Potential Pathways of the Gut-Brain-Skin Axis in Acne Vulgaris:  Psychological distress alone or in combination with  high fat diet, processed comfort foods devoid of fiber, cause alterations to  gut motility and microbiota profile . Loss of normal microbial biofilm (Bifidobacterium in particular) causes intestinal permeability and endotoxins gain systemic access . Burden of inflammation and oxidative stress is increased, substance P is elevated, insulin sensitivity is decreased due to endotoxemia . In those genetically susceptible to acne vulgaris, this cascade increases the likelihood of excess sebum production, exacerbations in acne and additional psychological distress. Both probiotics and antimicrobials may play a role in cutting off this cycle at the gut level.