ABSTRACT
Background
Although there is content diversity, there are several data about the impact of diet on acne. However, studies about patients' beliefs about the effects of diet on acne are limited. So, in this study, we aimed to assess the perceptions and beliefs of patients about the association between acne and diet.
Methods
It was a cross‐sectional study that was conducted on patients with a diagnosis of acne vulgaris in the dermatology clinic of Shohada Tajrish and Loghman Hakim Hospital (Tehran, Iran) from December 2022 to December 2023. A questionnaire was given to each patient, and basic data and beliefs of patients about the association between acne and diet were asked. All questionnaires were recorded in SPSS v.26 software and analyzed. A significant level was considered less than 0.05.
Results
In this study, 793 patients participated in the study. 328 patients (41.36%) were 12–19 years old, and 482 of all patients (60.78%) were male. Most of the patients believed that sweets and chocolates and fatty and fried foods had negative impacts on acne and that fruits and vegetables, vitamins, and supplements (zinc, omega‐3, selenium, and green tea) improved the disease condition. Acne severity and skin type had significant relationships with the beliefs of patients about the effects of diet on acne (p‐values < 0.05).
Conclusion
Although a considerable number of patients with acne believe that diet impacts acne, the patients should be educated about dietary habits that improve or aggravate the disease.
Keywords: acne vulgaris, belief, diet, perception
1. Introduction
Acne vulgaris is a complex inflammatory skin disorder, affecting 85% of patients aged 12–24 years [1]. Psychological stress, lifestyle, occupational exposure, medications, environmental pollutants, climate change, and diet can influence acne and its severity [2].
It is reported that the etiology of acne vulgaris entails the interplay of various factors, such as the activation of sebaceous glands due to androgens, immunological responses, and dysbiosis of the pilosebaceous microbiome. Furthermore, factors such as genetics and foods may also affect the disease's development and progression [3, 4]. So, dietary restrictions have been recommended as a part of acne treatment, emphasizing the limitation of carbohydrates, fats, and high‐fat dairy products [5].
The association between diet and acne has been a prominent subject in acne epidemiology research. Currently, numerous studies have established that a high‐sugar diet and dairy products are risk factors for acne. Elevated sugar consumption (≥ 100 g/d), regular consumption (≥ 7 times per week) of soft beverages (including carbonated sodas, sweetened teas, and fruit‐flavored drinks), and daily intake of dark chocolate were strongly correlated with acne [6, 7, 8, 9, 10]. However, data about the effects of different foods and supplements are not similar in different studies, and there are some diversities about the effects of foods on acne [11, 12, 13].
Recent studies demonstrated the relationship between diet and acne, but the patients' beliefs and perceptions about the effects of diet on acne were not assessed enough, and data about it is limited [14]. For example, Smollich et al. determined patient perceptions about acne and diet. They showed that 75% of interviewees assert a correlation between acne and food. Patients pursue supporting information primarily from Instagram (63%), internet forums (54%), and textbooks (46%). Participants perceive their nutritional interventions as ineffective and believe an information gap exists [15]. Therefore, in this study, we assessed patients' beliefs and perceptions about the impact of diet on acne.
2. Methods
This cross‐sectional study was performed on patients who were diagnosed with acne vulgaris at the dermatology clinic of Shohada Tajrish and Loghman Hakim Hospital (Tehran, Iran) from December 2022 to December 2023.
The inclusion criteria were a definite diagnosis of acne vulgaris or having a history of acne involvement, referring to the hospitals from December 2022 to December 2023, and an age between 12 and 45 years. The exclusion criteria were not having consent to participate in the study, lack of education to read or write the questionnaire, and failure to cooperate with the physical examination.
A questionnaire was designed for patients, and its content is seen in the supporting Information table (Data S1). The questionnaire consisted of three sections: demographic information, skin characteristics, and beliefs about the influence of dietary habits on acne. The first two sections were completed by a dermatologist. Patients' beliefs and perceptions were assessed by having the patients fill out the third part.
The severity of acne was assessed as mild, moderate, and severe [16], by the dermatologist, and skin type was categorized as normal, dry, oily, or mixed [17].
Two expert groups, four nutrition professors, and four dermatologists evaluated the questionnaire to establish its content validity, assessing its relevance, necessity, and quality. We found the Content Validity Ratio (CVR) and the Content Validity Index (CVI) for questions 10 through 34. The CVR values were above the critical level of 0.75, which means that most of the items had strong content validity. We excluded item 34 due to its insufficient validity. Cronbach's alpha measured the internal consistency, which was exceptionally high at 1.02.
2.1. Ethical Considerations
This study was approved by the ethics committee of Shahid Beheshti Medical University (IR.SBMU.MSP.REC.1403.090).
2.2. Statistical Analysis
We recorded and analyzed the data using SPSS software version 26. Descriptive statistics (mean, standard deviation, and frequency (percentage)) and inferential statistics (chi‐square tests) were used. A significance level of 0.05 was considered.
3. Results
3.1. Basic Data of Participants
The study included a total of 793 participants, with 482 (60.78%) males and 311 (39.22%) females. Table 1 shows basic data of all patients.
TABLE 1.
Basic data of patients.
| Variable | Value | Frequency (%) |
|---|---|---|
| Gender | Male | 482 (60.78%) |
| Female | 311 (39.22%) | |
| Age | 12–19 years old | 328 (41.36%) |
| 20–29 years old | 191 (24.09%) | |
| 30–39 years old | 247 (31.15%) | |
| 40–45 years old | 27 (3.40%) | |
| BMI | < 18.5 | 123 (15.51%) |
| 18.5–24.9 | 362 (45.65%) | |
| 25–29.9 | 253 (31.90%) | |
| ≥ 30 | 55 (6.94%) | |
| Education | < High school | 4 (0.50%) |
| High school | 345 (43.51%) | |
| University | 444 (55.99%) |
3.2. Clinical Data of Participants
Table 2 demonstrates the data about current and previous clinical data of the patients based on the history and physical examination.
TABLE 2.
Current and previous clinical data of the patients.
| Variable | Value | Frequency (%) |
|---|---|---|
| History of acne | Had before | 424 (53.47%) |
| Have now | 131 (16.52%) | |
| Had before and have now | 238 (30.01%) | |
| Severity of acne | Severe | 31 (3.91%) |
| Moderate | 384 (48.42%) | |
| Mild | 378 (47.67%) | |
| Skin type | Normal | 159 (20.05%) |
| Dry | 108 (13.62%) | |
| Oily | 269 (33.92%) | |
| Mixed | 257 (32.41%) | |
| Family history of acne | Yes | 353 (44.51%) |
| No | 440 (55.49%) |
3.3. Patients' Beliefs About Diet and Acne
We assessed patients' beliefs about the effect of diet on acne based on the questionnaire, and the related data are seen in Table 3. Out of all patients, 657 (82.85%) believed that diet can improve acne. 241 (30.39%) and 166 (20.93%) patients “significantly” and “absolutely” agreed with the belief that “dietary habits affect acne.”
TABLE 3.
Patients' beliefs about the impact of diet on acne.
| Variable | Value | Frequency (%) |
|---|---|---|
| Can dietary habits affect acne? | Never | 23 (2.90%) |
| Little | 60 (7.57%) | |
| Sometimes | 303 (38.21%) | |
| Significant | 241 (30.39%) | |
| Absolutely | 166 (20.93%) | |
| Does dietary change improve acne? | Yes | 657 (82.85%) |
| No | 136 (17.15%) | |
| Spices | Makes it worse | 272 (34.30%) |
| Makes it better | 21 (2.65%) | |
| No effect | 204 (25.73%) | |
| No comment | 296 (37.33%) | |
| Sweets and chocolate | Makes it worse | 601 (75.79%) |
| No effect | 77 (9.71%) | |
| No comment | 115 (14.50%) | |
| Snacks (chips and puffs) | Makes it worse | 457 (57.63%) |
| No effect | 163 (20.55%) | |
| No comment | 173 (21.82%) | |
| Nuts | Makes it worse | 388 (48.93%) |
| Makes it better | 36 (4.54%) | |
| No effect | 181 (22.82%) | |
| No comment | 188 (23.71%) | |
| Sunflower seeds | Makes it worse | 466 (58.76%) |
| Makes it better | 14 (1.77%) | |
| No effect | 118 (14.88%) | |
| 195 (24.59%) | ||
| Non‐alcoholic drinks | Makes it worse | 189 (23.83%) |
| Makes it better | 6 (0.76%) | |
| No effect | 257 (32.41%) | |
| No comment | 341 (43.00%) | |
| Milk | Makes it worse | 67 (8.45%) |
| Makes it better | 80 (10.09%) | |
| No effect | 288 (36.32%) | |
| No comment | 358 (45.15%) | |
| Caffeine | Makes it worse | 102 (12.86%) |
| Makes it better | 24 (3.03%) | |
| No effect | 350 (44.14%) | |
| No comment | 317 (39.97%) | |
| Spicy foods | Makes it worse | 265 (33.42%) |
| Makes it better | 8 (1.01%) | |
| No effect | 261 (32.91%) | |
| No comment | 259 (32.66%) | |
| Fatty and fried foods | Makes it worse | 484 (61.03%) |
| No effect | 151 (19.04%) | |
| No comment | 158 (19.92%) | |
| Eggs and meat | Makes it worse | 96 (12.11%) |
| Makes it better | 56 (7.06%) | |
| No effect | 346 (43.63%) | |
| No comment | 295 (37.20%) | |
| Butter and cream | Makes it worse | 376 (47.41%) |
| Makes it better | 18 (2.27%) | |
| No effect | 164 (20.68%) | |
| No comment | 235 (29.63%) | |
| Fruits and vegetables | Makes it worse | 11 (1.39%) |
| Makes it better | 454 (57.25%) | |
| No effect | 175 (22.07%) | |
| No comment | 153 (19.29%) | |
| High‐salt foods | Makes it worse | 119 (15.01%) |
| Makes it better | 6 (0.76%) | |
| No effect | 331 (41.74%) | |
| No comment | 337 (42.50%) | |
| Verjuice and lemon juice | Makes it worse | 18 (2.27%) |
| Makes it better | 181 (22.82%) | |
| No effect | 297 (37.45%) | |
| No comment | 297 (37.45%) | |
| Fast food | Makes it worse | 488 (61.54%) |
| Makes it better | 4 (0.50%) | |
| No effect | 127 (16.02%) | |
| No comment | 174 (21.94%) | |
| Dates | Makes it worse | 241 (30.39%) |
| Makes it better | 72 (9.08%) | |
| No effect | 256 (32.28%) | |
| No comment | 224 (28.25%) | |
| Vitamin A | Makes it worse | 20 (2.52%) |
| Makes it better | 337 (42.50%) | |
| No effect | 132 (16.65%) | |
| No comment | 304 (38.34%) | |
| Vitamin B | Makes it worse | 35 (4.41%) |
| Makes it better | 279 (35.18%) | |
| No effect | 141 (17.78%) | |
| No comment | 338 (42.62%) | |
| Antioxidants (vitamins E, selenium and green tea) | Makes it worse | 11 (1.39%) |
| Makes it better | 432 (54.48%) | |
| No effect | 94 (11.85%) | |
| No comment | 256 (32.28%) | |
| Omega‐3 (fish and fatty fish) | Makes it worse | 90 (11.35%) |
| Makes it better | 300 (37.83%) | |
| No effect | 132 (16.65%) | |
| No comment | 271 (34.17%) | |
| Zinc | Makes it worse | 36 (4.54%) |
| Makes it better | 399 (50.32%) | |
| No effect | 94 (11.85%) | |
| No comment | 264 (33.29%) |
3.4. Relationship Between Historical and Clinical Data With the Questionnaire Data
We assessed relationships between basic and clinical data of patients with the results of questionnaires. Due to the expanse of the analyses, we describe the results of the analyses. We found there were no relationships between age, gender, BMI, and education level with total perceptions and beliefs of patients about the impact of diet on acne (p value: 0.62, p value: 0.57, p value: 0.92, and p value: 0.90, respectively), but in subgroups, some relationships were found that are described below.
Acne severity and skin type had statistically significant relationships with the total perceptions and beliefs of patients about the effects of diet on acne. The findings indicated that 82 individuals (10.34%) with mild acne, 80 individuals (10.09%) with moderate acne, and 4 individuals (0.5%) with severe acne perceived that dietary habits could “absolutely” impact the exacerbation or improvement of acne. These results about “very high” impact on the exacerbation or improvement of acne were observed in 114 (14.38%), 119 (15.01%), and 8 (1.01%) of cases with mild to severe cases, respectively (p value: 0.00). Regarding skin type, 83 (10.47%) of participants with dry skin, 211 (26.61%) of participants with mixed skin, 144 (18.16%) of participants with normal skin, and 219 (27.62%) of participants with oily skin believed that changing their eating habits “absolutely” impacted the exacerbation or improvement of acne (p value: 0.01).
About subgroups of the questionnaire, we found that males were more likely than females to believe that snacks, spicy foods, fatty and fried foods, vitamin B, verjuice and lemon juice, and fatty food worsen acne (p values < 0.05). Patients with high BMI had higher beliefs about the effects of fatty and fried foods on the worsening of acne (p value: 0.00). The education level had statistically significant relationships with the perception and belief of patients about the effects of food consumption on acne in the subgroups of spicy foods, fatty and fried foods, fruits and vegetables, and butter and cream. Patients with higher education levels had more belief in the effects of these foods on the worsening of acne (all p values < 0.05).
4. Discussion
In this study, which was performed to evaluate the perception and belief of patients with acne about the relationship between acne and diet, it was observed that patients believed that some foods and supplements have a significant impact on the disease, especially sweets and chocolates, which were most commonly believed to exacerbate acne, while fruits and vegetables were recognized to be beneficial for improving acne. Moreover, most participants believed that snacks and fried/fatty foods, spices, and nuts exacerbated acne. We also found that age, gender, BMI, and education level had no significant relationships with the beliefs of patients, generally. In this respect, acne severity and skin type had significant relationships with the beliefs of patients about the effects of diet on acne.
Karciauskiene et al. evaluated perceptions and beliefs of patients about acne in Lithuania. They evaluated the beliefs of 1277 students aged 7 to 19 years, and 51.4% responded to their questionnaire. They found that patients with moderate or severe acne involvement were more aware of the disease. Based on the results of the questionnaire, patients believed that hormones, poor hygiene, and diet were the main causes of acne exacerbation [18]. In the current study, we evaluated the belief of patients about the relationship between acne and diet in detail, and it was one of the advantages of our study. Similar to Karciauskiene et al. we found that higher acne severity had a significant relationship with the belief of patients about the impact of diet on acne. The participants' views on a potential connection between acne and nutrition are notably correlated with their motivation to seek information from supplementary sources [19], and it appears that patients with more severe forms of acne are more likely to receive data about dietary information. These searches increase the knowledge of patients about the impact of diet on acne and affect patients' beliefs in this regard.
Burris et al. assessed patients' beliefs about the relationship between dietary factors and acne severity. They found that participants with moderate to severe acne reported higher consumption of added sugar, total sugar, daily milk servings, saturated fat, and trans‐fatty acids, as well as fewer daily servings of fish compared to those with minimal or mild acne. Among all participants, 58.1% said that food exacerbates or affects acne [6]. These findings were confirmed in the current study. We found that 82.85% of our cases believed that dietary habits can affect or improve acne conditions, and they reported that dietary habits were associated with acne severity.
Markovic et al. evaluated patients' beliefs about acne. They evaluated 452 schoolchildren aged 14 to 18 years, and 55.2% were girls. There were significant differences between boys and girls in terms of beliefs. Boys believed that dairy foods and smoking worsen acne, but girls believed that fatty foods and sweets have a negative impact on acne [20]. In the current study, we found that men believed that spicy foods, snacks, fatty and fried foods, vitamin B, verjuice and lemon juice, and fast food had a negative impact on acne significantly more than females. These findings were different from the study of Markovic et al. This difference may come from the difference between the study populations of the studies. Our study was conducted on 12‐ to 45‐year‐old patients, but Markovic et al.'s study was done on 14‐ to 18‐year‐old patients. This difference can demonstrate that patients' beliefs change over time.
Al‐Natour assessed the beliefs of 329 Saudi adolescent men aged 13 to 22 years. The results of his study showed that 71.5% of patients believed that diet affects acne, and 21% believed that drinking mineral water improves acne severity [21]. Our study was done on both genders, and we found that 20.93% of our patients believed that diet “absolutely” affects acne and 30.39% believed that diet “significantly” affects acne. Also, 38.21% of our patients believed that diet “sometimes” can affect acne. The findings of these two studies about the belief of the effect of diet on acne in patients were relatively similar. The findings suggest that dermatologists should conduct thorough consultations regarding the influence of diet on acne to address patients' medical and nutritional needs. Nutrition counseling for acne patients must address the existing lack of knowledge and mitigate the risk of imposing potentially harmful dietary restrictions.
According to our participants' perceptions, sweets and chocolates, snacks, and sunflower seeds had the most significant impact on exacerbating acne. Furthermore, according to the participants' opinions, antioxidants, fruits and vegetables, and zinc had the most significant impact on improving acne. In this regard, several studies suggest that chocolate consumption is associated with an increase in acne among men with a history of common acne [8, 22]. The study by Vongraviopap et al. found a significant correlation between white chocolate consumption and acne exacerbation, particularly in adolescents and young adults [8]. However, it should be noted that the results of studies are not similar. For example, Suppiah et al. reported that consumption of carbonated drinks, chips, potatoes, sweets, nuts, ice cream, and yogurt had no association with acne, and only chocolate and/or milk consumption was associated with the disease [11]. So, it seems that further studies are still needed in this respect.
Nguyen et al. evaluated 49 patients, and it was found that 92% of patients believed that diet affects acne and that fatty and fried foods, chocolates, dairy products, and soda drinks worsen acne [23]. We evaluated 793, and 2.9% of our patients believed that diet has no effect on acne. Based on our findings, our patients believed that sweets and chocolates, snacks, fried and fatty foods, spices, and nuts exacerbate acne. Although our study had a larger sample size, the findings of these two studies were relatively similar. Patients harbor misunderstandings regarding acne vulgaris. Accessible and precise community‐oriented educational activities can enhance awareness [24].
Consumption of sunflower seeds appears to increase the severity of common acne. In a randomized controlled trial, participants who consumed daily sunflower seeds showed a significant increase in their Acne Severity Index (ASI) compared to the control group [25]. These findings are consistent with the belief of the majority of our participants.
Antioxidants, whether topical or systemic, appear to be effective against acne by reducing oxidative stress and inflammation [26, 27, 28]. Researchers recommend vitamins and supplements like selenium as effective agents for acne treatment [29]. In our study, we observed that less than 60% of our patients believed that vitamins, antioxidants, and supplements are beneficial for the improvement of acne. So, these findings demonstrate the need to increase patients' knowledge about the effects of vitamins, antioxidants, and supplements on acne.
We found that patients with higher BMI believed that fatty and fried foods worsen acne, but Raditra et al. found that there was no significant relationship between BMI and acne based on patients' beliefs [30]. In a study by Gündüz et al. 72 patients aged 10–18 years were investigated, and it was reported that patients with higher BMI had severe forms of acne [31]. So, it seems that patients with a higher BMI may believe their diet, including fatty and fried food, worsens acne.
We also found that education level was significantly associated with the belief in the impact of diet on acne. Most of the participants in the current study had university education. Few studies evaluated the effect of education on knowledge about acne and dietary effects on acne. Alshammrie et al. conducted an epidemiological study about patients with acne in Saudi Arabia, and their results were similar to ours [32]. Patients with acne who have a higher education level can search easily in different databases about acne‐related factors, and it may increase their perception about the relationship between acne and diet.
Based on our knowledge, previous studies did not assess the relationship between skin type, foods, and acne. We assessed this relationship, and it was found that skin type had a significant relationship with the belief of patients about the effects of diet on acne. Further studies should evaluate this relationship because related data are lacking.
5. Conclusion
A remarkable percentage of acne patients believe that diet affects acne. Sweets and chocolates are commonly believed to exacerbate acne, whereas fruits and vegetables are considered beneficial for improving acne. Patients' beliefs about the effects of diet on acne were significantly associated with the severity of acne and skin type. BMI and education level impact patients' perception about the relationship between diet and acne in terms of some foods like fatty and fried foods. It seems that all patients with acne need to be educated about dietary habits that impact acne.
Author Contributions
F.G., M.S., S.D., Z.T., and Z.R. performed the research. F.G. designed the research study. F.G., M.S., and S.D. contributed essential reagents or tools. Z.R. analyzed the data. F.G., M.S., S.D., Z.T., and Z.R. wrote the paper.
Conflicts of Interest
The authors declare no conflicts of interest.
Supporting information
Data S1. Data collection instrument.
Salemi M., Dadkhahfar S., Tehranchinia Z., Razzaghi Z., and Ghalamkarpour F., “Evaluating the Association Between Acne Vulgaris and Diet: An Exploratory Study on Patient Beliefs and Perceptions,” Journal of Cosmetic Dermatology 24, no. 7 (2025): e70285, 10.1111/jocd.70285.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data S1. Data collection instrument.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.