How does gut health affect skin?
What is a ‘healthy gut’?
Our gut microbiome is a vast collection of bacteria, viruses, fungi, and protozoa colonizing our GI system. If this is unbalanced it is referred to as dysbiosis. There is growing evidence that dysbiosis of the gut microbiota is associated with the pathogenesis of both intestinal and extra-intestinal disorders. Intestinal disorders include inflammatory bowel disease, irritable bowel syndrome (IBS), and coeliac disease, while extra-intestinal disorders include allergy, asthma, metabolic syndrome, cardiovascular disease, and obesity.
The intestinal microbiome provides important metabolic and immune benefits to the host. Though not yet fully explored, the mechanisms by which intestinal microbiota exert their influence on skin homeostasis appear to be related to the modulatory effect of gut commensals on systemic immunity
How much do you think gut health and skin conditions, such as acne, rosacea, and eczema, are linked? *
There is a lot of interest currently around the so-called brain-skin-gut axis. This intimate link was identified as far back as 1930 when Stokes and Pillsbury attributed depression to altering the gut microbiome, leading to inflammatory skin diseases
In 2016 O’Neil et al published a review looking at the mechanisms linking the gut and skin health. One of the associations is through the microbiome. Although not fully explored, the gut microbiome appears to influence the skin though its effect on immunity. There may also be a more direct effect, gut bacteria and their metabolites have been found in skin; a suggested mechanism that a disturbed intestinal barrier can allow gut bacteria to leak into the blood and directly accumulate in skin.
Stress directly affects gut health and increasingly we are aware of an intimate relationship between the gut, skin and brain. By optimising the health in these areas i.e. Reducing stress, promoting a healthy gut we can optimise skin barrier function and skin health. There is increasing work being done looking at this symbiotic relationship.
What skin symptoms can signal an imbalanced gut?
Sometimes patients notice when they become stressed, they suffer with bloating at the same time as experiencing an exacerbation of their skin issues such as rosacea. Those with acne often note that during times of stress acne flares. Psoriasis and a specific form of eczema called seborrheic eczema have long been associated with higher levels of anxiety and depression.
Are there any recent studies you are aware of that link gut health and skin?
Although there are a lot of animal studies looking at changes to gut flora its effect on skin. There aren’t that many studies showing a change to the gut microbiome and the direct effect on skin. That said patients with psoriatic arthritis are at increased risk of developing IBD and have subclinical evidence of gut inflammation (2)
A study of 113 rosacea patients demonstrated that those with rosacea have a higher incidence of small intestinal bacterial overgrowth (SIBO) when compared to controls. Those with SIBO were treated with either antibiotics for 10 days or a placebo. Those who were treated with antibiotic therapy experienced an improvement in their symptoms for at least nine months
What are your recommendations for improving your skin via your gut health?
(e.g. diet, probiotics etc) Firstly I would suggest introducing an effective probiotic. Unfortunately, many of the milk and yoghurt-based probiotics are broken down by stomach acids. One of the probiotics I recommend in my clinic is Symprove. This has been rigorously studied. It is water-based and as such the gut isn’t as stimulated to produce stomach acid. It needs to be taken first thing in the morning, 10 minutes before any food or drink to give it time to reach the gut and start colonising. Usually I would recommend a course of a probiotic e.g. daily for 12 weeks. It is important during this time and afterwards that a healthy diet rich in rainbow fruits and vegetables is eaten, I recommend lots of fibre and pre-biotic foods that essentially feed healthy microbes in the gut. Examples include apple cider vinegar, onions and garlic, leeks and asparagus amongst others. Avoid processed foods and a sugar -based diet as this will affect a healthy microbiome as will alcohol and smoking. Regular exercise helps a healthy gut as does good quality sleep and minimising stress.
What are probiotics and how do they work?
(i.e. how long does it take for probiotics to affect the skin). Probiotics provide the gut with a healthy microbiome, as long as it is able to be delivered to the gut without being broken down by digestive acids (see above). I recommend taking for 12 weeks. Often my patients start to notice an improvement in bloating, anxiety and skin issues within a few weeks. Following this probiotic course with a diet rich in prebiotics is important. I am currently carrying out an observational study just looking to see if probiotics alone can help rosacea. More studies are needed to look at the effects of probiotics in inflammatory skin conditions.
(1) Cornelius C. Dodoo, Paul Stapleton, Abdul W. Basit, Simon Gaisford, Use of a water-based probiotic to treat common gut pathogens, International Journal of Pharmaceuticals Volume 556 2019
(2)Scher JU, Littman DR, Abramson SB. Microbiome in Inflammatory Arthritis and Human Rheumatic Diseases. Arthritis Rheumatol. 2016;68:35-45. (3) Parodi A, Paolino S, Greco A, Drago F, Mansi C, Rebora A, Parodi A, Savarino V. Small intestinal bacterial overgrowth in rosacea: clinical effectiveness of its eradication. Clin Gastroenterol Hepatol. 2008;6:759-764
Three of the best/newest treatments for acne scars
For this one, we just want to feature three of the best/newest treatments for acne scars and then talk a bit about how each one works, how long it takes to see a result, the research behind them, and your expert opinion, i.e. is one better than the other?
One of the issues with evaluating the evidence for treatment of acne scarring is there are no generalized clinical guidelines adopted to standardize atrophic acne scar treatment.
There are lots of studies available for the treatment of acne scarring but this lack of standardisation makes direct comparison between studies difficult.
With that caveat I will attempt to evaluate and discuss treatments for acne scarring. One of the newest treatments for acne is nano fractional laser. (1)
What proportion of adults are affected by acne and scarring?
(If there are any studies you could suggest for this that would be good) Up to 80% of the population at some point will suffer with acne. The risk factors for acne scarring include severity of acne, although a significant proportion of those with acne scarring have had mild to moderate acne. Some studies suggest that up to 90% of those with acne will suffer with some form of scarring. Delay in treating acne, inflammation, family history and frequent relapses increase the risk of scarring. Quite often however, I am asked about acne scarring when on closer inspection the individual has post- acne redness or pigmentation that will fade in time once the acne has settled. One of the biggest issues is post -acne pigmentation in those with skin of colour. I like topical retinoids as they can help to reduce post inflammatory pigmentation whilst treating acne in pigment-prone skin. I also advise to use topical vitamin C that can suppress the development of pigmentation and the use of a non-comedogenic sun lotion. Once the acne has settled, we can look at treatments to reduce pigmentation and any scarring but switching off the acne in the first place is the most important step. I frequently see individuals in my clinic who have had failed treatments for acne scarring, one of the reasons being the treatment has been started when the acne is still active.
Does the best treatment differ according to the type of scar?
Absolutely. It is very important to carefully evaluate the skin and look at the type of scarring as this will dictate the best treatment. After evaluation is very important to discuss what improvements can be achieved. Acne scarring can be difficult to treat, there may be a significant improvement from some treatments, but complete clearance is rare, beware miracle treatments being offered! It is absolutely vital to assess carefully before starting any treatment course and making sure that expectations are managed.
There are different types of acne scar, the majority are atrophic (dipped) . 60-70% of these atrophic acne scars are small sharply dipped scars (diam <2mm) that are called ‘ice pick’. Although these scars are small, they often penetrate quite deeply and as such many laser treatments including more aggressive resurfacing treatments just don’t treat deeply enough to improve their appearance. One approach is to combine what is referred to as cross TCA (trichloroacetic acid). Here a high concentration of TCA ( 70-100% ) is placed with a sharp tool such as a tooth pick into the scar to help encourage new collagen and over time to elevate the scar , this is then followed by a treatment to help to improve collagen and smooth the skin such as micro-needling or laser. The treatments are performed at 4 weekly intervals. The main concern is pigmentary issues in skin of colour, both post inflammatory increased and decreased pigmentation. (3)
Wider atrophic scars 1.5-4.0mm with vertical edges are known as box scars. Those with a depth < 0.5mm are usually amenable to treatment with resurfacing but > 0.5mm are more difficult to treat.
Rolling scars are the widest often > 5mm in diameter and dip and undulate, as they are tethered deeper in the skin. In order to improve their appearance, firstly there needs to be a process to treat the tethered scars. This can be done simply with a needle, placed under the skin, cutting through the scarring, so-called subcision. Once the tethering is improved there is usually more success with skin resurfacing and tightening. Some scars are raised and hypertrophic. These are seen more commonly in skin of colour. Again, these can be difficult to treat, injection steroids to help to soften and flatten them can help.
I will attempt to evaluate and discuss newer treatments for acne scarring. One of the newest treatments for acne is nano fractional laser. Fractional Radiofrequency technology delivers heat energy deep into the targeted dermis, resulting in fibroblast stimulation, dermal remodelling, new collagen and elastin, whilst only causing very minimal disruption of the top layer on the skin – the epidermis, reducing side effects and downtime. The treatment is given every 4-6 weeks, there are usually 6 treatments given but studies suggest it is an effective treatment for acne scarring (2).
I get very good results in those that have issues with post inflammatory redness and atrophic scarring with photo-fractional laser. This is a combination of intense pulse light that helps to reduce the erythema and fractional laser that uses puts columns of heat into the dermis to remodel it and improve acne scarring. There is minimal downtime and fractional component is relatively safe to use in skin of colour. We usually suggest at least 4 treatments approximately 6 weeks apart.
Combining these collagens stimulating and scar remodelling treatments including micro-needling with antioxidants such as vitamin C, hyaluronic acid and growth factors such as platelet rich plasma has been shown to be effective in enhancing outcomes.
(1)Journal of Cosmetic Dermatology, 23 Mar 2017, 16(2):186-192
DOI: 10.1111/jocd.12311 PMID: 28333405
(2) Arch Dermatol Res. 2015 Dec; 307(10):897-904.
Comparison of fractional microneedling radiofrequency and bipolar radiofrequency on acne and acne scar and investigation of mechanism: comparative randomized controlled clinical trial.
(3)Lee JB, Chung WG, Kwahck H, Lee KH. Focal treatment of acne scars with trichloroacetic acid: chemical reconstruction of skin scars method. Dermatol Surg. 2002;28(11):1017-1021
