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Journal of Nutritional Therapeutics, 2014, 3, 149-155 149
E-ISSN:
1929-5634/14 © 2014 Lifescience Global
The Impact of Diet on Common Skin Disorders
Saida Rezakovi
1,*
, Mirjana Pavli
2
, Marta Navratil
3
, Lidija Poani
4
, Kristina uul
5
and
Kreimir Kostovi
6
1
Policlinic “Eskulap” - Policlinic for Internal Medicine, Dermatovenerology, Neurology, Psychiatry, Surgery,
Gynecology, Urology, Otorhynolaryngology and Physical medicine - rehabilitation, Havidieva 9/11, Zagreb,
Croatia
2
Department of Medicine, Fraser Health Authority, Burnaby Hospital, 3935 Kincaid St, Burnaby, Canada
3
Department of Allergy and Pulmonology, Srebrnjak Children's Hospital, Srebrnjak 100, Zagreb, Croatia
4
Clinical Hospital Dubrava, Avenija Gojka uka 6, Zagreb, Croatia
5
Medical School, University of Zagreb, alata 4, Zagreb, Croatia
6
Department of Dermatovenerology, University Hospital Center Zagreb and School of Medicine University of
Zagreb, alata 4, Zagreb, Croatia
Abstract: The role of nutrition in the treatment of common dermatoses is often overlooked. Nevertheless, there is a
large amount of evidence suggesting that diet may have an important role in the pathogenesis, as well as in determining
the clinical course of common skin disorders; including acne, psoriasis, atopic dermatitis and allergic contact dermatitis.
Consequently, diet could have significant preventive or therapeutic impact in these skin conditions. Psoriasis, atopic
dermatitis and allergic contact dermatitis are chronic relapsing skin disorders characterised by remissions and flare-ups,
requiring long-term maintenance therapy. Although acne occurs most commonly during adolescence, and rarely
continues into adulthood, it has a large impact on patients' self-confidence and self-image. For each of these skin
conditions, a variety of foods may lead to exacerbation of the disease and may have a significant role in increasing the
risk of other comorbidities. The aim of this review is to present current knowledge on the relationship between high-fat
and high glycemic index diet and acne and psoriasis. Additionally, possible role of nutritional supplementation in such will
also be reviewed. And finally, the role of dietary restriction in patients with atopic dermatitis and low nickel diet, in those
who are sensitive to nickel, will be discussed. Although future studies are necessary in order to evaluate the effect of diet
in these skin disorders, identifying certain foods as a potential factor that could contribute to exacerbation of the disease
or to development of further complications can provide important preventive measure.
Keywords: Psoriasis, acne, atopic dermatitis, allergic contact dermatitis, dietary products, glycemic index, fatty
acids, low nickel diet.
INTRODUCTION
Acne, psoriasis, atopic dermatitis and allergic
contact dermatitis are among most common skin
disorders. Due to its clinical presentation, as well as
clinical course of the disease, these conditions
significantly decrease health-related quality of life and
represent a great psychological burden for the patient.
Despite major advances in treatment modalities for
these dermatological conditions, psoriasis, atopic
dermatitis and allergic contact dermatitis still remain
chronic, lifelong diseases for the majority of patients.
Although acne occurs mainly during adolescence, it
causes significant psychological burden, particularly if
more severe clinical form is present. Apart from the
current treatment options, the role and the impact of
diet in prevention or in therapeutic purposes has been
*Address correspondence to this author at the Policlinic “Eskulap” - Policlinic
for Internal Medicine, Dermatovenerology, Neurology, Psychiatry, Surgery,
Gynecology, Urology, Otorhynolaryngology and Physical Medicine Havidieva
9/11, 10020 Zagreb, Croatia; Tel: 00385916553701; Fax: 0038516553701;
E-mail: saida.rezakovic@gmail.com
widely discussed over the past years. A wide variety of
food items have been found to be associated with
aggravation of acne, psoriasis, atopic dermatitis and
allergic contact dermatitis. Consequently, identifying
certain foods and adopting new dietary habits may
have significant impact on prevention of flare-ups, as
well as on the improvement of final treatment outcome.
ACNE
Acne is a common skin disorder affecting 80-90% of
adolescents. It causes significant psychological
morbidity and stress in a large percentage of
adolescents, particularly if presented in more severe
clinical forms, including cystic and nodular form,
resulting in scarring and cosmetic disfigurement.
Although there is high likelihood of a genetic
predisposition involved in the development of acne,
there is evidence to suggest that environmental factors,
such as nutrition, could have a significant impact on
acne pathogenesis [1-4]. Possible connection between
diet and acne is based upon results of large
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150 Journal of Nutritional Therapeutics, 2014, Vol. 3, No. 3 Rezakovi et al.
epidemiological studies, that found significantly higher
incidence and prevalence of acne in Western
industrialized countries, compared to rural areas and
traditional socities [1,5]. Population living in non-
industrialized countries, such as Papua New Guinea,
Paraguay, Kitivan island and Okinawa Island have low
acne prevalence rates [6]. This is probably the result of
their dietary habits, since their nutrition mainly consists
of low glycemic index foods, fruit and fish [6,7]. In
addition, migrational studies have shown that when
these populations relocated to developed and
industrialized areas, and addopted a different lifestyle,
including different dietary habits, acne prevalence and
incidence increased [2,8]. These results support the
hypothesis that a low rate of acne in these socities is
primarily the result of the diet rather than genetic or
ethnic factors [8]. Furthermore, randomized controlled
trials have shown an improvement in clinical course of
acne after adopting a low glycemic index and low
glycemic load diet [3,4,6,9]. Study conducted by Smith
et al., which evaluated the impact of a low-glycemic
load diet on the improvement of acne, showed
significant reduction in acne lesions, suggesting
therapeutic effect of low glycemic index nutrition [6]. In
addition, randomized controlled trials demonstrated
that low-glycemic-index diet reduced acne risk,
suggesting possible preventive benefits of this dietary
intervention [6,9]. High glycemic index foods cause
complex hormonal changes including; hyperin-
sulinemia, eleveted levels of insulin-like growth factor 1
(IGF-1) and reduction of insulin-like growth factor
binding protein 3 levels (IGFBP-3) [10,11]. IGF-1 has
been found to be a potent mitogen that enhances
keratinocyte hyperproliferation, promoting hyperkera-
tinisation. IGF-1 is also a strong stimulator of
sebaceous lipogenesis [12]. Hyperinsulinemia, on the
other hand, stimulates the synthesis of androgens in
ovarian and testicular tissue [13]. All of these factors
play a major role in the pathogenesis of acne, and
contribute to acne development and aggravation of
symptoms [2,6,11], indicating that better understanding
of dietary effects on endocrine factors that are
important in acne development is required. Considering
that research indicates that decrease in inflammatory
acne lesions is associated with a low glycemic diet,
nutrition should be accepted as a preventive measure,
as well as an adjunct to current treatment modalities
[3,6]. Patients should be educated and encouraged to
avoid processed foods, which is typically composed of
high glycemic index foods (high in white flour and
sugar) including: white bread, pasta, sweets, chocolate
and white rice. Consumption of meat, fish, fruits and
vegetables should be advised instead. However,
certain fruits and vegetables should be avoided,
including melon, pineapple, pumpkin and potatoes,
considering that these foods, even not processed, still
have a high glycemic index [3,4,6]. Besides association
between high glycemic index foods and acne, fatty
acids, milk and other diary products, also seem to have
an important role in acne pathogenesis [3,14]. Although
the association of dairy products and acne still remains
unclear, results of several studies demonstrated an
association between the intake of milk and other dairy
products with acne [3,15]. This could be explained by
the hormonal content of milk, including presence of
androgen precusors like androstenedione, dehydroe-
piandrosterone-sulfate, 5-androstanedione, 5-
pregnanedione, and dihydrotestosterone, which may
promote comedogenesis [16]. Moreover, milk has been
associated with increased IGF-1 levels, consequently
having similar impact as high glycemic index diet on
acne [14,15,17]. Some researches indicate that
fermented milk products, such as cheese or yogurt,
have an even greater impact on hormonal changes,
due to the fact that the process of fermentation leads to
production of more androgenic hormones from the
precursors present in milk [15]. It is also important to
note that, considering that both skim and whole milk
promote an increase in plasma insulin levels, the
addition of whey proteins to products to improve their
consistency, may play a role in pathogenesis of acne
[15]. Thus, it would be advised, for patient with acne, to
limit milk product intake [14]. Consumption of fatty
acids has an impact on the development and on the
clinical course of acne. It has been shown that omega-
6 fatty acids have a pro-inflammatory effect, resulting in
acne flare-ups [3,18]. In contrast, omega-3 fatty acids
tend to have anti-inflammatory properties and may be
associated with decreased risk of acne by decreasing
IGF-1 levels and follicle inflammation [3,18].
Epidemiological studies demonstrate that societies that
follow such diet have significantly lower acne
prevalence [19]. Western diet is deprived of omega-3
fatty acids, and is primarily based on high omega-6
fatty acids intake, which contributes to comedogenesis
[20]. Good source of omega-3 fatty acids includes fish
and seafood, green leafy vegetables, nuts and seeds
[19]. Thus, increased intake of these foods should be
advised [20]. Nevertheless, further studies are needed
to evaluate the impact of low glycemic index diets,
dietary products and fatty acids on acne development.
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PSORIASIS
Psoriasis is a common, chronic relapsing immune-
mediated skin disorder, with estimated prevalence of
approximately 2%. It occurs worldwide, and depending
on the severity and the location of the skin lesions,
patients experience significant psychological and
psychosocial discomfort. The role of nutrition in the
prevention and treatment of psoriasis has been
postulated for many years, primarily due to the higher
risk of comorbidities associated with psoriasis,
including dyslipidemia, insulin resistance, metabolic
syndrome and cardiovascular disease [21-23]. Studies
evaluating dietary behaviours of patients with psoriasis
found that this subset of patients tends to have a higher
carbohydrate intake, as well as a higher intake of high-
fat foods, saturated fats and polyunsaturated fats
[23,24]. This can partly explain higher prevalence of
cardiovascular disease and metabolic syndrome in
these patients. Considering that these conditions are
the leading cause of morbidity and mortality, prevention
is the key. Although a low fat diet and low glycemic
index diet has not been proven to be beneficial in
improvement of psoriatic skin lesions, it can still
significantly reduce the risk of associated conditions
[25]. Some authors also suggest that a low calorie diet,
not only significantly decreases serum lipids, but also
improves clinical course of the disease, indicating that
change of dietary habits may still have an important
role in the prevention and treatment of mild and/or
moderate psoriasis [25]. Furthermore, weight loss
induced by such diet has benefits, not only through
lowering the risk of associated conditions, but,
considering that obesity is a risk factor for development
of psoriasis, it may have an impact on the severity of
clinical symptoms [22]. Number of studies have shown
that, not only a low-fat and low glycemic index diet, but
also a vegetarian diet and a diet rich in unsaturated
fatty acids from fish oils, will lead to clinical
improvement of the skin lesions [23,24]. Furthermore,
given evidence suggesting that psoriasis occurs more
frequently in people with insulin resistance, high
glycemic index foods leading to characteristic
postprandial insulin response should be avoided
[23,24]. Alcohol is another factor that represents a
significant risk for psoriasis exacerbations, and it has
been identified as a trigger for psoriasis [23,24]. Some
researchers suggest that alcohol consumption may
contribute to the development of psoriasis in genetically
predisposed individuals [26]. Unfortunately, considering
high psychological burden and substantial impairment
of quality of life in psoriasis patients, they tend to lead
an unhealthy lifestyle including poor dietary habits, and
often develop harmful coping mechanisms such as
alcohol abuse [27]. This represents a significant risk for
psoriasis exacerbations. Several studies have shown
that alcohol intake is positively correlated with psoriasis
flare-ups, severe clinical presentations and poor
therapeutic response [27]. Some studies suggest that
certain dietary supplements may have a beneficial
effect in psoriasis, these include; fish oils, selenium and
oral vitamin D3 [23,24]. Selenium is known to have an
inhibitory effect on DNA synthesis, UVA and UVB
protective action, and antioxidative and anti-
inflammatory effects. Consequently, the association
between selenium and psoriasis has been thoroughly
investigated [23,24]. One randomized controlled trial
included patients with severe forms of psoriasis, such
as erythrodermia and arthropathic psoriasis, and
demonstrated that selenium supplementation has a
beneficial effect on clinical course of the disease, when
used in combination with coenzyme Q10 and vitamin E
as antioxidant therapy [23,28,29]. In contrast, in
patients with moderate clinical forms of psoriasis,
beneficial effects were not found [23,29]. Vitamin D is
well known for its anti-proliferative and differentiation-
inducing effects [23,24]. As a result of these properties,
calcitriol, synthetic analogue of 1,25(OH)2-D3 is
effectively used in the local treatment of mild to
moderate psoriasis. Several studies and case reports
have shown that oral vitamin D3 leads to moderate
improvements, when used for treatment of moderate
psoriasis and psoriatic arthritis [28,30,31]. However,
caution is advised when taking these supplements,
considering that it can be associated with serious
adverse events including hypercalcemia,
hypercalciuria, and kidney stones when used in large
doses for a prolonged period of time [30,31].
Vitamin B12 has a significant role in DNA synthesis,
thus there is evidence of beneficial effect on psoriatic
lesions, probably due to the immunomodulatory effects
on T lymphocytes and cytokines [32]. Clinical trial
evaluating therapeutic efficacy of topical B12 cream
treatment compared to calcipotriol treatment, showed
beneficial effects with both topical agents, although
significant improvement in regression of psoriatic
lesions was slower to develop when using topical B12
cream [32]. Effect of a gluten free diet on psoriasis is
still controversial. Numbers of studies have implied an
association between psoriasis and celiac disease,
mainly based on similar genetic and inflammatory
mechanisms [23,24,32]. Gluten free diet, which is the
main treatment modality in celiac disease, seems to
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152 Journal of Nutritional Therapeutics, 2014, Vol. 3, No. 3 Rezakovi et al.
have beneficial effects in psoriasis patients with
elevated serum IgA and/or IgG antigliadin antibodies
[23,33]. There is also evidence to suggest that diet rich
in n-3 polyunsaturated fatty acids from fish oils has a
beneficial effects, probably due to its anti-inflammatory
effect [23,24]. This observation, together with the fact
that populations with high intake of n-3 polyunsaturated
fatty acids have low rates of heart disease, has
increased interest in the use of fish oils for its potential
benefits [34]. Diet rich in omega-3 fatty acids such as
salmon, sardines, tuna, shellfish, almonds and walnuts
can be recommended [24]. Considering a decreased
antioxidant capacity and increased oxidative stress in
patients with psoriasis, increased intake of fresh fruits
and vegetables is also advised, as these foods also
have beneficial antioxidative properties [35]. The role of
a low-fat, low carbohydrate and gluten free diet, as well
as supplementation with selenium, oily fish and fish oil
supplements, vitamin D and omega-3 fatty acids is not
fully elucidated. Considering inconsistency of the
available data and some contradictory results, there is
a need for more studies and trials. Dietary interventions
in patients with psoriasis should be aimed at risk
reduction of related comorbidities such as diabetes and
cardiovascular disease [23,24]. The diet that most
efficiently reduces cardiovascular risk is Mediterranean
diet, which is typically high in fruits, vegetables, whole
grains, beans, nuts, seeds and olive oil and low in dairy
products and red meats [36]. Furthermore, achieving
optimal body weight is an additional valuable
preventive and therapeutic measure, considering that
obesity is a significant risk factor for psoriasis
exacerbation [37].
ATOPIC DERMATITIS
Atopic dermatitis (AD) is a chronic, inflammatory,
relapsing and pruritic skin disorder with a very high
prevalence, affecting up to 20% of children and 1–3%
of adults [38]. It has a significant impact on quality of
life of patients as well as their families. Considering that
food allergens alter the clinical course of AD in patients
who exhibit food sensitivity, dietary intervention may
play an important role in the preventive as well as
therapeutic approach to the disease. Food allergy is a
form of adverse reaction caused by an immunological
response to a food item [39]. Although the association
between food allergies and atopic dermatitis is not fully
elucidated, body of evidence suggests that food can
induce and aggravate symptoms of AD in some
patients [38,40]. However, contrary to popular beliefs
widely accepted by general population and some
parents, it should be noted, that not all patients with AD
suffer from food allergies [38]. Clinical manifestation of
food allergy includes a broad spectrum of symptoms
affecting skin but also gastrointestinal and respiratory
systems. It is estimated that approximately 35% of
children with moderate to severe AD have food allergy
[38,40]. As opposed to children, food hypersensitivity
has little, if any, role in adult patients with AD [38].
Foods commonly associated with allergic reactions
include eggs, milk, wheat, and soy and these account
for almost 75% of all reactions [40]. Other less frequent
foods, which tend to have more severe reactions,
include peanut, tree nuts, fish, and shellfish [41]. There
is a greater risk of aggravating AD with food if a patient
suffers from a more severe form of the disease [42].
Furthermore, early onset of AD is positively correlated
to higher risk for developing food sensitivity [42]. Type
of foods responsible for aggravation of AD symptoms
can vary with the age; in younger children eggs, cow’s
milk, peanut, and soy are the most common ones, and
in older children, tree nuts, wheat, fish, and shellfish
are the main causative agents [38,43]. Food allergies
are rare in adults, but nevertheless, there are some
food sensitivities that tend to persist throughout life,
including allergy to shellfish, fish, walnuts, almonds,
and peanuts. In children, foods high in protein cause
90% of the allergic reactions, most frequently including
peanuts, milk, wheat, soy, fish, and eggs [38,43]. For
the most types of food sensitivities, patients will gain
tolerance over some period of time, and finally outgrow
their sensitivities [38,43]. Therefore, previous allergens
may not persist as a trigger for patients eczema flare-
ups [38,43]. Elimination diet, as a preventive strategy,
is recommended only in cases of confirmed food
allergy, based on diagnostic testing, including; skin
prick tests, food-specific IgE antibodies levels, and/or
standardized oral food challenge [38,43]. The need for
diagnostic confirmation is essential, considering that
elimination diet may cause significant nutrient intake
deficiencies, even severe malnutrition, particularly in
young children [38,43]. Furthermore, restriction diets
may lead to a decreased intake of antioxidants, which
can result in an increased risk of AD or asthma flare-
ups [44], and it should only be conducted if indicated.
As such, in cases where patients exhibit significant
clinical improvement during the elimination diet trial,
intake of offending foods items should be avoided
completely or at least minimised [38,43]. However, if
the clinical symptoms of atopic dermatitis are only mild
to moderate and develop after consumation of larger
amounts of offending foods, there is no need to pursue
a full elimination diet [41,45]. The decision to institute
an elimination diet, as a therapeutic option, should be
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The Impact of Diet on Common Skin Disorders Journal of Nutritional Therapeutics, 2014, Vol. 3, No. 3 153
made based upon the benefit-risk ratio, taking into
account that majority of food allergens provide valuable
nutrients to the patient. Nevertheless, if elimination diet
is absolutely necessary, consumption of alternative
foods containing similar nutrient properties should be
provided in order to prevent nutritional deficiencies
[38,43]. It is important to note that AD patients also
exhibit pollen–plant food syndromes; a cross-reactivity
between inhaled pollen and ingested food allergens. As
an example; allergy to birch tree pollen and allergy to
apples, carrots, celery, potatoes, oranges and
tomatoes [39]. In summary, recognition of potential
food allergens as causative agents responsible for
exacerbations of the disease is important in order to
minimize exacerbation and prolong periods of
remission.
CONTACT ALLERGIC DERMATITIS
Contact allergic dermatitis (CAD) is a hypersensitive
reaction caused by contact with an allergen presenting
as eczema or papules and blisters, depending on the
causative substance. CAD represents significant
distress for the patient, particularly considering the fact
that once the individual has developed a skin reaction
to a certain substance, it is most likely to reoccur [46].
For the majority of patients it has chronic and relapsing
course, causing significant discomfort and having a
negative impact on a daily life. In general, females are
affected more commonly than males [47]. Nickel is the
leading cause of allergic contact dermatitis worldwide,
with increasing incidence in Western industrialized
countries [47,48]. The metal is frequently used for
jewellery and clothes (buttons, clasps, zippers), as well
as coins, which can partly explain the high rate of this
skin disorder [47]. Avoidance of further exposure to all
possible sources of nickel is crucial in order to minimise
exacerbation [47,48].
One of the key aspects of prevention is limiting
consumption of foods high in nickel [47]. This is of
particular importance for patients presenting with
severe clinical forms and with a chronic course of the
disease [47]. Systemic contact dermatitis develops
following oral nickel exposure from water or
consumption of high-nickel diet [49,50]. Even though
any body part can be affected, the hands are most
commonly involved in nickel-sensitive individuals [46].
Foods containing considerable amount of nickel
include: dried fruits, nuts, cocoa, chocolate, soy
products, wheat flour, green vegetables, cereals,
potatoes, poultry, fish, eggs, fats, green tea, black tea,
garlic, lentils, vitamin supplements and canned foods
[47,51].
Apart from the foods, there are number of other
factors that can contribute to high levels of nickel
content in the food, including soil composition, which is
dependent on the region, or equipment used for food
processing [46,47]. In addition, it should be taken into
consideration that cooking and food preparation
methods can also affect nickel content in the food. For
instance, cooking acidic food, such as, vinegar or
lemon in stainless steel may cause nickel leaching from
cookware [46]. Another important factor that may affect
the ingestion and metabolism of dietary nickel are
levels of vitamin C or iron, which decrease absorption
of nickel [46,47]. Consequently, possible underlying
iron deficiency or anemia could contribute to clinical
improvement and prevent eczema flare-ups. Nickel
contact allergy is a life-long condition for the majority of
patients, and is characterised by high relapse rates,
making preventive measures, including dietary
interventions a necessary component of therapy.
CONCLUSION
The role of diet as a preventive and/or treatment
tool in common skin disorders including; acne,
psoriasis, atopic dermatitis and contact allergies, is yet
to be established. Nevertheless, evidence thus far
clearly demonstrates huge impact of diet on clinical
course and aggravation of symptoms in these
disorders. Acne is associated with increased intake of
high glicemyc index food, omega-6 fatty acids and
dietary products. The role of nutrition in psoriasis and
its effect on improvement of skin lesions is still
controversial, but considering higher incidence of
comorbidites associated with psoriasis, dietary
interventions should be instituted to lower
cardiovascular risk and risk of metabolic syndrome. In
atopic dermatitis, elimination diet should be conducted
rationaly, only in cases of confirmed food allergy and in
severe clinical forms. Nickel allergy is one of the most
frequent causes of contact allergic dermatitis.
Considering that nickel is present in majority of dietary
items, diet low in nickel plays an important role in
prevention of eczema flares up.
CONFLICT OF INTEREST STATEMENT
None declared.
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Received on 11-09-2014 Accepted on 29-09-2014 Published on 03-10-2014
DOI: http://dx.doi.org/10.6000/1929-5634.2014.03.03.6
For Author's Personal Use
