, several research groups studied this subject , and one of the largest studies involved 65 patients . over a four - week period , subjects were administered either a chocolate bar or a placebo bar , and no difference in acne severity was seen . this belief was reflected in textbooks , patient information brochures , and the medical literature . however , later researchers noted methodological flaws in the original study , including the fact that the placebo bar contained a similar total sugar and fat content as the chocolate bar . a randomized controlled trial of australian males   demonstrated significant improvement of acne severity after 12 weeks of adherence to a low - glycemic - load diet , compared to the high - glycemic - load diet control group . follow - up studies   have noted that switching to a low glycemic diet led to better insulin sensitivity , lower androgen bioavailability , and altered skin sebum production . it is not known , however , what role individual differences , duration of dietary changes , and other factors play in this association . therefore , studies such as di landro et al.s   have documented the opposing view that weekly consumption of cakes , sweets , and chocolate  foods high in glycemic load  was not associated with a higher risk of acne . in addition , researchers examining the link between dairy consumption and acne have noted some association . studies   have demonstrated this link in three separate populations , though in each instance the correlation results were considered relatively weak . closer evaluation of this link revealed that only skim milk showed a statistically significant correlation with acne , perhaps due to its increased processing and/or decreased estrogen content in comparison to whole milk . a number of other dietary factors have been studied for their potential role in improving acne . for example , an inverse relationship has been found between acne severity and consumption of omega-3-rich fish   with the mechanism of action postulated as omega-3-mediated reduction of inflammatory acne . while some promising results have been noted from in vitro or animal studies , studies in humans are limited , and each of these dietary factors requires further investigation before recommendations may be made to patients . these include foods or supplements containing vitamin a , omega-3 fatty acids , zinc , antioxidants , and fiber . . given that the scientific literature on this topic is rapidly evolving , it would be expected that patients might receive conflicting advice . patients have long held certain beliefs about diet and acne , including the common perception that fried , greasy foods would lead to oily skin and acne . however , it is not known whether patients are aware of the research findings that support a link between specific dietary factors and acne . patients seek out and receive medical information from multiple sources , and current patient beliefs about diet and acne are not known . this study was designed to be an initial , exploratory survey study of current patient perceptions about the link between diet and acne . the aim was to identify common beliefs , misconceptions , and current information sources regarding the connection between diet and acne . as in other exploratory survey studies , these findings would help indicate directions for future research and would be of benefit to clinicians when counseling patients . patients presenting to an academic dermatology clinic for the treatment of acne or acne scarring were asked if they wished to participate in a survey study about the link between diet and acne . if so , they completed a self - administered questionnaire prior to the physician visit . subjects were asked to classify their acne from mild to severe , based on their personal perception of the disease s impact . demographic data , such as age , gender , weight , height , and education level , was included in the questionnaire . of the 50 questionnaires administered , 49 were completed in full and were included in the analysis . the mean age of patients was 28.5 years ( range , 16 to 45 years ) ; 38 were female and 11 were male . three respondents had an under - weight bmi of less than 18.5 ; 30 respondents had a normal bmi between 18.524.9 ; 13 respondents were overweight with bmi 2529.9 ; and 2 respondents qualified as obese with bmi greater than 30.0 . a majority , 45 of 49 respondents , was educated at the college level ( table ia ) . respondents reported the following acne severity distribution : 13 patients had mild acne , 1 patient had mild - moderate , 29 patients had moderate , 1 had moderate - severe , and 5 had severe acne ( table ib ) . among our population only 3 of 38 ( 8% ) female patients and 1 of 11 ( 9% ) male patients believed that diet had no effect on acne . of female patients , 30 of 38 ( 81% ) patients believed that diet affected acne either somewhat , a lot , or was the complete cause of acne . among male patients , a majority , 35 of 49 patients ( 71% ) , had changed their diets in order to help their acne ( table iia ) . thirteen of the 35 ( 37% ) tried dietary changes before medications , compared to the 14 patients that first attempted medications . of those 14 , 9 tried over - the - counter medications first ( 25% ) and 5 tried prescription first ( 14% ) . four patients tried a combination of dietary changes with prescription medications ( 11% ) ; 2 combined dietary changes with over - the - counter medications ( 6% ) ; and the remaining tried a combination of all three or a combination of over - the - counter and prescription medications ( table iib ) . the dietary item most frequently implicated to worsen acne was fried , greasy foods ( 71% ) . other responses included chocolate ( 53% ) , followed by dairy products ( 47% ) . this was followed by soda drinks ( 35% ) , caffeine ( 27% ) , and refined carbohydrates ( 27% ) . among the named categories of dietary items believed to aggravate acne , sugar was named by the lowest percentage of respondents ( 16% ) . the category listed by most respondents as helping acne was that of vitamin a ( 41% ) , followed by antioxidants ( 33% ) , fish / omega-3s ( 29% ) , and zinc ( 27% ) ( table iiib ) . twenty percent reported acne improvement with less fried or greasy foods , followed by 14% reporting improvement with less dairy products and 14% reporting improvement with less refined carbohydrates ( table iiic ) . the most widely utilized source of information was a google search ( 49% ) , followed by dermatologist ( 43% ) and then family members and tv ( tied at 41% ) . medical websites , specifically sites such as webmd or that of the american academy of dermatology , were used by 31% , while primary care physician ( pcp ) was used by 18% ( table iva ) . respondents were split evenly between those satisfied with the information provided on their sources ( 49% ) and those not satisfied ( 51% ) ( table ivb ) . this trend was found in almost all categories of sources listed except for : dermatologist , family members , medical websites , and pcp . of the 24 out of 49 satisfied respondents , 18 ( 75% ) marked dermatologist as one of their sources of diet and acne information . not satisfied with their information , only 3 ( 12% ) had marked dermatologist as a source of information . similarly , 10 of 24 satisfied respondents ( 42% ) marked medical websites as one of their sources , whereas 5 of 25 unsatisfied respondents ( 20% ) reported the use of medical websites . these findings reverse when looking at family members as a source of information . among unsatisfied respondents , 52% had marked family members as a source of diet and acne education , as compared to 29% of satisfied respondents ( table ivc ) . in fact , only 5% of female patients and only 9% of male patients believed that diet had no effect on acne . a majority of respondents , 71% , had changed their diet in order to help their acne . of the foods listed , the highest percentage of respondents ( 71% ) chose a category that patients have historically described as an acne trigger food : that of fried / greasy foods . this is a popular , long - held belief , as anecdotally , patients sometimes make the connection between greasy foods and increased oil production on the face . the strongest research evidence , however , supports a link between a high glycemic index ( gi ) diet and acne . while fried or greasy foods may contribute to a high gi diet , so would sugar , soda drinks , and refined carbohydrates . these categories , however , were listed by much lower percentages of respondents ( 16% , 35% , and 27% , respectively ) . this is an important point to emphasize to our patients . while fried , greasy foods are a concern , so are a number of other foods . as dermatologists , we should be emphasizing that even innocuous foods , such as white bread , pasta , and other refined carbohydrates , when part of an overall high gi diet , may worsen acne . chocolate as a dietary factor triggering acne is also a long - held belief , and studies evaluating its role in acne were performed in the 1960s . at this time , though , there is no evidence that a factor specific to chocolate can trigger acne . rather , research points to its sugar content and contribution to a high gi diet as a possible trigger . ideally , then , chocolate , sugar , and refined carbohydrates would have similar ratings by patients , as they may all contribute to a high gi index diet . in fact , while 53% reported chocolate as a possible trigger food , only 16% reported sugar as a potential trigger . while chocolate bars may serve as an acne trigger , sugar and other sugary foods are just as concerning . of note , although some studies have shown a link to dairy , less than half ( 47% ) of our respondents believed that dairy products could aggravate acne . an interesting finding is that a significant proportion of respondents believed that certain foods or supplements could help acne . this may be due to reports of high - dose vitamin a therapy used in the past as acne therapy , and the fact that acne medications such as tretinoin and isotretinoin are related to vitamin a. our survey did not distinguish between standard vitamin a supplements and high - dose supplementation , and therefore it is not known whether a belief in vitamin a therapy extends to standard supplement dosing . when vitamin a is removed from the analysis , the highest category becomes antioxidants ( 33% ) , followed by fish or omega-3s ( 29% ) , zinc ( 27% ) , and dietary fiber ( 20% ) . for each of these nutrients , while some promising results in the treatment of acne have been noted from in vitro or animal studies , studies in humans are limited . at this point , these can not be recommended routinely , but their use by patients can not be dismissed entirely either . in conclusion , while there is limited research performed in the area of foods or supplements that may help in the treatment of acne , many of our respondents believe they may help . in an era of rapid dissemination of information , patients are sometimes made aware of promising findings from small studies . this highlights the need for dermatologists to stay abreast of the latest dietary findings , and in particular not to dismiss these out of hand . in addition , dermatologists must be cognizant of the fact that a significant proportion of patients may believe that certain foods or supplements have the ability to combat acne , and therefore must be able to provide information on the limited evidence that exists to support their use . in order to disseminate accurate , evidence - based information in our survey study , less than half ( 43% ) relied on dermatologists for information . the remaining respondents turned to a variety of sources , including the internet ( google search and medical websites ) , mass media ( magazines , television , and newspaper ) , and personal relationships ( mainly family members and friends ) . the sources of information utilized by patients have changed markedly . in a survey study from 1999 , general information on acne was obtained most frequently from family physicians ( 71% ) . in our survey the mass media continues to play a role in providing health information . in the 1999 survey study , magazines and television were utilized by 44% each . in our survey study , magazines were utilized by 27% , and television was utilized by 41% of respondents . the most notable change has been the rise of the internet as a tool for health information . our respondents utilized google most frequently ( 49% ) as a source of information , with medical websites utilized by 31% . in the 1999 study , it is clear that the internet has had a significant impact on health information - seeking behavior . what is less clear is how physicians should respond to this change when educating our patients . in this study , more patients obtained information from the internet than from their primary care physician or their dermatologist . however , a significant number of those satisfied with their diet and acne education had marked pcp ( 25% ) or dermatologist ( 75% ) as one of their sources of information . conversely , the majority of respondents not satisfied with their information source did not mark dermatologist or pcp as a source of information ( 86% ) . thus , with so many acne patients making dietary changes , and many of them turning to the internet for information to guide them , it becomes even more imperative that physicians be educated on the topic of acne and diet and be able to serve as an authoritative source . for those patients who seek further information , we also need to be able to refer patients to credible sources of online health information , with specific recommendations for high - quality , up - to - date health information websites . our study suggests that education from physicians and medical websites is correlated with higher satisfaction in patients . physicians must also counsel patients on the drawbacks of utilizing search engines for health information , as opposed to utilizing well - regarded medical websites . if relying on a google search , patients may be directed to commercial sites or sites containing inaccurate information . finally , we need to ensure , as a profession , that health education materials are easily available on the internet and that such information is accurate , evidence - based , free from commercial bias , and reflective of the most current research findings . due to the design of this exploratory survey study , patients were recruited from the population of patients seeking treatment for acne at a single academic institution . most , 31 of 49 , were of normal weight ( 63% ) , with only 15 of 49 ( 31% ) categorized as overweight or obese . population , in which 69% are overweight or obese ; 29% are college educated ; and 51% are female . another weakness of the study may be the lack of a quantitative definition of acne severity . in the past , multiple quantitative classification systems have been proposed , though these methods have been inconsistently accurate in the clinical setting . given the variable expressions of acne , as well as its psychosocial factors difficult to quantitate , a more important assessment of severity may be the patient s perception of its impact , which we elicited in the study . in fact , only 5% of female patients and only 9% of male patients believed that diet had no effect on acne . a majority of respondents , 71% , had changed their diet in order to help their acne . of the foods listed , the highest percentage of respondents ( 71% ) chose a category that patients have historically described as an acne trigger food : that of fried / greasy foods . this is a popular , long - held belief , as anecdotally , patients sometimes make the connection between greasy foods and increased oil production on the face . the strongest research evidence , however , supports a link between a high glycemic index ( gi ) diet and acne . while fried or greasy foods may contribute to a high gi diet , so would sugar , soda drinks , and refined carbohydrates . these categories , however , were listed by much lower percentages of respondents ( 16% , 35% , and 27% , respectively ) . this is an important point to emphasize to our patients . while fried , greasy foods are a concern , so are a number of other foods . as dermatologists , we should be emphasizing that even innocuous foods , such as white bread , pasta , and other refined carbohydrates , when part of an overall high gi diet , may worsen acne . chocolate as a dietary factor triggering acne is also a long - held belief , and studies evaluating its role in acne were performed in the 1960s . at this time , though , there is no evidence that a factor specific to chocolate can trigger acne . rather , research points to its sugar content and contribution to a high gi diet as a possible trigger . ideally , then , chocolate , sugar , and refined carbohydrates would have similar ratings by patients , as they may all contribute to a high gi index diet . in fact , while 53% reported chocolate as a possible trigger food , only 16% reported sugar as a potential trigger . while chocolate bars may serve as an acne trigger , sugar and other sugary foods are just as concerning . of note , although some studies have shown a link to dairy , less than half ( 47% ) of our respondents believed that dairy products could aggravate acne . an interesting finding is that a significant proportion of respondents believed that certain foods or supplements could help acne . this may be due to reports of high - dose vitamin a therapy used in the past as acne therapy , and the fact that acne medications such as tretinoin and isotretinoin are related to vitamin a. our survey did not distinguish between standard vitamin a supplements and high - dose supplementation , and therefore it is not known whether a belief in vitamin a therapy extends to standard supplement dosing . when vitamin a is removed from the analysis , the highest category becomes antioxidants ( 33% ) , followed by fish or omega-3s ( 29% ) , zinc ( 27% ) , and dietary fiber ( 20% ) . for each of these nutrients , while some promising results in the treatment of acne have been noted from in vitro or animal studies , studies in humans are limited . at this point , these can not be recommended routinely , but their use by patients can not be dismissed entirely either . in conclusion , while there is limited research performed in the area of foods or supplements that may help in the treatment of acne , many of our respondents believe they may help . in an era of rapid dissemination of information , patients are sometimes made aware of promising findings from small studies . this highlights the need for dermatologists to stay abreast of the latest dietary findings , and in particular not to dismiss these out of hand . in addition , dermatologists must be cognizant of the fact that a significant proportion of patients may believe that certain foods or supplements have the ability to combat acne , and therefore must be able to provide information on the limited evidence that exists to support their use . in order to disseminate accurate , evidence - based information , we must understand what sources patients utilize for medical information . in our survey study , the remaining respondents turned to a variety of sources , including the internet ( google search and medical websites ) , mass media ( magazines , television , and newspaper ) , and personal relationships ( mainly family members and friends ) . the sources of information utilized by patients have changed markedly . in a survey study from 1999 , general information on acne was obtained most frequently from family physicians ( 71% ) . in our survey the mass media continues to play a role in providing health information . in the 1999 survey study , magazines and television were utilized by 44% each . in our survey study , magazines were utilized by 27% , and television was utilized by 41% of respondents . the most notable change has been the rise of the internet as a tool for health information . our respondents utilized google most frequently ( 49% ) as a source of information , with medical websites utilized by 31% . in the 1999 study , it is clear that the internet has had a significant impact on health information - seeking behavior . what is less clear is how physicians should respond to this change when educating our patients . in this study , more patients obtained information from the internet than from their primary care physician or their dermatologist . however , a significant number of those satisfied with their diet and acne education had marked pcp ( 25% ) or dermatologist ( 75% ) as one of their sources of information . conversely , the majority of respondents not satisfied with their information source did not mark dermatologist or pcp as a source of information ( 86% ) . thus , with so many acne patients making dietary changes , and many of them turning to the internet for information to guide them , it becomes even more imperative that physicians be educated on the topic of acne and diet and be able to serve as an authoritative source . for those patients who seek further information , we also need to be able to refer patients to credible sources of online health information , with specific recommendations for high - quality , up - to - date health information websites . our study suggests that education from physicians and medical websites is correlated with higher satisfaction in patients . physicians must also counsel patients on the drawbacks of utilizing search engines for health information , as opposed to utilizing well - regarded medical websites . if relying on a google search , patients may be directed to commercial sites or sites containing inaccurate information . finally , we need to ensure , as a profession , that health education materials are easily available on the internet and that such information is accurate , evidence - based , free from commercial bias , and reflective of the most current research findings . due to the design of this exploratory survey study , patients were recruited from the population of patients seeking treatment for acne at a single academic institution . most , 31 of 49 , were of normal weight ( 63% ) , with only 15 of 49 ( 31% ) categorized as overweight or obese . population , in which 69% are overweight or obese ; 29% are college educated ; and 51% are female . another weakness of the study may be the lack of a quantitative definition of acne severity . in the past , multiple quantitative classification systems have been proposed , though these methods have been inconsistently accurate in the clinical setting . given the variable expressions of acne , as well as its psychosocial factors difficult to quantitate , a more important assessment of severity may be the patient s perception of its impact , which we elicited in the study . this survey study was designed to explore patient beliefs regarding the link between diet and acne . in this small sample , this belief impacted behavior , as the majority had changed their diets in order to improve their acne . due to the study design , the results from this patient sample can not be applied to the general population . however , even in this highly educated patient population , there was a persistence of long - held beliefs that certain foods may serve as acne triggers ( i.e. , fried or greasy foods and chocolate ) and less recognition of the foods that research has identified as potential triggers ( i.e. , sugars , refined carbohydrates , and dairy ) . many respondents also reported a belief that certain foods or supplements could help acne , an area with some promising preliminary results but one that requires further investigation before any conclusions may be drawn . especially given the multiplicity of information sources utilized by patients , as well as the ongoing research in this area and subsequent evolving recommendations , dermatologists must serve as an authoritative information source . dermatologists must be able to provide a balanced overview of this topic to their patients and be able to direct patients to credible , balanced sources for additional dietary change recommendations . these findings indicate a need for further study on the best practices in providing health information , especially as medical recommendations are evolving . our population was highly educated , and the majority was of normal weight . further research in this area must target a more diverse population . even within this skewed population , however , we noted widely conflicting beliefs among acne patients . there is a clear need for easily available , evidence - based , and up - to - date information on the link between diet and acne .
background : in the past , medical literature reflected that diet was not a proven cause of acne . 
 however , studies in recent years have substantiated a link between certain dietary factors and acne . 
 it is unclear whether patients are aware of recent research findings.objectives:acne patients were surveyed to explore beliefs regarding the link between diet and acne , to determine whether these beliefs translated into behavior change and to identify health information sources.patients/methods:upon institutional review board ( irb ) approval , surveys were administered to 50 acne patients at an academic dermatology clinic in 2014 , with 49 completed in full and included in this analysis.results:ninety-two percent of respondents believed that diet could affect acne . 
 seventy - one percent attempted to change their diet to improve acne . 
 seventy - one percent believed acne to be caused by fried or greasy foods , although chocolate ( 53% ) , dairy ( 47% ) , and soda drinks ( 35% ) were highly implicated . 
 patients obtained information from google searches ( 49% ) , dermatologists ( 43% ) , family members and tv ( 41% each ) , and medical websites ( 31%).conclusions : in this exploratory study , 
 patients reported utilizing a diversity of information sources , a majority from the internet . in those surveyed 
 , there was a persistence of long - held belief that fried / greasy foods and chocolate may serve as acne triggers , and less belief in trigger foods supported by recent research , including refined carbohydrates and sugar . 
 given the multiplicity of beliefs and utilized sources among acne patients in our survey , there is a need to establish up - to - date and reliable methods to educate patients on diet and acne .