In the last article I tried to answer the question whether different racial groups have different risks for developing acne. We saw that on average countries with predominantly Black or Asian populations showed much lower rates of acne than countries with predominantly White populations (1), but strangely enough, when looking at the United States, Blacks living within the U.S. seemed to be affected more by acne then Whites (2). How can this be?

 

Let’s look at a study from west Africa more closely (3): In Nigeria the overall rate of acne is much lower than in the United States (4). However, researchers discovered that overweight and obese Nigerian teenagers had acne rates of about the same as teenagers in the United States whereas underweight teenagers had almost only half as much acne (3). The prevalence of obesity in adolescents in the United States is about 7-times higher than in Nigeria. (5) (6) So, it appears that the difference in bodyweight as well as the diet and lifestyle that leads to obesity might in fact be the reasons that Nigerians have lower rates of acne than Americans and not the difference in race and any distinct physiological features that come with it.

 

But what about the difference between Whites, Blacks and Hispanics within the same cities in the U.S.? (2) Isn’t that a sign that Blacks and Hispanics are really more prone to acne? No, actually the same underlying cause might be at play here as well. In the U.S., Black and Hispanic children have a much higher rate of obesity than Whites. (5) It is likely then that the higher rates of acne are, in fact, primarily a result of higher rates of obesity and the lifestyle that leads to this rather than physiological differences between races. This recent meta-analysis also speculated that the differences are rather due to different lifestyle factors. (7)
The reason why Blacks and Hispanics are more obese than Whites in the first place is still not fully understood, but different factors such as socioeconomic status might play into it. (8)

 

Asians in the US are less obese then other ethnicities. (8) In the U.S. Census this includes Far East Asians as well as continental Indians. Thus it is not surprising that both racial groups have rather low rates of acne in the U.S. (2)
Part of the Asians in this study were recruited from Akita, Japan, and they showed even less acne, possible due to the healthier diet in Japan than in the U.S. as the authors pointed out. (2)

 

The increased rate of obesity over the last decades (8), with Blacks being especially affected, might also explain why acne and puberty start increasingly early in children. This is most pronounced in black girls (7). One reason for that is probably that fat tissue produces estrogen, a female sex hormone. (9) (10) Naturally this hormone increases when a girl hits puberty but the increased estrogen production in the fat tissue of overweight girls might jump start this process leading to an early onset of puberty and acne. (11)

 

However, not just obesity itself might facilitate early onset of puberty but also specific foods. Associations have been found for sugar sweetened beverages (12), dairy (13) (however, the evidence is mixed here (14)), red meat (15), and artificially sweetened, caffeinated drinks (16), the last one independently of bodyweight. In how far these associations are causal remains to be elucidated, but it is striking that many of these same foods are also implicated in the promotion of acne, especially high glycemic carbohydrates such as sugary drinks, dairy and meat. (17)

 

Thus we can conclude that for all acne patients regardless of racial group, it is crucial to follow a healthy lifestyle and keep a healthy weight.

 

All this is not to say that physiological differences between racial groups don’t play any role in the formation of acne but it appears that individual lifestyle, especially diet, has a much higher impact than those physiological differences between races. The differences in acne rates between races that have been documented so far can probably be explained mostly by difference in lifestyle rather than genetics.

 

Little side note here: Genetic differences between individuals of any racial group do, of course, influence acne very heavily. No matter which racial group you belong to, your genes can make you very prone to acne or protect you against it. (18)

 

Back to bodyweight and diet. Just being of healthy weight, however, only seems to reduce your risk of acne by about 25%, given the data from Nigeria. (3) So you can still suffer from acne even if you have a healthy weight. Good news though, improving your diet appears to be able to immensely influence the severity of acne even in healthy weight individuals as we see in some indigenous populations that show no single case of acne. (19) Therefore I would suggest everyone suffering from acne to dramatically improve their lifestyle especially their diet. You can find my dietary recommendations in this video.

 

There is, however, one strong difference between acne in different racial groups independent of bodyweight and that is postinflammatory hyperpigmentation (20) which is a permanent darkening of the skin in the spot where a pimple was. This phenomenon especially affects Blacks and Hispanics. In the next article I will address that issue and how you can treat it.

 

Also, here you can find my videos on how to best treat acne with concrete advice on what to eat, what skincare and what supplements are effective as well as an explanation of common medications.

 

If you want to learn more about all that or would like to support my work, you can check out my book or get a personal counselling session.

 

If you have any questions regarding acne or wishes for future articles, please post them in the comments below. I’ll do my best to answer every question.
Thank you so much for reading. Stay positive and remember you're not alone with this.

 

 

 

 

 

 

References

 

1. GBD Compare . [Online] Institute for Health Metrics and Evaluation (IHME), University of Washington, Seattle, WA, 2015. [Cited: April 9, 2020.] https://vizhub.healthdata.org/gbd-compare/.

 

2. A.C. Perkins, C.E. Cheng, G.G. Hillebrand, K. Miyamoto, A.B. Kimball. Comparison of the epidemiology of acne vulgaris among Caucasian, Asian, Continental Indian and African American women. Journal of the European Academy of Dermatology and Venereology. 2011, Vol. 25, 9, pp. 1054–1060.

 

3. Emeka Okoro, Adebola Ogunbiyi and Adekunle George. Prevalence and pattern of acne vulgaris among adolescents in Ibadan, south-west Nigeria. Journal of the Egyptian Women’s Dermatologic Society. 2016, 13, pp. 7-12.

 

4. Gary M. White, MD. Recent findings in the epidemiologic evidence, classification, and subtypes of acne vulgaris. Journal of the American Academy of Dermatology. 2, 1998, Vol. 39, 3, pp. 34-37.

 

5. Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion. Childhood Obesity Facts. [Online] Ceters for Disease Control and Prevention, June 24, 2019. [Cited: April 9, 2020.] https://www.cdc.gov/obesity/data/childhood.html.

 

6. Innocent Ijezie Chukwuonye, Abali Chuku, Collins John, Kenneth Arinze Ohagwu, Miracle Erinma Imoh, Samson Ejiji Isa, Okechukwu Samuel Ogah, Efosa Oviasu. Prevalence of overweight and obesity in adult Nigerians – a systematic review. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy. 2013, 6, pp. 43-47.

 

7. J.K.L. Tan, K. Bhate. A global perspective on the epidemiology of acne. British Journal of Dermatology. 2015, 172, pp. 3-12.

 

8. Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion. Adult Obesity Facts. [Online] Centers for Disease Control and Prevention, February 27, 20. [Cited: April 9, 2020.] https://www.cdc.gov/obesity/data/adult.html.

 

9. Nelson LR, Bulun SE. Estrogen production and action. Journal of the American Academy of Dermatology. 2001, 45, pp. 116-124.

 

10. Erin E. Kershaw, Jeffrey S. Flier. Adipose Tissue as an Endocrine Organ. The Journal of Clinical Endocrinology & Metabolism. 2004, Vol. 6, 89, pp. 2548–2556.

 

11. Wenyan Li, Qin Liu, Xu Deng, Yiwen Chen, Shudan Liu, Mary Story. Association between Obesity and Puberty Timing: A Systematic Review and Meta-Analysis. International Journal of Environmental Research and Public Health. 2017, 17.

 

12. Carwile JL, Willett WC, Spiegelman D, Hertzmark E, Rich-Edwards J, Frazier AL, Michels KB. Sugar-sweetened beverage consumption and age at menarche in a prospective study ofUS girls. Human Reproduction. 3, 2015, 30, pp. 675–683.

 

13. Wiley, Andrea S. Milk Intake and Total Dairy Consumption: Associations with Early Menarche in NHANES 1999-2004. PLOS ONE. 2, 2011, 6.

 

14. Audrey J Gaskins, Ana Pereira, Daiana Quintiliano, John A Shepherd, Ricardo Uauy, Camila Corval an, and Karin B Michels. Dairy intake in relation to breast and pubertal development in Chilean girls. The American Journal of Clinical Nutrition. 2017, 105, pp. 1166–75.

 

15. Erica C Jansen, Constanza Marin, Mercedes Mora-Plazas, Eduardo Villamor. Higher Childhood Red Meat Intake Frequency Is Associated with Earlier Age at Menarche. The Journal of Nutrition Nutritional Epidemiology. 4, 2016, 146, pp. 792-798.

 

16. Noel T Mueller, David R Jacobs, Jr, Richard F MacLehose, Ellen W Demerath, Scott P Kelly, Jill G Dreyfus, Mark A Pereira. Consumption of caffeinated and artificially sweetened soft drinks is associated with risk of early menarche. The American Journal of Clinical Nutrition. 3, 2015, 102, pp. 648–654.

 

17. Darren D Lynn, Tamara Umari, Cory A Dunnick, and Robert P Dellavalle. The epidemiology of acne vulgaris in late adolescence. Adolesc Health Med Ther. 2016, 7, pp. 13-25.

 

18. Petridis C, Navarini AA, Dand N et al. Genome-wide meta-analysis implicates mediators of hair follicle development and morphogenesis in risk for severe acne. Nat Commun. 1, 2018, 9.

 

19. Cordain L, Lindeberg S, Hurtado M, Hill K, Eaton SB, Brand-Miller J. Acne vulgaris: a disease of Western civilization. Arch Dermatol. 12, 2002, 138.

 

20. Andrew F. Alexis, Julie C. Harper, Linda F. Stein Gold, Jerry K. L. Tan. Treating Acne in Patients With Skin of Color. Seminars in Cutaneous Medicine and Surgery. 37, pp. 71-73.