Rev Endocr Metab Disord
DOI 10.1007/s11154-016-9374-z
Nutrition and skin
Apostolos Pappas 1 & Aikaterini Liakou 2 & Christos C. Zouboulis 3
# 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 di-
etary interventions where well-documented studies have dem-
onstrated 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
1
Johnson & Johnson Consumer, Inc., 199 Grandview Road,
Skillman, NJ 08558, USA
2
Second Department of Dermatology and Venereology, Attikon
Hospital, Athens, Greece
3
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 suc-
cessfully 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 in-
dividually, 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 de-
ficiencies is low in the western world, unbalanced and incom-
plete 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 improv-
ing the skin condition and preventing skin diseases have been

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 pro-
cesses 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 impor-
tant 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 sup-
plementation. 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 hu-
man skin can only be achieved by nutrition. Carotenoids consist
of a family of highly lipophilic pigments that are synthesized by
photosynthetic organisms and some non-photosynthetic micro-
organisms, but not animals. However, evidence indicates the
role of endogenous carotenoids in systemic protection and
Rev Endocr Metab Disord
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 all-trans 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 in-
vestigated 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 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 significant-
ly UV-induced erythema. In addition, human intervention
studies with a mix of carotenoids confirmed their
photoprotective effect [38, 41].
Rev Endocr Metab Disord
It should also be noted that beta-carotene has been pro-
posed as a possible dietary therapeutic agent for dermatolog-
ical conditions, such as porphyria cutanea tarda, polymorphic
light dermatosis, and vitiligo. Beta-carotene 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 thera-
peutic for most patients [42, 43].
Beta-carotene has also been proposed as a possible preven-
tive 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 squa-
mous 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, conse-
quently, 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
immune-suppressed 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 metabo-
lism 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 photoag-
ing. 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 prema-
ture aging of the skin called photoaging. Sunburn is also a
phenomenon related to exposure to UV radiation.
5 Topical application
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 com-
pared the topical efficacy of the various forms of vita-
min E for photoprotection against UV-induced erythema
in rabbits and against UV-induced photoaging in mice.
In a long-term, 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 effec-
tive 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
6.1 Skin aging
The literature on the effect of the various carotenoids on the
skin photoprotection is vaster than the aforementioned nutri-
ents. 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 photodamage-induced 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-
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 resis-
tance [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].
Rev Endocr Metab Disord
6.3 Atopic dermatitis
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 supplementa-
tion 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
meta-analysis 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.
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 exam-
ined the effect of the ingested flaxseed (rich in -
linolenic acid) or borage (rich in linoleic acid) oil dem-
onstrated 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 re-
vealed that roughness and scaling of the skin were sig-
nificantly 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 pathophysi-
ology, but a lot of unknown topics need to be further
investigated.
Rev Endocr Metab Disord
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
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