DOI 10.

1007/s11154-016-9374-z

Nutrition and skin

Apostolos Pappas
Zouboulis

& Aikaterini

Liakou

& Christos

C.

# Springer Science+Business Media New York 2016

Abstract Nutrition has long been associated with skin

health, including all of its possible aspects from beauty
to its integrity and even the aging process. Multiple
pathways within skin biology are associated with the
onset and clinical course of various common skin
diseases, such as acne, atopic dermatitis, aging, or even
photoprotection. These conditions have been shown to
be critically affected by nutritional patterns and dietary
interventions where well documented studies have demonstrated beneficial effects of essential nutrients on
impaired skin structural and functional integrity and
have restored skin appearance and health. Although the
subject could be vast, the intention of this review is to
provide the most relevant and the most well-documented
information on the role of nutrition in common skin
conditions and its impact on skin biology.
Keywords Skin . Nutrient . Diet . Vitamin . Antioxidant .
Aging . UV . Acne . Atopic

1 Introduction
The majority of consumers tightly associate good health
with nutrition and skin quality. Apparently, most of them
also

* Apostolos Pappas
apappas@its.jnj.com

Johnson & Johnson Consumer, Inc., 199 Grandview Road,

Skillman, NJ 08558, USA

Second Department of Dermatology and Venereology, Attikon

Hospital, Athens, Greece

Department of Dermatology, Venereology, Allergology and

Immunology, Dessau Medical Center, Dessau, Germany

desire to live longer healthy lives while maintaining a

youthful appearance. Epidemiological and clinical
studies have successfully linked various nutrients to
health benefits in tissues and organs, therefore in
overall health and proper physiology. Recent focus in
such relations is triggering the interest of the
dermatological community, particularly in connections
be- tween diet and skin, which have previously been
dismissed. A profound number of publications and
findings support ideas and validate theories that certain
key nutrients are imperative for healthy skin and hair.

2 Deficiencies and essential nutrients

Skin is the largest organ in humans, and collectively
and individually, its three layers work towards
protecting all of the internal tissues and the vital organs
from daily environmental challenges. Skin also plays
an important role in regulating body temperature and
controlling water loss.
Deficiencies of vitamin A, vitamin C, riboflavin,
niacin, pyridoxine, vitamin E, zinc, selenium, and
certain essential fatty acids or amino acids have been
shown to cause skin and hair anomalies. Although the
frequency of nutritional deficiencies is low in the
western world, unbalanced and incomplete diets could
result from disease, aging, and chemical sub- stance
abuse that would certainly influence health and thereby
affect the skin health [1, 2]. Adjusting and improving a
diet may not only prevent skin and hair problems but,
certainly, also correct any potentially underlying
condition. Studies in- vestigating the effects of oral
supplementation with relatively high doses of vitamins,
trace minerals, and fatty acids have demonstrated the
possibility that some of these components can
modulate skin function and possibly hair health [1, 3].
Reviews on the effect of nutrient supplementation for
improving the skin condition and preventing skin
diseases have been

Rev Endocr Metab Disord

published, outlining the nutritional factors that bring

potential benefits on the skin [4].
Antioxidants and provitamins protect against free
radical quenching, ultraviolet (UV) damage, and aging.
Visible signs of premature skin aging are credited to the
recurrent exposure to environmental insults, including
solar UV radiation. This results to the generation of
oxidative free radical molecules, which can damage
cellular lipids, proteins, but also DNA which
consequently influences cell survival or death.
Free radicals influence and dictate many biological
processes in both plants and animals. They are also of
great im- portance to signaling processes in the human
body. Once the concentration of free radicals in the body
exceeds a critical concentration, cells or cell
compartments are damaged. This, in addition to the
genetic material DNA, applies to molecules such as
elastic fibers in elastin and collagen [57]. Thus, the free
radicals comprise a pivotal factor that accelerates skin
aging [8]. A boost of the antioxidative network of
human skin is recommended [911].
Multiple reasons could lead to enhanced radical
formation in the human skin as environmental factors,
such as ultraviolet radiation of the sun, contact with
environmental hazards, smoking, excessive alcohol
consumption, illness, insomnia, and stress on the
professional or personal life [12]. However, the human
body has developed a protective system against the
harmful action of free radicals by utilizing a variety of
important antioxidant and, particularly, in the skin that
includes vitamins A, C, E, and D as well as the
carotenoids such as beta-carotene, lycopene, lutein, and
in addition, polyphenols [13, 14]. It is self-explanatory
though that most of the abovementioned antioxidants
cannot be produced by the hu- man cells; therefore, they
must be taken in by nutrition. Consequently, a diet rich
in fruit and vegetables and other sources of these
antioxidants is a fundamental basis and re- quirement for
healthy skin.
A major concern though could be that many
populations in the world do not or would not have a
sufficient supply of certain antioxidants or vitamins
despite an increased supply of fresh fruits and
vegetables. This perhaps helped certain industrial sectors
to advocate towards additional ways of supplementation.
However, the ingestion of dietary supplements, at least,
should not be an excuse for poor nutritional practices
and a compensation for an unhealthy diet.

3 Carotenoids and photoprotection

High antioxidant levels and especially carotenoids in the
human skin can only be achieved by nutrition.

Carotenoids consist of a family of highly lipophilic

pigments that are synthesized by photosynthetic organisms
and some nonphotosynthetic micro- organisms, but not
animals. However, evidence indicates the role of
endogenous carotenoids in systemic protection and
maintenance of skin health [15, 16]. The main purpose of
the existence of these pigments in plants is to quench free
radicals. In this way, they preserve the photosynthetic
complex by protecting it against damage by solar UV.
Carotenoids selectively accumulate in tissues
expressing a high density of LDL receptors such as the
adrenals, testes, liver, adipose tissue, kidney, and the
skin [17, 18]. Dietary carotenoid bioavailability is
rather low in comparison to other macronutrients;
however, processing could alter it, as lyco- pene
concentrations in the human serum increased only
when tomatoes were subjected to 1 h of boiling in the
presence of oil [19]. Processing of plant foods also
induces isomerization of carotenoids, and baking is
associated with isomerization and degradation of alltrans beta-carotene to the cis isomers [20]. A
combination of carotenoids with dietary proteins or
dietary fibers has been shown to decrease their
absorption [21, 22]. On the other hand, parallel
ingestion of dietary fat with carot- enoids promotes the
absorption of these provitamins, which has been
extensively reported either from a salad meal by the
addition of avocado or avocado oil [23] or by
enhancing mi- celle formation in the small intestine
and, consecutively, the increased synthesis and
secretion of chylomicrons by enterocytes (that is also
induced by dietary fat) [24].
Interactions between dietary carotenoids may also
exist and antagonize the absorption of one another [25,
26]. The overall health status of an individual could
also influence the absorp- tion of carotenoids [27].
Once carotenoids clear the intestinal epithelial barrier
and reach the systemic circulation via lym- phatics,
they would be further stored in the liver but they would
also reach other tissues, including the skin. It has been
demonstrated that the yellow component of skin color
may be closely associated with carotenoid levels of the
skin at various body sites [28, 29].
Carotenoids with their 11 conjugated double bonds,
such as beta-carotene, lycopene, zeaxanthin, and lutein,
have potent antioxidant functionality as effective
naturally occurring scav- engers of single oxygen and
peroxyl radicals [30, 31]. Upon supplementation with
lutein and zeaxanthin, significantly de- creased skin
lipid peroxidation was observed [32, 33]. The efficacy
of beta carotene in systemic photoprotection was
investigated in several human intervention studies [15,
3438], and an additional meta-analysis study
confirmed that beta- carotene supplementation is
efficient in providing protection [39]. The daily dose of

Rev Endocr Metab

Disord

20 mg for a minimum of 10 weeks of supplementation

was concluded to be required.
In addition, lycopene from tomato paste intake (16
mg) for 10 weeks of supplementation reduced dorsal
erythema forma- tion by 40 % [40] or 10 mg of
lycopene as synthetic or tomato extract (Lyc-o-Mato),
or a drink (containing solubilized Lyc- o-Mato) for 12
weeks of supplementation reduced significantly UVinduced erythema. In addition, human intervention
studies with a mix of carotenoids confirmed their
photoprotective effect [38, 41].
It should also be noted that beta-carotene has been
proposed as a possible dietary therapeutic agent for
dermatolog- ical conditions, such as porphyria cutanea
tarda, polymorphic light dermatosis, and vitiligo. Betacarotene can decrease the severity of photosensitivity
reactions in those patients and can increase their ability
to tolerate sunlight. When the patients were carotenemic,
they also react less intensely to artificial light.
Laboratory evidence suggests that beta-carotene
quenches free radicals and singlet oxygen, which are
produced when porphyrins, for example, are exposed to
light and air. Carotenodermia (yellowing of the skin)
usually develops after 46 weeks and coincides with the
start of photoprotection. Protection decreases within 12
weeks after discontinuation of therapy. Plasma
concentrations of 46 mcg/mL are therapeutic for most
patients [42, 43].
Beta-carotene has also been proposed as a possible
preventive agent against cancer supported by animal
studies where it protected against skin cancer [41, 44].
However, the evidence for protecting human skin cancer
is still debatable since epi- demiological studies
demonstrated no association between di- etary
carotenoids and basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) [4547]. In several
intervention studies, the beta-carotene supplementation
failed to decrease the risk of non-melanoma skin cancer
among men [4851] or solar keratosis [51].

4 Mechanisms of incorporation
The mechanisms that lead to the incorporation of
micronutrients such as carotenoids into the skin or the
needed doses from servings of fruits and vegetables are
unknown. Therefore, future studies are needed to decode
this and, in parallel, elaborate on the benefit that
ingestion of fruits and vegetables has for the skin. It is
known that these are the primary dietary sources that
contain these bioactive agents, which not only protect
plants against solar UV damage but also play a
significant role in the photoprotection of skin, which has

started to be investigated and appreciated during the last

few decades. The dietary supply of carotenoids may
contribute significantly to skin health and complement
the use of sunscreens. Perhaps, the real active agents are
metabolites or oxidation products of the parent
carotenoids such as reti- noids or apocarotenals which
are the highly active molecules and ligands to receptors
and transcriptional factors [5254].
Beta-carotene is the precursor of vitamin A and,
consequently, of retinoids that exhibit more potent
biological activ- ities than retinol (vitamin A). Retinoic
acid is produced by in vivo oxidation of retinol. Its two
isoforms, all trans retinoic acid and 13-cis retinoic acid,
are present in the human plasma. Retinoids are used in
several therapies, systemic or topical, for various skin
diseases such as acne, seborrhea, psoriasis, epi- thelial
tumors, and hand eczema. Retinoids are also used as
therapeutic agents for hyperkeratotic and parakeratotic
skin diseases and the prophylaxis for epithelial skin
tumors in immunesuppressed patients, in addition to
therapy for non melanoma skin cancers and cutaneous T
cell lymphoma.
The oral bioavailability of retinoids can be
increased, in similar ways as carotenoids do and
especially by fatty acids or fat ingestion, which prevent
the binding of retinoids with albumin and hence
improve the clinical effect. The metabolism of
retinoids mainly takes place in the liver, isotretinoin is
detectable after 30 min in the blood, and maximum
concen- trations are reached 24 h after oral intake.
More than 99 % of the isotretinoin in the plasma is
bound to plasma albumins.
The carotenoids (provitamin A) and vitamins C and
E have been associated with the protection of the
skin against photodamage (sunburn, tanning) and
subsequently
photoaging.
The
synergistic
enhancement of oxidative damage to the skin when the
skin is exposed to UVA and environmental irritants,
including cigarette smoke, has been reported in many
studies. Visible signs of the premature skin aging have
been attributed to the repeated exposure of the skin to
solar UV radiation, which is leading to the generation
of oxidative free radical molecules that may cause
damage to cellular lipids, proteins, and DNA.
Therefore, UV radiation and the skin type of the
individual exposed are important parameters for
premature aging of the skin called photoaging. Sunburn
is also a phenomenon related to exposure to UV
radiation.

5 Topical application

Rev Endocr Metab Disord

Topical application of vitamins C and E over time is

promising for repair and against photodamage,
either by enhancing collagen production or by
inhibition of the elastin synthesis by fibroblasts [55].
Topical vitamin C has also been shown to enhance
collagen production
in the human skin in vivo.
Possibly, this happens via the enhanced synthesis of
collagen and inhibition of matrix metalloproteinase-1
(MMP-1) decreases wrinkles [56]. Moreover, few
controlled studies have directly compared the topical
efficacy of the various forms of vitamin E for
photoprotection against UV-induced erythema
in
rabbits and against UV-induced photoaging in mice.
In a longterm, mouse study, two vitamin E forms, d-tocopherol and d--tocopheryl succinate, were proven
effective in protecting against all acute and chronic
UV-induced damages, with d--tocopherol most effective for all parameters (i.e., decreasing sunburn,
tanning, skin cancer incidence). Clinical evidence has
also been published in human studies, but again for
the topical use of d--tocopherol, with registered
benefits on skin tone, on the periorbital wrinkles, and
with documented histological improvements [57].

6 Nutrients and skin diseases

mic carbohydrates, milk, as well as other insulinotropic

dairy products appear to share a common endocrine
mechanism of action implicated in acne pathogenesis.
Both high glycemic load diets and insulinotropic dairy
products have been shown to raise serum insulin levels
and free IGF-1 concentrations and induce insulin
resistance [60]. There is ongoing controversy on the role
of milk and dairy consumption as an aggravating factor
in acne pathogenesis [61]. In 1949, a case series
published by Robinson on 1925 subjects with acne
reported that milk was the most commonly implicated
food in acne flares. Although the number of studied
subjects was high, no reliable data or statistical
analyses had been provided [62].
Adebamowo et al. presented a retrospective cohort
study using a food frequency questionnaire of distant
dietary intake and subject report on physician-diagnosed
severe acne. They found that acne was positively
associated with intake of milk, particularly skim milk,
instant breakfast drink, sherbet, and cottage cheese, all
known as dairy products associated with elevated
plasma insulin concentrations. The weakness of this
study lies mainly on its retrospective design, memory
based recall of diet and acne. Therefore, any association
between dairy products and acne remains debated and
requires further investigation [63].Atopic dermatitis

6.1 Skin aging

The literature on the effect of the various carotenoids on
the skin photoprotection is vaster than the
aforementioned nutrients. The effects of dietary
carotenoids in protecting the skin against the damaging
effects of the UV exposure have been recently
summarized by Thakkar et al., and certainly, their
efficacy in scavenging the UV-reactive oxygen species
has been more extensively described. It is therefore fair
to assume that their proven presence in various skin
components protects the skin from the photodamageinduced aging [58].

6.2 Acne
Vitamin A and its natural metabolites have been
approved for topical and systemic treatment of mild,
moderate, and severe, recalcitrant acne as well as
photoaging and biological skin aging [59].
The association between acne disease and nutrition
has been highly controversial. The low glycemic load
diet resulted in a significant reduction in weight, body
mass index, and free androgen index and increased
insulin-like growth factor binding protein-1 (IGFBP-1)
serum levels coupled with reduced bioavailability of
free IGF-1 and improved insulin sensitivity. High glyce-

Atopic dermatitis has been also associated to

macronutrients and micronutrients. Specific nutritional
interventions using probiotics are described in some
studies to exert beneficial effects on atopic dermatitis.
The use of oral probiotics for promoting immune
responses in the skin has been explored in relation to
ultraviolet light-induced skin damage, where one
clinical study suggested that probiotic treatment may
have a role in promoting recovery from such damage in
those most susceptible to it [64].
The alleviation of atopic dermatitis has also been the
target of several oral intervention studies with essential
fatty acids (EFAs). Van Gool et al. summarized that
early supplementation with -linolenic acid (GLA) in
children at high familial risk tends to alleviate the
severity of atopic dermatitis in later infancy in these
children. Van Gool et al. also performed a metaanalysis of placebo-controlled EFA trials and
concluded that the effects of EFAs were negligible.
Foster et al. [65] performed a similar analysis on the
particular effect of borage oil on atopic dermatitis. He
reached the conclusion that a ma- jor clinical effect is
unlikely. However, he noted that it may be useful in
some patients with less severe AD and could be used as
maintenance treatment for the prevention of flare-up in
milder cases [66, 67].
Dietary supplementation with blackcurrant seed oil
transiently reduced the prevalence of atopic dermatitis.

Rev Endocr Metab

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GLA supplementation has been investigated and

seemed to reduce total IgE in the first year of life
[68]. In the study of Callaway et al., subjects with
atopic dermatitis used hempseed oil compared with
olive oil; reduced skin dryness and skin itching
was observed in the hempseed oil group [69]. Two
additional studies have demonstrated an improvement
of barrier function after supplementation by GLA in
elderly subjects and in younger population [70, 71].
Another study that examined the effect of the
ingested flaxseed (rich in - linolenic acid) or borage
(rich in linoleic acid) oil demonstrated amelioration on
skin irritation, blood flow, and skin hydration for both
regimens
rich in these
EFAs (p < 0.05).
Transepidermal water loss was decreased in both
groups and surface evaluation of living skin revealed
that roughness and scaling of the skin were significantly decreased with both oils rich in EFAs, when
comparing week 0 and week 12 [72].

7 Conclusion
A number of clinical studies have shown the firm
relationship between nutrition and cutaneous
physiology and pathophysiology, but a lot of unknown
topics need to be further investigated.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict
of interest.

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