Case study: Acne vulgaris
Client: A 19-year-old-male university student
Initial presentation: The client presents with moderate inflammatory acne affecting the face (cheeks, jawline and forehead), upper back and chest. Lesions include papules and pustules, with post-inflammatory erythema and early scarring along the jawline.
He reports persistent breakouts since age 15, with worsening over the past 6 months during university exams. Skin is described as oily, with flares occurring 1-2 weeks after high stress periods.
Diet consists of frequent takeaway meals, simple carbohydrates, protein bars and whey-protein shakes after the gym. He consumes dairy daily (milk in coffee, cheese and Greek yogurt). Low diversity of fruit and vegetable intake, with minimal water consumption.
He trains at the gym 5-6 days/week and reports high stress, poor sleep onset (midnight-1am bedtime) and 5-6 hours’ sleep per night. Bowel motions occur every 1-2 days, with occasional bloating reported.
Naturopathic assessment: 19-year-old-male presents with moderate inflammatory acne vulgaris likely caused by androgen-mediated sebum production, high glycaemic load diet, dairy intake and gut dysbiosis contributing to systemic inflammation. Exacerbated by stress and suboptimal sleep.
Key factors considered:
- Androgen activity & sebum production - Acne in young males is strongly influenced by androgens, particularly dihydrotestosterone (DHT), which increases sebaceous gland activity and keratinocyte proliferation. Excess sebum combined with abnormal follicular keratinisation promotes comedone formation.
- Insulin & IGF-1 signalling - High glycaemic load diets elevate insulin and insulin-like growth factor (IGF-1), which stimulate androgen production and increase sebum output. High dairy consumption may further increase circulating IGF-1, exacerbating acne severity.
- Inflammation & oxidative stress - Inflammatory acne involves colonisation of follicles by Cutibacterium acnes (C. acnes) (formerly Propionibacterium acnes/P. acnes), triggering immune activation and pro-inflammatory cytokine release (IL-1β & TNF-α). Oxidative stress contributes to lipid peroxidation of sebum, worsening inflammation and tissue damage.
- Gut-skin axis - Impaired gut barrier function and dysbiosis may increase systemic endotoxin load, promoting inflammatory cascades that manifest in the skin. Bloating and irregular bowel motions suggest possible intestinal dysbiosis.
- Stress & sleep disturbance - Elevated cortisol increases sebaceous gland activity and inflammation, while poor sleep impairs skin repair and immune regulation. Exam stress has been identified by the client as a notable trigger for acne flares.
Herbal medicine:
Green tea (Camelia sinensis) - Rich in epigallocatechin gallate (ECGC), which targets the primary pathogenic features of acne. ECGC reduces sebum production, exerts anti-inflammatory and antioxidant effects, and induces cytotoxicity of SEB-1 sebocytes via apoptosis and decreases the viability of C. acnes. Clinically shown to modulate androgen activity and improve inflammatory lesions.
Burdock (Arctium lappa) - Traditionally used as a depurative herb to support lymphatic drainage and skin health. Demonstrates antioxidant and antibacterial activity relevant to acne management.
Turmeric (Curcuma longa) - Potent anti-inflammatory and antioxidant that downregulates NF-κB and reduces proinflammatory cytokines (IL-1β & TNF-α) involved in acne pathogenesis.
Black pepper (Piper nigrum) - Enhances the absorption and bioavailability of curcumin, to amplify its therapeutic properties. A potent antioxidant to neutralise reactive oxidative species.
Calendula (Calendula officinalis) - Traditionally used as a depurative herb to support lymphatic drainage and skin health. Supports wound healing by encouraging cell proliferation, as well as reducing post-inflammatory scarring.
Withania (Withania somnifera) - A tonic for the nervous system. Withania modulates the stress response by regulating cortisol release and supports overall endocrine balance.
Herbal formula for acne and stress support - 200 mL
Green tea (Camelia sinensis) 1:2 - 50 mL
Burdock (Arctium lappa) 1:2 - 30 mL
Turmeric (Curcuma longa) 1:1 - 50 mL
Black pepper (Piper nigrum) 1:2 - 5 mL
Calendula (Calendula officinalis) 1:2 - 25 mL
Withania (Withania somnifera) 3:2 - 40 mL
Dosage: 7.5 mL twice daily (BD).
Note: Client is advised to drink one glass of water with each dose of herbal medicine, to support the liver and kidneys natural processing of alcohol.
Topical herbal treatment
Mānuka oil (Leptospermum scoparium) - A potent antibacterial herb that is highly effective against gram-positive bacteria such as C. acnes.
Totarol™ (Podocarpus totara) - Supports skin health through antioxidant and antibacterial activity.
Meadowfoam (Limanthes alba) - Supports skin barrier function by increasing moisture retention and hydration.
Eucalyptus leaf oil (Eucalyptus globulus) - Antimicrobial and anti-inflammatory properties work to soothe irritated and inflamed skin, while preventing infection.
Dosage: Apply to affected area 2-3 times daily, after washing and cleansing.
Additional recommendations:
Dietary modifications
- Reduce high glycaemic load foods - Replace white bread and simple carbohydrates with whole grains (wholegrain bread, brown rice, quinoa, steel-cut oats) to stabilise insulin and reduce IGF-1 stimulation.
- Trial dairy reduction - Implement a 6–8-week dairy-free trial to assess impact on acne severity. Incorporate dairy-free alternatives including plant-based milks, soy or coconut yogurt, dairy-free cheese and bone-broth or pea-based protein powder.
- Increase diversity of fruits and vegetables - Aim for 5+ servings daily to increase antioxidant intake (vitamin C, polyphenols, carotenoids) and maximise diversity in the gut microbiome to combat inflammation and oxidative stress.
- Increase omega-3 intake - Consume oily fish (salmon, sardines, mackerel) 2-3x weekly or add ground flaxseeds and chia seeds daily. Omega-3 fatty acids reduce inflammatory mediators (IL-1β & TNF-α) involved in acne pathogenesis.
- Hydration - Aim for 2-2.5 L water daily to support detoxification pathways and skin hydration.
Lifestyle modifications
- Improve sleep hygiene - Aim for 7-9 hours' sleep each night. Establishing a consistent sleep-wake time, limiting screens 60 minutes before bed and exposing the eyes to natural light upon waking can help reinforce the circadian rhythm, enhancing overall sleep quality. Adequate sleep is essential for skin healing and recovery.
- Implement daily stress management techniques - Relaxation techniques including breathwork, yoga Nidra or mindfulness meditation to encourage parasympathetic activity and reduce significant cortisol fluctuations.
- Post-exercise hygiene - Shower promptly after sweating and change out of gym clothing to reduce follicular occlusion on the chest and back.
- Non-comedogenic skincare - Use a gentle cleanser twice daily, avoid harsh over-exfoliation and select a non-comedogenic facial moisturiser and sunscreen to protect skin barrier function.
Supplements
- Zinc (15-30 mg daily) - Reduces inflammation, supports immune regulation, decreases sebum production and exerts antibacterial activity against C. acnes.
- Strain specific probiotics (Lactobacillus and Bifidobacterium) - Target the gut-skin axis by modulating the gut microbiota to help improve acne through immune regulation and reduced systemic inflammation. Lactobacillus plantarum CJLP55 has been clinically shown to significantly reduce acne lesions, improve skin hydration and strengthen the skin's lipid barrier. Lactobacillus rhamnosus SP1 has been associated with decreased IGF-1 levels, suggesting it may help regulate insulin signalling pathways relevant in acne pathogenesis. Bifidobacterium breve has also demonstrated clinical effectiveness in significantly reducing inflammatory acne lesions.
- Omega-3 (EPA/DHA, 1-2g/daily) - Reduces inflammatory mediators (IL-1β & TNF-α) and supports skin barrier function to improve skin healing. Regulates sebum production by reducing IGF-1 levels, which is linked to acne severity.
Follow up:
During the four-week-follow-up, the client reported early but encouraging improvements. Inflammatory papules and pustules have reduced slightly in number and severity, although occasional new lesions are still emerging. Post-inflammatory erythema is still present, as expected at this early stage with no progression of scarring.
Bowel regularity has improved (at least 1 bowel movement per day) and bloating has reduced, indicating positive early changes within the gut-skin axis. He has switched to a bone broth protein powder and successfully transitioned to dairy-free alternatives. though adherence to low glycaemic food choices has been challenging. He consumes chia seeds and ground flaxseeds daily but has struggled to eat oily fish 2-3 weekly. Sleep onset has improved. He is consistently going to bed at 11pm and is sleeping approx. 6-7 hours nightly. The client reports feeling calmer since taking the herbal formula.
Continued treatment is indicated, with addition of a 1-2g/day omega-3 (EPA/DHA) supplement for anti-inflammatory support. Dietary consistency, stress management and sleep hygiene have been reinforced to support sustained improvements over the next 4-8 weeks.