Concern arises from so much information out there about vitamins, especially on the Internet. I’ve had a number of patients mention a myriad of claims that they hear about these substances, and often these claims are either completely false or so blown out of proportion that they have led me to research this issue more.
A Medline search on acne and vitamins yielded fewer than 30 articles, yet when these same words were “Googled” in an advanced search (limiting results) there were more than 3,900 hits. Patients who review these choices unfortunately think that they represent data from evidence-based medicine.
This month, I will review the role of vitamins in the treatment of acne. In addition to highlighting some items with proposed efficacy, I will discuss what happens when patients take vitamins in excess.
Vitamin Excess
Vitamin A has long been associated with the treatment of acne.1 Isotre-tinoin, and the topical retinoids all offer ways of delivering medications structurally related to vitamin A, and in the days prior to such medicines, high-dose vitamin A was used as a treatment for acne. Some have hypothesized that a vitamin A deficiency could be a cause of acne. Case in point:
A recent study measured the plasma of 200 Jordanian patients and found a significant decrease in the levels of vitamins A and E in acne patients, and these decreased levels were more pronounced in those who had severe acne.2
What does this suggest? True vitamin deficiencies are rare in the United States. If other symptoms are present, a thorough history and physical may be necessary and supplementation given as needed.
However, for treating acne in this day and age, isotretinoin represents an improvement over high-dose vitamin A, even with all its regulatory mechanisms and restrictions. Also we have great topical retinoids that avoid all of the systemic side effects of isotretinoin. Regardless, I still have seen patients taking high doses of vitamin A to treat their skin.
From my own experience in my clinic, I recall treating a pubescent girl who had diffuse hair loss. Her mother, an aesthetician, had been giving her long-term supplementation with large doses of vitamin A. This exemplifies what can happen when patients are misinformed about “natural” cures for acne.
Also, zinc, which we will discuss below, has been purported for years to help with acne, both topically and orally.
A disturbing example involves a case report of a 17-year-old boy who, on the advice of his dermatologist to take zinc for his acne, developed hyporcupremia, with resultant anemia, leucopenia and neutropenia after 6 to 7 months of zinc supplementation.3
Prolonged use of zinc caused a deficiency of copper that then led to the other conditions already listed.
This patient’s symptoms and laboratory values had returned to normal by his 4-month follow-up visit.
Other examples of excess include the formation of acne caused by “megadoses” of vitamins B6 and B12.4 These occurrences are consistent with previous reports of injectable vitamin B12 causing a monomorphic acneiform eruption.5
Positive Outcomes with Vitamins
Some vitamins, however, have been shown to help with the inflammatory component of acne.
A vitamin combination of niacinamide (nicotinamide) 750 mg, folic acid 0.5 mg, zinc 25 mg and copper 1.5 mg (put in to prevent hypocupremia discussed above), is marketed as the branded, Nicomide tablets, and it’s also available as a generic.
This combination is FDA approved for the treatment of inflammatory skin conditions, including acne. The tablet is taken twice daily, and its most common side effect in my hands has been gastrointestinal disturbance.
This finding is consistent with the recent multicenter trial evaluating this combination product that also found that the most common side effect was nausea (in 5.5% of patients in the study).6 (Please note that nicotinamide and niacinamide are the same compounds.)
How Well Do These Substances Work?
Some physicians have questioned me as to whether I think there is a noticeable improvement in patients. I have some patients who do well on this medication. Usually they are patients with mild-to-moderate inflammatory acne, resistant to the idea of taking systemic antibiotics.
I believe this combination works better in conjunction with topical medications. However, my first systemic choice for patients with mild-to-moderate acne remains oral antibiotics.
A multicenter trial comparing Nicomide alone and in combination with other treatments, including oral antibiotics, topical retinoids and/or topical benzoyl peroxide in combination, but not to a placebo, confirmed this.
The study produced data that showed that adding a retinoid to the Nicomide tablet offered improved outcomes; whereas, adding additional topicals or oral antibiotics added no significant improvement.6
How Does This Medication Work?
A recent review mentioned the mechanisms of actions of Nicomide in the treatment of acne and other inflammatory dermatoses. The formulation is though to inhibit:
• leukocytes from migrating into the skin
• the release of lysosomal enzymes from theses cells
• lymphocytic transformation and antibody production
• release of vasoactive amines. Zinc alone has been shown to inhibit the lipase of Propionibacterium acnes.7
Topical Preparations
Topical preparations of nicotinamide are available in cream and gel formulations. In the comparison with 1% clindamycin gel (68% patient improvement), topical nicotinamide gel (85% patient improvement) showed comparable efficacy to the antibiotic after 8 weeks of therapy in a study of 76 subjects.8
This result is similar to another trial where 4% nicotinamide was found to produce similar results as 4% erythromycin gel.9
What Do We Tell Our Patients?
In my practice, I tell patients to avoid purchasing vitamins for the treatment of acne. This is because we really don’t have the data to support the use of these supplements, and newer retinoids represent better ways to treat acne than large doses of vitamin A, especially when the vitamins are used outside of the realm of the physician.
If patients are interested in “vitamin treatment” for their acne, I suggest nicotinamide/zinc combination as this formulation has FDA approval for treating inflammatory skin conditions. I would also suggest to patients that they use standard topicals in addition to this oral supplement.
Although I have listed some of the major issues concerning vitamins that have come up in my clinic, it is no means a comprehensive review. However, I believe this will give you a place to start when you are asked such questions.
In my next column we will discuss alternative/herbal treatments for acne.
Concern arises from so much information out there about vitamins, especially on the Internet. I’ve had a number of patients mention a myriad of claims that they hear about these substances, and often these claims are either completely false or so blown out of proportion that they have led me to research this issue more.
A Medline search on acne and vitamins yielded fewer than 30 articles, yet when these same words were “Googled” in an advanced search (limiting results) there were more than 3,900 hits. Patients who review these choices unfortunately think that they represent data from evidence-based medicine.
This month, I will review the role of vitamins in the treatment of acne. In addition to highlighting some items with proposed efficacy, I will discuss what happens when patients take vitamins in excess.
Vitamin Excess
Vitamin A has long been associated with the treatment of acne.1 Isotre-tinoin, and the topical retinoids all offer ways of delivering medications structurally related to vitamin A, and in the days prior to such medicines, high-dose vitamin A was used as a treatment for acne. Some have hypothesized that a vitamin A deficiency could be a cause of acne. Case in point:
A recent study measured the plasma of 200 Jordanian patients and found a significant decrease in the levels of vitamins A and E in acne patients, and these decreased levels were more pronounced in those who had severe acne.2
What does this suggest? True vitamin deficiencies are rare in the United States. If other symptoms are present, a thorough history and physical may be necessary and supplementation given as needed.
However, for treating acne in this day and age, isotretinoin represents an improvement over high-dose vitamin A, even with all its regulatory mechanisms and restrictions. Also we have great topical retinoids that avoid all of the systemic side effects of isotretinoin. Regardless, I still have seen patients taking high doses of vitamin A to treat their skin.
From my own experience in my clinic, I recall treating a pubescent girl who had diffuse hair loss. Her mother, an aesthetician, had been giving her long-term supplementation with large doses of vitamin A. This exemplifies what can happen when patients are misinformed about “natural” cures for acne.
Also, zinc, which we will discuss below, has been purported for years to help with acne, both topically and orally.
A disturbing example involves a case report of a 17-year-old boy who, on the advice of his dermatologist to take zinc for his acne, developed hyporcupremia, with resultant anemia, leucopenia and neutropenia after 6 to 7 months of zinc supplementation.3
Prolonged use of zinc caused a deficiency of copper that then led to the other conditions already listed.
This patient’s symptoms and laboratory values had returned to normal by his 4-month follow-up visit.
Other examples of excess include the formation of acne caused by “megadoses” of vitamins B6 and B12.4 These occurrences are consistent with previous reports of injectable vitamin B12 causing a monomorphic acneiform eruption.5
Positive Outcomes with Vitamins
Some vitamins, however, have been shown to help with the inflammatory component of acne.
A vitamin combination of niacinamide (nicotinamide) 750 mg, folic acid 0.5 mg, zinc 25 mg and copper 1.5 mg (put in to prevent hypocupremia discussed above), is marketed as the branded, Nicomide tablets, and it’s also available as a generic.
This combination is FDA approved for the treatment of inflammatory skin conditions, including acne. The tablet is taken twice daily, and its most common side effect in my hands has been gastrointestinal disturbance.
This finding is consistent with the recent multicenter trial evaluating this combination product that also found that the most common side effect was nausea (in 5.5% of patients in the study).6 (Please note that nicotinamide and niacinamide are the same compounds.)
How Well Do These Substances Work?
Some physicians have questioned me as to whether I think there is a noticeable improvement in patients. I have some patients who do well on this medication. Usually they are patients with mild-to-moderate inflammatory acne, resistant to the idea of taking systemic antibiotics.
I believe this combination works better in conjunction with topical medications. However, my first systemic choice for patients with mild-to-moderate acne remains oral antibiotics.
A multicenter trial comparing Nicomide alone and in combination with other treatments, including oral antibiotics, topical retinoids and/or topical benzoyl peroxide in combination, but not to a placebo, confirmed this.
The study produced data that showed that adding a retinoid to the Nicomide tablet offered improved outcomes; whereas, adding additional topicals or oral antibiotics added no significant improvement.6
How Does This Medication Work?
A recent review mentioned the mechanisms of actions of Nicomide in the treatment of acne and other inflammatory dermatoses. The formulation is though to inhibit:
• leukocytes from migrating into the skin
• the release of lysosomal enzymes from theses cells
• lymphocytic transformation and antibody production
• release of vasoactive amines. Zinc alone has been shown to inhibit the lipase of Propionibacterium acnes.7
Topical Preparations
Topical preparations of nicotinamide are available in cream and gel formulations. In the comparison with 1% clindamycin gel (68% patient improvement), topical nicotinamide gel (85% patient improvement) showed comparable efficacy to the antibiotic after 8 weeks of therapy in a study of 76 subjects.8
This result is similar to another trial where 4% nicotinamide was found to produce similar results as 4% erythromycin gel.9
What Do We Tell Our Patients?
In my practice, I tell patients to avoid purchasing vitamins for the treatment of acne. This is because we really don’t have the data to support the use of these supplements, and newer retinoids represent better ways to treat acne than large doses of vitamin A, especially when the vitamins are used outside of the realm of the physician.
If patients are interested in “vitamin treatment” for their acne, I suggest nicotinamide/zinc combination as this formulation has FDA approval for treating inflammatory skin conditions. I would also suggest to patients that they use standard topicals in addition to this oral supplement.
Although I have listed some of the major issues concerning vitamins that have come up in my clinic, it is no means a comprehensive review. However, I believe this will give you a place to start when you are asked such questions.
In my next column we will discuss alternative/herbal treatments for acne.
Concern arises from so much information out there about vitamins, especially on the Internet. I’ve had a number of patients mention a myriad of claims that they hear about these substances, and often these claims are either completely false or so blown out of proportion that they have led me to research this issue more.
A Medline search on acne and vitamins yielded fewer than 30 articles, yet when these same words were “Googled” in an advanced search (limiting results) there were more than 3,900 hits. Patients who review these choices unfortunately think that they represent data from evidence-based medicine.
This month, I will review the role of vitamins in the treatment of acne. In addition to highlighting some items with proposed efficacy, I will discuss what happens when patients take vitamins in excess.
Vitamin Excess
Vitamin A has long been associated with the treatment of acne.1 Isotre-tinoin, and the topical retinoids all offer ways of delivering medications structurally related to vitamin A, and in the days prior to such medicines, high-dose vitamin A was used as a treatment for acne. Some have hypothesized that a vitamin A deficiency could be a cause of acne. Case in point:
A recent study measured the plasma of 200 Jordanian patients and found a significant decrease in the levels of vitamins A and E in acne patients, and these decreased levels were more pronounced in those who had severe acne.2
What does this suggest? True vitamin deficiencies are rare in the United States. If other symptoms are present, a thorough history and physical may be necessary and supplementation given as needed.
However, for treating acne in this day and age, isotretinoin represents an improvement over high-dose vitamin A, even with all its regulatory mechanisms and restrictions. Also we have great topical retinoids that avoid all of the systemic side effects of isotretinoin. Regardless, I still have seen patients taking high doses of vitamin A to treat their skin.
From my own experience in my clinic, I recall treating a pubescent girl who had diffuse hair loss. Her mother, an aesthetician, had been giving her long-term supplementation with large doses of vitamin A. This exemplifies what can happen when patients are misinformed about “natural” cures for acne.
Also, zinc, which we will discuss below, has been purported for years to help with acne, both topically and orally.
A disturbing example involves a case report of a 17-year-old boy who, on the advice of his dermatologist to take zinc for his acne, developed hyporcupremia, with resultant anemia, leucopenia and neutropenia after 6 to 7 months of zinc supplementation.3
Prolonged use of zinc caused a deficiency of copper that then led to the other conditions already listed.
This patient’s symptoms and laboratory values had returned to normal by his 4-month follow-up visit.
Other examples of excess include the formation of acne caused by “megadoses” of vitamins B6 and B12.4 These occurrences are consistent with previous reports of injectable vitamin B12 causing a monomorphic acneiform eruption.5
Positive Outcomes with Vitamins
Some vitamins, however, have been shown to help with the inflammatory component of acne.
A vitamin combination of niacinamide (nicotinamide) 750 mg, folic acid 0.5 mg, zinc 25 mg and copper 1.5 mg (put in to prevent hypocupremia discussed above), is marketed as the branded, Nicomide tablets, and it’s also available as a generic.
This combination is FDA approved for the treatment of inflammatory skin conditions, including acne. The tablet is taken twice daily, and its most common side effect in my hands has been gastrointestinal disturbance.
This finding is consistent with the recent multicenter trial evaluating this combination product that also found that the most common side effect was nausea (in 5.5% of patients in the study).6 (Please note that nicotinamide and niacinamide are the same compounds.)
How Well Do These Substances Work?
Some physicians have questioned me as to whether I think there is a noticeable improvement in patients. I have some patients who do well on this medication. Usually they are patients with mild-to-moderate inflammatory acne, resistant to the idea of taking systemic antibiotics.
I believe this combination works better in conjunction with topical medications. However, my first systemic choice for patients with mild-to-moderate acne remains oral antibiotics.
A multicenter trial comparing Nicomide alone and in combination with other treatments, including oral antibiotics, topical retinoids and/or topical benzoyl peroxide in combination, but not to a placebo, confirmed this.
The study produced data that showed that adding a retinoid to the Nicomide tablet offered improved outcomes; whereas, adding additional topicals or oral antibiotics added no significant improvement.6
How Does This Medication Work?
A recent review mentioned the mechanisms of actions of Nicomide in the treatment of acne and other inflammatory dermatoses. The formulation is though to inhibit:
• leukocytes from migrating into the skin
• the release of lysosomal enzymes from theses cells
• lymphocytic transformation and antibody production
• release of vasoactive amines. Zinc alone has been shown to inhibit the lipase of Propionibacterium acnes.7
Topical Preparations
Topical preparations of nicotinamide are available in cream and gel formulations. In the comparison with 1% clindamycin gel (68% patient improvement), topical nicotinamide gel (85% patient improvement) showed comparable efficacy to the antibiotic after 8 weeks of therapy in a study of 76 subjects.8
This result is similar to another trial where 4% nicotinamide was found to produce similar results as 4% erythromycin gel.9
What Do We Tell Our Patients?
In my practice, I tell patients to avoid purchasing vitamins for the treatment of acne. This is because we really don’t have the data to support the use of these supplements, and newer retinoids represent better ways to treat acne than large doses of vitamin A, especially when the vitamins are used outside of the realm of the physician.
If patients are interested in “vitamin treatment” for their acne, I suggest nicotinamide/zinc combination as this formulation has FDA approval for treating inflammatory skin conditions. I would also suggest to patients that they use standard topicals in addition to this oral supplement.
Although I have listed some of the major issues concerning vitamins that have come up in my clinic, it is no means a comprehensive review. However, I believe this will give you a place to start when you are asked such questions.
In my next column we will discuss alternative/herbal treatments for acne.
