Acne

This new Dermatologist podcast is sponsored by La Roche-Passe. Effacladeur+ is specifically formulated for oily blemish-prone skin in adults and teenagers. The formula works to unclog block pores, help control sebum to mattify skin and control shine. Also suitable for acne-prone skin. La Roche-Passe, a better life for sensitive skin. Available from selected retailers, pharmacies and online. Welcome to the new Dermatologist podcast. We are a group of Dermatology consultants who are friends and we've done a series of educational events collectively and individually. This podcast is aimed at GP colleagues or anyone with an interest in common dermatological conditions. I am Victoria Atcrass. I'm a consultant dermatologist at St George's Hospital and I have a special interest in skin cancer and connective tissue disease. Today's podcast is on acne. This is a condition which can be extremely distressing for patients and we certainly have a large number of people referred in to secondary care with this problem and it has a significant impact on quality of life. My friend and colleague Dr. Shavali Rajpot Pat is here today to share treatment tips. So welcome Shavali. Hello, thanks for having me. It's great to have you here. Shavali is a consultant dermatologist based at Barth's Health in London and she has a special interest in skin cancer and postgraduate medical medical education and also in acne. I also have with me a GP colleague today, Dr. Janani Bodhi. So welcome Janani. It's lovely to have you. Thank you. Janani is a qualified GP. She qualified in 2013 and she's currently working with Booper and as a Locum NHS GP in North London. The information in this podcast is based on available evidence and the experience of the clinicians involved. It is intended to be a useful guide for clinicians and the advice given in the podcast must take into account an individual patient's background and be adapted accordingly. So let's talk about acne over to you Janani. Okay, so in mild to moderate acne, how do you decide which topic or product to use? I think to understand the rationale behind acne treatments it's helpful to consider the different types of acne lesion. So the earliest signs of acne appear around puberty with a build-up of oil on the skin and we call this sebaria. This is followed by comodones so that's the black heads and white heads and then inflammatory lesions which are the papules and postules which can lead to scarring. Now most people will have a mixture of these lesions but in some one type may predominate so they may have predominantly inflammatory or comodonal acne. In terms of treatment, patient choice is important and compliance is better when they're involved in the decision-making. Some may prefer to try a non-prescription over the counter product first and I know we're going to talk about these later but in terms of prescription treatments, topical retinoids generally work better on comodones and benzoyl peroxide which is antibacterial and active against p-acnes is better for papules and postules as it has a much milder comedolytic effect. Antibiotics whether you're using topical or oral products work best on inflammatory lesions and so having this knowledge can guide your initial choice of topical treatment. Okay that's really helpful. So what are the advantages or disadvantages of using a combination benzoyl peroxide with retinoid overusing each of them individually? So the main advantage I think is being able to adapt the treatment to the main lesion type. So if you're seeing in inflammatory lesions as well as comodones which is often the case then a combination treatment may work better and the options we have here are benzoyl peroxide with adapolline so that's epiguro. Benzoyl peroxide with antibiotic so that would be duac and antibiotic with retinoids such as treclin and in reality you may end up starting with one product and switching to another if one doesn't work but these are good starting points. The main disadvantage of both benzoyl peroxide and retinoids is their irritant and drying effect on the skin and this is something that this tolerability is often a problem. So these products are only really suitable for small surface areas such as the face or localized areas on the trunk. They'd be too irritant if they were to be applied across the whole back for example. Also benzoyl peroxide bleach is fabric and so you need to warn your patient or their parent that if these products are used at night for example the pillow case will get bleached and another consideration is pregnancy. Retinoids whether they are topical and of course oral need to be avoided in somebody trying to conceive or if someone's pregnant. Okay so you've touched on it already but also how can we best advise patients who are starting a topical retinoid to avoid these skin reactions? So this is a really important question because it's a common problem and a frequent reason for poor compliance. It's important to warn the patient in advance that their skin is going to become a bit dry and a bit irritated. Really it's what you want to happen it's it's an indication that the treatment is doing something and it's an expected side effect but it shouldn't be excessive it needs to be balanced against you know comfort and importantly it's not analogy because I think some patients stop these products because they think they're having an allergic reaction. So I tend to introduce the retinoid product quite gradually and the same would apply to benzoyl peroxide. For the first two weeks of treatment I tell them to apply it for a few hours in the evening after school or after work and this this is after moisturizing and then for the following two weeks I'd say apply it two or three times a week and then as tolerated. Patients with more greasy skin will tolerate more frequent application and those with sensitive dry or eczema prone skin will need to be more cautious and this slow introduction allows the skin to get used to the new product. I also tell them to moisturize first and this little tip makes a big difference so they need to clean their skin, apply their moisturizer and then wait about 10 to 15 minutes before applying the retinoid and a good moisturizer is a great adjunct to help soothe irritated skin. Thirdly you can also try different retinoids so you have the options of retinoin versus a dapline you can also vary the strength. So for example epigioge comes in two adapling strengths 0.1% and 0.3% and the same applies to benzoyl peroxide which is available in different formulations as a leave in or a wash off product and also at different strengths. Could I ask you something Shavarlie? Are there any benefits to using higher concentrations of benzoyl peroxide? So if the lower concentration fails is there any benefit in stepping up to a higher concentration? Yes absolutely so the higher concentration tends to work better but the problem is the tolerability. So I do exactly the same as you I would start with the lower strength particularly in patients with sensitive skin and if they don't respond then I would work up to a higher concentration but institute some of those tips that we've just talked about. Great thank you. And what about SPF protection especially for patients using retinoids? Patients often report that many sunscreens worse in their acne so how can we advise them there? Regarding sunscreen a moisturizer containing SPF30 is plenty particularly in the UK. It's best to use a moisturizer that is formulated for the face and for acne prone skin and the Efeclar range by La Roche Posse is a good example of this so Efeclar Duo +30 contains SPF30. However if you just want a sunscreen for example if you're going on holiday or something like that then good options are Anthelios by La Roche Posse, photo derm by Bioderma, LTMD and Cetaphil daily defence. When using a topical retinoid it's advisable not to intentionally sunbathe as there's a high risk of burning. Do you tell people to put the retinoids on at night? Because obviously you don't want them to put it on and then go out in the daytime. Yes I do. And still staying with topical treatments, why do they only work in some people? So I think the main reason for treatment failure is incorrect use and poor compliance. Most patients will apply the topical treatment to the spots whereas they should be treating the whole face. Acne treatments don't just work on what's already there but they can also act to prevent the next outbreak. And as you don't know where your next spot is going to be the entire acne prone area needs to be treated. Also some patients give up quickly. These treatments take time to work and I would usually wait at least eight if not 12 weeks before assessing the response. So it's helpful to tell the patient they need to be patient especially at the beginning because it's going to take time for these treatments to kick in. Large surface areas can't be treated with topicals so if you know if a topical treatment has been prescribed for the back often it's just not practical because patients can't reach and the product may be too irritant so they give up quickly. And topical antibiotics tend to accumulate in the follicle they're thought to exert an anti-inflammatory effect. They're best used with benzoperoxide which increases the efficacy and reduces bacterial resistance. So antibiotic monotherapy, even if it's just with a topical antibiotic, is another reason for treatment failure. However, in some cases, despite good compliance, the treatment is just not effective and then you need to move on to another modality. Do you ever use azalea acid, that's popular with some patient, with some GPs and some consultants as well? Yes. I don't use it very much. A second line, if anything, it tends to be a bit more irritant and I think rather than being very helpful for acne, which it can for some patients, it helps reduce post-inflammatory hyperpigmentation more effectively. So I think in the acne setting, I would use it for PIH rather than specifically for acne itself. Yeah, thanks. Moving on to oral treatments, how long should patients try oral antibiotics? Guidelines state that little evidence of benefit over three months, patients are often on them for longer. So how long is too long? That's a good question. We use oral antibiotics to treat moderate to severe or severe inflammatory acne. Mild to moderate acne, where topicals have failed, and isolated acne, so where you've just got spots mainly on the back, call the chest. And I usually start with lomycycline. I find that with this drug, there's better compliance as dosing as once daily, and there are no restrictions around mealtimes. I assess the response at three months, and if there has been some improvement, but the patient is still getting spots, then I continue with the same antibiotic for another three months. But if the acne is unchanged after the first three month period, then it's unlikely something different is going to happen in the subsequent three months. So I switch at that point to a different antibiotic. You'll find that most people will plateau within six months or have an adequate response, and you can stop the antibiotic at that stage. But if that's not the case, then it's best to switch. Thanks, Shavalli. So you don't give oral antibiotics an isolation, do you? No, not at all. Tural resistance to antibiotics is a constant concern, and it's really important not to use antibiotics as monotherapy as this promotes resistance. So it's best to prescribe either benzoyl peroxide or a topical retinoid or the two in combination alongside the antibiotic, and this greatly reduces bacterial resistance. Great. Thank you. I mean, I guess it's retinoids don't really decrease resistance directly, but I guess the aim is that after the three month period on oral antibiotics, the patient can continue with topical retinoids and maintain their responses. Is that right? Absolutely. Yeah. It's good as maintenance treatment, and I think that antibiotics, because they work additively with the antibiotic, they probably reduce the duration for which you need the antibiotic. And as a maintenance treatment, you're less likely to need an antibiotic again soon. So overall, the total amount that you're using is less, and that in itself will reduce resistance. Great. That makes sense. Thanks. And sticking with antibiotics, in terms of how we should manage flare-ups when they're coming off antibiotics, and is there any help in tapering antibiotics off? So, sadly, flare-ups are really common, so topical maintenance treatment is essential. When you stop an oral antibiotic, continue the prescription of the topical retinoid or benzal peroxide for at least six months afterwards. This maintenance treatment provides continued clearance for months after discontinuation of the systemic therapy. So I think that's probably the best way of managing the flare-up, and rather than tapering the antibiotic off, which probably promotes resistance. And it doesn't really do much to reduce the acne flare-up. Yeah. Okay. And in terms of repeated courses of antibiotics, is that safe to do? So we come back to the problem of bacterial resistance. Apart from that, there are also reported associations with long-term antibiotic use and inflammatory bowel disease, pharyngeitis, C-diff infection, and candida vulva vaginitis. So yes, you can have repeat courses of antibiotics, but it's important to try and keep the treatment time as short as possible. And if the acne just comes straight back, i.e. within weeks of stopping the antibiotic, then I would consider it a treatment failure, and then it's best to look at other options. Right. And in terms of choice of antibiotics, should we be using trimethoprim in primary care? So trimethoprim is usually restricted to use in patients who have failed other treatments. I've seen it work really well, but it has more side effects than other antibiotics, and about 10% of patients will have a skin reaction, and that's quite a lot. Severecutaneous adverse reactions are more common with this antibiotic than they are with others. And by this, I mean Stephen Johnson syndrome, toxic epidermal necrolasis, or dress syndrome. So quite serious reactions for a associated with this drug. So I don't use trimethoprim very much anymore, and when I do, I really stress the importance of stopping it immediately if there's any sign of an allergic reaction. It's also linked with blood discrasias. So if you are going to use it for more than three months, then it's useful to check a full blood count at the three months stage before prescribing anymore. Right. Do you ever use arithromycin? Sometimes. Sometimes. Arithromycin is associated with more bacterial resistance than the other antibiotics. And I think you see more gastrointestinal upset with arithromycin than you do with others. So I use it in certain circumstances in pregnancy, it's safe to use, and in children under age when you can't use the tetracycline, but on the whole, I don't use a lot of oral arithromycin. Yeah, it's interesting. The children thing, because I don't use tetracycline in children under 12, but I know that a lot of the pediatric dermatologists do sometimes use them between the ages of 8 and 12. It's a bit nervous about doing it, but yeah. So yeah, okay, so I think that covers all my antibiotic questions. So moving on to PCOS patients, they're patients with polycystic ovarian syndrome, who have responded well to dionettes, for instance. And as such, they're very reluctant to come off it as inquitation marks, nothing else works. So how should we proceed with these patients? If the acne keeps coming back when you stop dionette, then it's not really providing a long-term solution, and there are other treatments that can. So that's usually my leverage to say, let's move on to something else. You can offer a combined oral contraceptive pill, but it's best to avoid the progesterone only pills. And if they've also failed antibiotics as well as dionette, then it's worth considering Ice Trash No-In. I must admit, I find all the oral contraceptives really bewildering. Are there any combined oral contraceptives that are better than others for acne? So the third and fourth generation pills are better, they're less androgenic, and examples of them are marvalon, celest, gadrel, and jasmine. I know that there is a slightly higher VTE risk with some of these, but for acne it's not just dionette that works, so there is a choice, and you have got some more options. So in patients with hormonal acne, or acne that flares up before or during their periods, how can we best manage them? Most acne patients will have normal hormone levels, and so I only tend to test their hormones when there are features suggestive of hyperandrogenism. So in post-pubertal women, signs of this include oligomineria, herstiotism, androgenetic alopecia, infertility, polycystic ovaries, or trunkal obesity. And obviously when there is an underlying cause that needs to be taken into consideration, and PCOS is the most common reason for elevated ovarian androgens. An important diagnosis not to miss in both men and women is nonclassical, congenital adrenal hyperplasia, which can cause recalcitrant acne and androgenic stress. For the majority of patients with normal hormone levels, I treat in the usual way, but in some women, spinal actone may be helpful. Thanks, chef. I wonder if you could take us through how you would diagnose polycystic ovarian syndrome, because I know that that confuses a lot of the dermatologists as well. Absolutely. I think in its most simplified form, you need two out of three from androgenic stress, either clinical or biochemical, ovulatory dysfunction, and ultrasound evidence of polycystic ovaries. on to sort of adult answer acne. Is this the same as adolescent active acne and should be be treating it in the same way. So we think of acne as a teenage condition, but really this is a myth, because there are many patients who have acne in their 20s, their 30s, and sometimes beyond that as well. So a subset of patients will have acne that starts in the post adolescent years with no history of teenage acne and they're, and they usually come in and they say, "I had great skin as a teenager, I can't believe I'm getting spots now." And many of these women are, many of these patients, sorry, are women, and when they develop their acne after the age of about 25, we call it later on set acne. And you may have noticed in these women that their acne is lower down on the face, so it's lower cheeks, jawline, submandibular area, on the chin and on the lateral neck. Whereas in teenage acne, you see more lesions on the forehead, on the nose and on the upper cheeks. In adult onset acne, the lesions tend to be more inflammatory, they may be nodular and tender, and there are fewer comodones, and peri-menstrual flares are more common. I would still treat this type of acne in the usual way, but these post adolescent women are more likely to fail conventional treatment, including isotratinoin. So again, this is another situation where I would think about spironal actone. Yeah, so why is the treatment failure in this group so much higher? Women with later onset acne usually have normal levels of circulating androgens, but they have higher levels of tissue derived androgens that act locally and promote acne. This may in part explain why they're harder to treat, and using a drug that has more anti-androgenic properties may be more helpful for this group. Yeah, so you've already kind of touched on it, but is there a role for spironal actone in primary care management of acne, and if so, which patients may benefit from them? I think spironal actone is probably underused both in primary care and in secondary care. So I don't usually use it first line, and I don't think most dermatologists would, but if other options haven't worked, then it is a good second or third line option. And I think specific situations where it's useful is when you have a woman who has acne with menstrual flares, somebody who hasn't responded to conventional treatment, and in women who don't want or can't have isotretinoin for whatever reason. The dose that people use is quite variable, so you can use a dose anywhere between 50 milligrams daily and 200 milligrams daily. I think the average is probably around 100. Personally, I tend to use 75 to 100. In terms of biochemical testing, if you have a young and otherwise healthy woman, you actually don't need to check their potassium level, but personally, I do check at baseline a week or two after starting and then six monthly when they're on a stable dose. And for spironal actone, I found that it's the side effects that often limit the dose increases. So women will have some, may have some menstrual irregularity and breast tenderness. And there's also been concern in the past about the cost and agility of this drug, but there have been really huge studies looking into this and there hasn't been any association. So in short, a good drug has a useful place and a reasonably good side effect profile, so something to think about in specific situations. And presumably, you'd use it for as long as the woman has acne, is that right? That's right. I think that's why a lot of secondary care physicians kind of don't feel that comfortable prescribing it without a primary care physician then taking over because the patient will be coming to see you for an infinite amount of time. So you're absolutely right. Yes. Sticking with women and often we find that a women during pregnancy have flares of acne. So what options, what say options do we have for treatment for pregnant women? So we often see women who are considering pregnancy or who are pregnant and the options here, as you know, are much more limited. So in terms of topical treatments, we can use benzoyl peroxide, azaleic acid, erythromycin, and of course, there are over the counter products that they may want to add in. You can also use erythromycin both in a topical form or orally if you've got somebody with more severe acne, but often pregnant women don't really want to take something systemic, unless they absolutely have to. But erythromycin, I think in this situation sometimes works really well. Of course, you can't use any form of retinoid, whether it's topical and of course, oral retinoids are contraindicated. Can I ask you, chef? I mean, not in the context of pregnancy, because obviously people don't use lasers and lights in pregnant women, but for a non-pregnant patient with acne, I get asked this a lot by patients. Do you know if lasers and lights are useful in treating acne at all, because patients seem to have a lot of faith in physical treatments like this. They often ask about them. You're absolutely right. They're looking for physical interventions rather than taking a pill. Yeah. Unfortunately, the evidence here is really lacking. So there was a Cochrane review in 2017 of lasers and light devices, and this concluded that there wasn't any high-quality evidence for the use of these therapies in people with acne. That doesn't mean to say that they don't work. It just means there isn't a huge body of evidence. And at the moment, there aren't any standardized protocols. Patients often need multiple treatments. And in most cases, I think this is a good adjunct treatment rather than a primary treatment for acne. It's also something that's not really available on the NHS. Yeah. And would need to be self-funded. And for many patients, that is the limiting step. Yeah. I think it's quite expensive, isn't it, to have that done privately. Some patients want to be referred for rhoacutane, for clinically mild and moderate acne. And actually, sometimes don't want to try anything else prior to that. How would you manage these patients? So this is about managing expectation rather than managing their acne, I think. Some patients think that isotratinoin is a quick, simple cure for acne. Unfortunately, it's none of these things. A typical course of treatment will last at least six months. There are many potential side effects, and there is no cure for acne. Whatever treatment we give, however effective it is, there is the risk that the acne will come back. So most dermatologists won't prescribe isotratinoin first line for patients with mild acne, especially if they're treatment naive, unless, and this is a caveat here, they have significant scarring. So in mild cases, it's in the patient's best interest to try something topical and/or systemic, such as an antibiotic or a contraceptive pill, before being referred, as that's what we're going to advise, and they're really just delaying the inevitable. I find with isotratinoin because we have the same situation. We'll see somebody who's quite treatment naive and all they want is isotratinoin because they're sister or their boyfriend or somebody they know had it. When you go through the side effects, that sometimes does put people off. The duration of treatment can be of putting some women are considering pregnancy, so obviously it's not suitable then, and you have to keep our call quite minimal when you have isotratinoin, and for some people that's unknown as well, or they might choose a different time of year to have it. And I think when you go through the side effects, you explain some of the other treatments, explain that they do take time to work, and explain their correct use, and that they may actually be quite successful for mild acne. Then for many patients, they will not need isotratinoin in a mild stage. So when do you refer patients in, when do you expect a piece to refer patients in, for treatment with row acutane? So if the acne hasn't responded to traditional treatment, it's a good reason for referral. If you have got severe acne from the outset, then one could argue, let's just go for something that's likely to be more effective, and I think isotratinoin in that setting is much more likely to be effective than fapping around with antibiotics or the pill. If you have mild acne but there is significant scarring, then that's another reason for referral. Or if you've got recurrent acne after a previous course of isotratinoin, I think in these patients it's very difficult to persuade them to have anything else because nothing else has worked previously, so it is likely that they will need a second course of row acutane. If you do refer a patient for isotratinoin, then it's helpful if they have had baseline liver function tests and a lipid profile in advance, we would do the pregnancy test on the day, and I usually give them a big spiel about the side effects of isotratinoin followed up by the British Association of Dermatologist Patient Information leaflet, but if they've had that leaflet in advance, it's quite helpful, and sometimes they may have questions arising from that that we can deal with at that first consultation. Yeah, I also think it's quite helpful if a GP does refer a woman for row acutane that they've already started her on a combined oral contraceptive at least a month prior to the patient attending, so that they hit the ground running and they're able to start the treatment because with isotratinoin, and they have to be on two forms of contrast. for at least a month prior to commencing treatment. Absolutely, I agree. If I could just add in a little bit here about some advice that I give patients when they're on isotretinoin, so we get a lot of questions about skin care and moisturizers and what they should do. And I think your skin does change quite a bit when you take isotretinoin. It can become quite dry as the sebaria diminishes, so as the oils go down. And I often recommend ETH by Larosh Possea as a facial moisturizer in this specific situation. It contains niacinamide, which reduces inflammation and seromides, which help to restore the skin barrier. And it's moisturizing but not overly greasy and it's quite well suited to these patients. The other major change that patients will notice when they take isotretinoin is they develop dry cracked lips. And if they don't have dry cracked lips, it means they're not taking their pills. It's a universal side effect. And so I would tell them to start with something like Vaseline. If that's not as effective as you'd want it to be, there's lots of other lip balms out there on the market. But Sikka Plast by Larosh Possea is quite helpful. And I also recommend Elizabeth Arden 8-hour cream, which is really good at settling those cracked lips. Thanks, yep, that's useful. Sometimes we see patients who have not been active acne, but post acne changes, so scarring and hyperpigmentation. What treatments can we offer them? Most importantly, for these patients, it's important that you don't treat the scarring until you've treated the acne. So if they've still got active acne and they're getting several new lesions, we need to deal with that first. Otherwise, you're just chasing your tail. Darker skin types often have worse acne scarring, and skin types five and six, so that's your African and Caribbean skin on the whole, can have devastating, kiloidal scarring. So if you have a patient with significant scarring, but mild acne, and I've alluded to this previously, I'm much more aggressive with these patients, and would consider isotretinoin at an earlier stage. Remember, it's much easier to treat the acne than it is the scars. Hyperpigmentation is common, especially in skin of color, and there are some good over-the-counter products, such as pigment regulator by a company called Skin Suiticles. There's also pigment clad by La Rochepurse, and other ingredients that I think are helpful are alpha hydroxy acid, such as glycolic, salicylic acid, and antioxidants such as vitamin C, and there are lots of serums that contain these products. So for people who don't want prescription strength treatment for their hyperpigmentation, these are some options. But often you do need a prescription product, because it's quite stubborn that pigmentation, and it takes a while to clear. And the products that I use are 20% azaleic acid, which is skin-orin. Topical retinoids are really good, it doesn't matter which one, and even in combination with benzoyl peroxide. And then there are various products based on klingman solutions. So these are hydroquinone-based, and they also have a topical retinoid and a mild topical steroid in. My go-to product there is pigmentome, but there's also others such as trilumar. They aren't always available on the NHS, and again, they're quite pricey, but they do sometimes work. And then the other thing that's simple to add in is some SPF. Because these darker areas will turn faster, and especially if you have somebody with pigmented skin, the pigmentation is going to become more noticeable without sunscreen. So important to use a daily sunscreen. Right, yeah, that's really helpful. And sort of what non-affordable, non-prescription over the counter, sort of options are there for patients who don't want to use prescription strength medication. That's a great question, because there's so many products on the market, and I think everybody has their favourites. I think there are some important principles here. So first of all, I tell them to keep their skin care routine simple. There are lots of women, and I know there are some men who probably wear makeup and use lots of products, but generally women who apply a lot of layers. So they may start off cleansing and toning their skin. But this will be followed by some sort of serum, followed by some sunscreen, followed by moisturizer, and then there's their foundation. There might be a primer underneath that, some sort of powder on top, and then a finishing spray, not to mention the cream blush and anything else that goes on. So you've got lots and lots of layers here. So I say try and minimise the layers, and keep it as simple as possible. Gentle foaming cleansers are what I would tell them to use. Avoid cleansers that have got little bits in them, scrubs and exfoliants, because they tend to irritate acne. You might want to do it once in a while, but certainly not on a daily basis. And then in terms of moisturizer, you're looking for something that's non-commetogenic, has a mild, curatalytic effect, but is soothing and anti-inflammatory. And I do often recommend Effaclar Duo Plus, by La Roche Posse, as it has all of these properties. In terms of other products, I think the bio-dermarange is also very good, and the Cetaphil products are good for acne-prone skin. So often you need a combination of these things. I find that people with moderate or severe acne probably won't get better with these over-the-counter products by themselves, but they are complementary to other things that we may use on prescription. It is remarkable as well how many patients with acne come in telling you that they use oils and oils are just a complete no-no. Absolutely, I completely agree. Moving on to sort of diet and acne. Lots of our patients are convinced that there is a dietary element to their acne and they want to cure it through their diet. Should we be including diet in our conversation regarding management and if so, what advice should we be giving our patients? Oh, I bet you get asked this question a lot. So the evidence suggests that diets with a high glycemic load may be associated with acne, but there have only been a handful of studies where participants have followed a low GI diet and seen improvements in their acne. And in one Korean study that I've read, Skin Barbsies were even taken that showed a reduction in sebaceous gland size and a decrease in the number of inflammatory cells. But the problem with all of these studies is that the sample sizes have been really small. So I think before giving any conclusive advice, more data is needed. But the evidence suggests that there might be a link with high GI diets and acne. So I tell people to cut back on sugary foods. The other question that I'm often asked is the link between dairy and acne. There haven't been any randomized control trials looking at this, but in observational studies, there is a link with skimmed milk. So if your patient is drinking lots of skimmed milk, then I tell them to cut back, but it seems that cheese and yogurt seem to be okay. A few. The other area that is sort of hot topic for acne now is the microbiome. There is a microbiome in the sebaceous gland, which is predominantly peacines. And then we have a lot of staff on the skin. And there's also this relationship between the skin microbiome and the gut microbiome. So this skin gut axis. So I'm sure as time goes on, we'll learn more about the role of diet in managing the microbiome between the two and no doubt there'll be a connection there. Thank you, that's great. Thank you both for a really informative and practical session. I hope our listeners have enjoyed it as much as I have. Janani, your questions were great, and Javali's tips have really been on points. So thanks guys. To our listeners, I hope you found this useful and that you join us again soon for some more new dermatologist podcasts on managing common skin conditions. If you would like to do the challenge questionnaire on this topic, then go to www.thenewdermatologist.co.uk This podcast was brought to you by 1129 media.