our spots. Such picking at acne blemishes increases the risks of skin infection and scarring and also spreads the bacteria to other parts of the skin, creating a chain reaction of acne when stressed. Sit on your hands and meditate, it’ll do wonders for your skin and is a free acne remedy!

Meditation and mindfulness may also be helpful for autoimmune skin diseases such as vitiligo which, like acne, also have a stress connection.