The most infamous “acnegen” is 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD), the poison that disfigured then-presidential candidate Victor Yushchenko of Ukraine with severe chloracne (Figure 5.1). This chemical is slowly eliminated, a small part of it in sebum [1]; and, despite receiving an estimated 2 mg of TCDD, he survived and eight years later he was planning a return to politics.

Numerous medications produce acneform reactions. Litt’s Drug Eruptions and Reactions Manual lists 210 such medications from acamprosate to zonisamide [2]. The most acute form of these eruptions is induced by the epidermal growth factor receptor (EGFR) inhibitors (see Section 3.0.4.5). With the mechanism of causation in doubt, management of this new arrival is not yet standardized. Variants of anti-acne and anti-inflammatory therapy are in use [3, 4].

There are new androgens in the pipeline with potential therapeutic applications. Two do not require 5α-reduction to exert their maximal androgenic effects: dimethandrolone (7α,11β-dimethyl-19-nortestosterone) and 11β-methyl-19-nortestosterone [5]. Will these new androgens, with no 5α-reduction, be acnegens? We don’t know yet.

5.2 Endocrine imitators and disruptors

Our modern world is contaminating itself at a remarkable rate. Signs of this contamination have been showing up for years, and it is a wonder that the effects have not been far worse than have been noted to date. Everyday exposure to everything from pesticides through plastics to phytoestrogens in soy may be seen as a threat. Extensive documentation to date has but scratched the surface of the problem. Regulation of potential threats faces truly daunting economic, social, and legal hurdles. We are living with endocrine-disrupting chemicals (EDCs), we are learning about their effects [6], but they do not seem to be impacting acne in humans to a noticeable or measurable degree.

On the other hand, because many are estrogenic and therefore anti-androgenic, one wonders whether the possibility exists that such artificial endocrine disruptors may actually be beneficial in the acnes! The scare tactics surrounding the question of phytoestrogens and soy must be tempered by the fact that all plants contain phytoestrogens, although some more than others. After all, phytoestrogens are to growing plants what human estrogens are to growing humans, essential chemical messengers guiding reproductive life.

5.3 Foods

All that we consume can impact our health, usually positively but sometimes negatively. There is nothing more natural than mothers’ milk for babies, but dairy products are now consumed by hundreds of millions for whom they were not intended. The tendency of consumers to seek “all-natural” or “organic” products is a step in the right direction, but the all-natural label can apply to poison ivy as well as to broccoli. And any food that contains toxins from whatever source, even unknowingly, obviously loses its “organic” designation despite claims on the label.

There are also a few normally innocent compounds that can be troublesome. This includes the acnegens in foods we consume every day. Defining them is a challenge, but we can start by noting that numerous ecologic and migrant studies demonstrate increased prevalence of acne vulgaris with a more “Western” lifestyle and diet. Steiner saw no acne in Okinawans and noted, “Milk from goats or cows was used only by those who were ill and by babies whose mothers had insufficient milk. Cheese was repellent to the Okinawans” [9]. Robinson’s food diary study named milk as the most common exacerbant reported [10]. Fisher’s personal study of over 1000 consecutive acne patients implicated milk [11]. Never published, it is now at http://www.acnemilk.com. On the simple-carbohydrate side, Bendiner reported,

Acne vulgaris now scars the hitherto renowned complexions of the Eskimo [sic] and the evidence leaps at one from even the most casual glance at the faces of the youngsters who seem constantly to be nibbling at candy bars or drinking soda pop out of a can. Indeed, the whites have swamped the Eskimo in a mass of sugar and carbohydrates. Shelves of the Hudson Bay Trading Company stores are heavily stocked with a glittering variety of chocolates, gumdrops, potato chips, sodas. These readily absorbable carbohydrates have flooded the system of a people totally unused to them and highly vulnerable to their effects, Dr. Shaeffer [sic] has pointed out [12]. Eskimos lack the white’s ability to stabilize their blood sugar levels. Consequently their systems react by over-stimulating their production of insulin, as well as growth hormones, glucocorticoids, and catecholamines. Canadian doctors draw little comfort from the fact that the Eskimo young people are growing taller. [13]

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Acne in pregnancy The handouts Appendices The acne hormones Management The three acnes and their impact

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