Introduction

Recently a 22-year-old female spent two weeks in a vacation rental. Prior to the vacation with her family, she had no known health concerns and she had clear skin. A week after returning from the vacation she developed acne. The home smelled of mold and mildew, and some visible mold was present in the bathrooms and showers. The home was in an area previously affected by Hurricane Irma. In September 2017 the vacation home suffered flood damage from the hurricane; the home had been remediated for mold. Could mold still be present? Is there a link between mold exposure and skin conditions such as acne? These are questions to be answered.

Mold

Mold can easily grow in water-damaged buildings, creating adverse health effects. Some seem to be more sensitive to mold than others. Visible signs of mold growth can include condensation on surfaces or structures such as windows, visible mold, especially black mold, mildew smell and mold odor, and history of water damage (leaks, wet basement, plumbing).¹

Mold and mold components such as mycotoxins can create inflammation, oxidative stress, disrupt the gut microbiome, alter the immune system, cause dermatological issues and respiratory conditions in the person exposed.² Household mold can wreak havoc on the body. For example, one study states it can cause an estimated 21% of asthma in the US. It found that 67% of adult-onset asthma started after working in a water-damaged office building.¹

Mycotoxins are the secondary metabolites of mold organisms. Mold and mycotoxins, including ochratoxin (OTA), aflatoxin, and trichothecene mycotoxins, have been found in homes and offices affected by water damage. Aflatoxins are often produced by Aspergillus species and various species of Penicillium, Rhizopus, Mucor, and Streptomyces.  Ochratoxin A is produced by Aspergillus species and species of Penicillium, Petromyces, and Neopetromyces. Trichothecenes are produced by Stachybotrys, Fusarium, and Myrothecium mold.^3-5 Gram positive bacteria such as Streptomyces, Mycobacteria, and Nocardia, have also been found in water-damaged buildings.^1,2 Exposure to these can trigger an inflammatory response in the body, affect the neurological and immune system, affect the pulmonary system, and even cause dermatitis such as unexplained rashes and acne.^6-9 Household mold exposure is linked to chronic fungal sinusitis, peripheral neuropathy, sarcoidosis, and chronic fatigue.¹⁰ A recent study of 104 patients with chronic fatigue syndrome showed 93% had at least one mycotoxin present in their urine; ochratoxin-A was the most prevalent.¹¹

Can Mold and Mycotoxin Exposure Cause Acne?

Mold exposure can induce dermatological changes through changes to the immune system as well as the gut microbiome. It’s not just airborne exposure to mycotoxins that affects us. Mycotoxins can be introduced into the body from food contamination. According to the World Health Organization 25% of the world’s crops such as cereals, rice, nuts, and other grains are contaminated by mold. Ingestion of mold and mycotoxins can alter gut health by altering the normal barrier function and nutrient absorption. They disrupt the gut microbiome balance, dysregulate intestinal functions, and impair local immune response, which may eventually result in skin changes such as acne and dermatitis. ¹²

It is well known that alterations in the gut microbiome leads to acne and dermatitis. An increase in release of inflammatory mediators as seen in mold exposure is also linked to acne and other dermal conditions.¹³ Mycotoxins create altered release of inflammatory makers and changes in the gut microbiome and could indirectly be linked to acne. One study found that exposure to airborne mold and mycotoxins is linked to rashes and itchy skin in school children exposed to mold in the classroom.¹⁴ The skin has its own microbiome that can be penetrated by mycotoxins and cause skin microbiome disruption which can lead to acne.^15,16 These are just a few methods in which mold and mycotoxin exposure could influence the development of acne.

Case

Back to the patient that started the search for the link between household mold exposure and acne. As previously stated, a 22 -year-old female spent two weeks in a vacation rental. In September 2017, the vacation home suffered flood damage from the hurricane. The home had been remediated, repaired, and remodeled per the owner. Although the owner stated the home had been remediated, the family renting the home did see and smell mold. Her other family members who stayed at the home all returned with some fatigued, had itchy skin but no visible rash or acne. All felt like they developed a mild cold or allergy-like symptoms that eventually resolved upon returning home.

The 22-year-old female presented to the office for help with acne that started immediately following the trip. She had visible acne on her face; otherwise, the exam was unremarkable and vitals normal of BMI 22.5. Review of systems, including digestion and bowel function was normal. She had never had acne prior to staying in the vacation home. She said her diet was different during the two weeks. She ate more seafood than she normal. She is allergic to dairy and avoids all dairy, and she eats minimal refined sugars and carbohydrates. She stated that her sugar and carbohydrate intake did not increase during the trip. She was not stressed while on vacation and used all her own soaps, shampoo, cleanser, and personal care products. She brought these from home. She felt tired and had a stuffy nose for a week after returning from vacation as did her other family members who stayed in the home. She returned from vacation two weeks prior to the visit and still has the acne present—a total of 3 weeks. Her menstrual cycles were regular, every 27-28 days, no cramps, light flow, and no PMS. She is not on hormonal contraception and takes no medication but does take a probiotic and multivitamin. Basic labs and hormones were ordered as well as blood mercury because she ate more fish than usually on the vacation.

Hormone imbalance is often a common cause of acne in this age group so all androgens and ovarian hormones as well as inflammatory markers were ordered. She declined testing for mold/mycotoxins at this time and wanted to start with testing her hormones and initiating treatment. The parents didn’t want to spend money on mold testing since they are convinced, they were exposed to mold. Mold/Mycotoxin testing is offered by several labs and can be done through urine or nasal sampling. In many states patient can order the urine, nasal tests themselves without a doctor’s order. Sputum or tissue biopsy can also be done by a physician.

Lab results- CBC, CMP, LIPID panel, TSH, FT4, ESR, CRP, vitamin-D, B12, DHEA, testosterone and blood mercury were all normal.

The initial treatment plan was based on presumed mold exposure. Since she was no longer staying in the home avoidance was already initiated by default and it is not possible for her to have the home tested for mold. Typically, if a patient is working, studying, or living in a home with water damage, mold smell or visible mold, the home or building should be tested for mold.  The ERMI test (Environmental Relative Moldiness Index) was developed by the US Environmental Protection Agency to investigate mold contamination in homes. The ERMI test involves the analysis of a single sample of dust from a home or building. Several companies offer this test.

Treatment plan included oregano oil capsule (1 twice a day), activated charcoal (1 capsule twice a day), and a supplement that included caprylic acid, garlic extract, milk thistle, Oregon grape root extract, and grapefruit seed extract (2 capsules twice a day).² She returned for a follow up after four weeks and her skin was 25%-30% improved. Her probiotic was changed to a spore-based probiotic and oral vitamin A was started, 10,000 IU a day for one month. (She is not sexually active). At the next follow up, her skin improved and cleared.

Summary

Mold and mycotoxin exposure from water-damaged buildings and homes is a common occurrence that produces adverse health effects. Mycotoxins can also occur through contaminated food in small amounts, but most health issues are from mold exposure due to water damage. The most obvious health effect is on the pulmonary system as asthma and other respiratory conditions are linked to mold. Mold and mycotoxins can affect the immune system, create inflammation and oxidative stress, causes rashes, itchy skin, chronic fatigue and even acne. Mold is linked to acne through disruption of the gut microbiome as well as the microbiome of the skin. According to the American Academy of Dermatology, acne affects almost 50 million Americans a year. Although there are several causes of acne, mold exposure and mycotoxins are often overlooked, and a thorough environmental health history of current and recent exposures could identify a link to mold and acne.

References

1. Crinnion, W., & Pizzorno, J. E. (2019). Clinical environmental medicine: Identification and natural treatment of diseases caused by common pollutants. St. Louis, MO: Elsevier
2. Hope J. A review of the mechanism of injury and treatment approaches for illness resulting from exposure to water-damaged buildings, mold, and mycotoxins.  ScientificWorldJournal. 2013;767482.
3. Brasel TL, et al. Detection of airborne Stachybotrys chartarum macrocyclic trichothecene mycotoxins in the indoor environment. Applied and Environmental Microbiology. 2005;71(11):7376–7388.
4. Straus DC, Wilson SC. Respirable trichothecene mycotoxins can be demonstrated in the air of Stachybotrys chartarum-contaminated buildings. Journal of Allergy and Clinical Immunology. 2006;118(3):760.
5. Thrasher JD, et al. A water-damaged home and health of occupants: a case study. Journal of Environmental and Public Health. 2012;10.312836.
6. Hodgson MJ, Morey P, Leung WY, et al. Building-associated pulmonary disease from exposure to Stachybotrys chartarum and Aspergillus versicolor.  Journal of Occupational and Environmental Medicine. 1998;40(3):241–249.
7. Liu J, Wang Y, Cui J, et al. Ochratoxin A induces oxidative DNA damage and G1 phase arrest in human peripheral blood mononuclear cells in vitro. Toxicology Letters. 2012;211(2):164–171.
8. Doi K, Uetsuka K. Mechanisms of mycotoxin-induced neurotoxicity through oxidative stress-associated pathways. International Journal of Molecular Sciences. 2011;12(8):5213–5237.
9. Bouslimi A, Ouannes Z, Golli EE, Bouaziz C, Hassen W, Bacha H. Cytotoxicity and oxidative damage in kidney cells exposed to the mycotoxins Ochratoxin A and citrinin: individual and combined effects. Toxicology Mechanisms and Methods. 2008;18(4):341–349.
10. Brewer JH, Thrasher JD, Hooper D. Chronic illness associated with mold and mycotoxins: is naso-sinus fungal biofilm the culprit? Toxins (Basel). 2013;6(1):66-80.
11. Brewer JH, Thrasher JD, Straus DC, Madison RA, Hooper D. Detection of mycotoxins in patients with chronic fatigue syndrome. Toxins (Basel). 2013 Apr 11;5(4):605-17.
12. Liew WP, Mohd-Redzwan S. Mycotoxin: Its Impact on Gut Health and Microbiota. Front Cell Infect Microbiol. 2018;8:60.
13. Clark AK, Haas KN, Sivamani RK. Edible Plants and Their Influence on the Gut Microbiome and Acne. Int J Mol Sci. 2017;18(5):1070.
14. Norbäck D, Hashim JH, Cai GH, et al. Rhinitis, Ocular, Throat and Dermal Symptoms, Headache and Tiredness among Students in Schools from Johor Bahru, Malaysia: Associations with Fungal DNA and Mycotoxins in Classroom Dust. PLoS One. 2016;11(2):e0147996.
15. Dréno B, Dagnelie MA, Khammari A, Corvec S. The Skin Microbiome: A New Actor in Inflammatory Acne. Am J Clin Dermatol. 2020 Sep;21(Suppl 1):18-24.
16. Boonen J, Malysheva SV, Taevernier L, Diana Di Mavungu J, De Saeger S, De Spiegeleer B. Human skin penetration of selected model mycotoxins. Toxicology. 2012 Nov 15;301(1-3):21-32.