Hormonal acne can be a frustrating condition to work with. I see you! Sometimes it can feel like one step forward, three steps back.
Acne is a symptom of something not quite being right. It can be complex to treat and typically involves multiple pathways that drive inflammation. This is where working with a professional is key to uncovering the root cause of your acne.
Treat the root cause and you will get long-lasting results!
What is Acne?
Acne vulgaris is a chronic inflammatory skin condition that involves the appearance of skin lesions such as papules, pustules, or nodules located on the face, chest, back, or shoulders. Individuals can experience an acute flare when progressing through puberty and experiencing an overgrowth of Cutibacterium acnes, or it can progress to chronic recurrences well into adulthood. There are several types of acne lesions:
1. Papules: small bumps that can become inflamed – they may be warm and sore to touch.
2. Whiteheads: Bumps that remain closed by dead skin and oil build-up. They may appear white or yellowish.
3. Blackheads: Open, but clogged pores that contain dead skin and excess oil.
4. Nodules: Rounded, shaped masses that can be deep in the skin. Often very painful to touch, and have no head.
5. Pustules: Puss-filled pimples containing a whitehead, but are surrounded by a discoloured ring.
6. Cysts: Pimples filled with thick yellow fluid composed of fatty acids, dead white blood cells, and bacteria.
It is important to note that hormonal acne is not always caused by an over-production of hormones, but rather a change relative between testosterone, estrogen, and progesterone.
In general, I go through the following questions to determine whether my client’s acne is being driven by hormones.
1. Is the congestion/ acne placed along the chin and lower jawline?
2. Is acne worse in the luteal phase and then begins to clear after menstruation?
3. Diet – high in refined sugar OR having intense sugar cravings?
4. Has the client recently come off the pill OR did they go on the pill specifically to treat acne?
5. Does the client have a ‘symptomatic’ menstrual cycle? PMS? Heavy/painful bleeding?
6. Does the client have PCOS or are they having anovulatory cycles (no ovulation)?
7. Are they moving their bowels twice daily?
8. Are there any other symptoms of poor detoxification? (see list further below)
Factors contributing to Hormonal Acne
High androgens
High testosterone can cause excess sebum (oil) production in the sebaceous glands. This is more common in those with high androgen PCOS where their free testosterone and DHEA are elevated, or, if they are experiencing anovulatory cycles and not producing enough estrogen and progesterone to keep testosterone in check.
If your testosterone is normal, it could be that estrogen and progesterone are too low, which results in a ‘skew’ relative to testosterone, contributing to high testosterone symptoms like acne along the chin, jaw, and dark hair growth.
Estrogen – protective effects
You may notice that after menstruation your skin clears up again. This is due to estrogen, which supports our skin barrier by improving skin elasticity and hydration. Estrogen acts like a buffer by suppressing testosterone production and therefore sebum production, and also reducing pore size.
During the luteal and menstruation phases when estrogen is lower, sebum production by the sebaceous glands can be accelerated by testosterone converting to 5a-dihydrotestosterone. This is where we see acne worsening right before your period, and acne that is situated on the lower jaw-line, chin, and neck.
Estrogen – when there is “too much”
On the flip side, too much estrogen can also contribute to hormonal acne. This is more commonly caused by our body’s inability to excrete estrogen rather than overproducing it.
Estrogen is excreted in urine and feces, however, if our detoxification is poor, our bowels are sluggish, or our microbiome is out of balance, estrogen can be reabsorbed through the rectum and gastrointestinal wall and recirculates in the bloodstream. Our body then believes we have estrogen dominance. This is what contributes to estrogen-dominant symptoms such as heavy and painful bleeding, sore and tender breasts, and cramping throughout the menstrual cycle.
Signs of sluggish detoxification
· Constipation – moving your bowels twice daily is ideal
· Bloating
· High alcohol or caffeine intake
· Headaches and migraines
· Weight gain
· Fatigue / general feeling of being ‘sluggish’
· Skin disruptions such as acne, eczema or psoriasis
. High-estrogen symptoms - heavy and painful bleeding, sore breasts, and cramping throughout the menstrual cycle.
Insulin and insulin growth factor
Some researchers have coined acne as ‘diabetes of the skin’ and from a meta-analysis, researchers found approximately 76 – 81% of acne patients had insulin resistance.
High levels of insulin cause the ovaries to overproduce androgens and make more testosterone, leading to more sebum production within the skin. High insulin also stimulates the pituitary gland to make more luteinizing hormone (LH), which again stimulates more androgens.
As you can see, good nutrition is imperative here to support acne. I often recommend a low refined sugar diet, blood sugar regulation tips, and for some, going completely dairy-free, as both sugar and insulinotropic milk/ dairy products increase insulin growth factor-1.
Stress weakens the skin barrier
Chronic exposure to cortisol inhibits the production of collagen and hyaluronic acid within the skin, both of which are needed to maintain the integrity, hydration, and elasticity of the skin barrier. At the same time, stress will deplete your body of essential vitamins and minerals that are required for collagen synthesis and maintaining a strong skin barrier such as Zinc, Iron, vitamins C, D, and A.
Why the pill is not the answer
I understand that skin conditions can impact our self-confidence, self-worth, and mental health, and we wish for fast results. It may give you clear skin fast, but when you stop taking the pill years later, your acne will come back if the root cause is not resolved.
Some contraceptive methods have a ‘low androgen index’ measure, meaning they reduce testosterone and regulate sebum production. This is what makes some very effective in reducing acne.
In New Zealand, these are contraceptive pills that contain the synthetic estrogen ethinylestradiol, and synthetic progestins drospirenone, norgestimate, and cyproterone. They do such a good job at suppressing sebum that our skin has to upregulate sebum production to maintain our skin moisture levels. This upregulation continues when you stop the pill, resulting in producing more sebum than you’ve ever had and what feels like your acne coming back with a vendetta!
While experiencing this sebum rebound, coming off the pill can further trigger your ovaries to temporarily make more androgens as they begin to ‘switch on’ again. So, this can lead to both post-pill acne and post-pill PCOS (read all about PCOS here)
Your treatment plan - How to heal hormonal acne
Strengthening your gut microbiome and lining
I've lost count of the number of clients I've seen who present with hormonal acne, irritable bowel syndrome, leaky gut, and candida overgrowth. Having an inflamed gut will inflame your whole body, and it will show in your skin's appearance.
Factors that affect your microbiome composition and integrity of the gut lining include antibiotic and medication use, oral contraceptive use, consistent alcohol and drug use, stress, past gut infections picked up while traveling, and an inflammatory diet high in refined sugars, processed foods, and low in fibre.
Supporting Candida overgrowth
Candida is an opportunistic fungus that overgrows within the gut, skin, and vagina when our microbiome balance is poor due to the above. A Candida overgrowth contributes to intense sugar cravings, skin fungal infections, thrush (oral, gut, and vaginal), PMS, and acne. By craving sugars and consuming more of them, we will continue to worsen the cycle of insulin resistance, inflaming the gut, inflaming the ovaries, and increasing androgen production.
Supporting your skin’s natural oil balance
As you have seen, this can be caused by high androgens and post-pill sebum production. Other factors that can contribute to your skin's oil balance, are, not consuming adequate amounts of omega-3 fatty acids, using skincare that strips your natural oils, over-exfoliating, not changing your pillowcases regularly, and not cleansing your face twice daily to remove impurities from air pollution and products.
Medicinal herbs
The herbs chosen for your herbal formula may support excess testosterone, modulate estrogen and progesterone levels, support gut microbiome balance, improve detoxification capability, support blood sugar balance, and cleanse the skin and lymphatic system.
Reversing insulin resistance: Supporting your blood sugars with nutrition and exercise
To support your blood sugars at every meal, aim to eat your non-starchy vegetables first, protein and fat portion second, followed by starchy carbohydrates last. Eating your meals and snacks in this order alone can reduce your blood glucose spike by 30%.
Daily movement is also crucial to support your blood sugar levels and insulin sensitivity. When our muscles contract with movement, our cells will use stored glycogen and glucose within the bloodstream for energy. Our muscles become more sensitive to insulin 12-48 hours post-exercise, enabling our muscles to ‘soak up’ glucose faster, lowering our blood sugars.
Addressing nutrient deficiencies
Specific nutrients to strengthen the skin barrier and support the immune system are vitamin's A, C, D, and omega-3 fatty acids.
If there are indications of anovulation resulting in lower levels of progesterone, then we can increase nutrient intake to stimulate the ovaries for ovulation. This would include iodine, zinc, selenium, B12, B6, and folate.
As you can see, there are multiple things to address with hormonal acne. I also want to stress that there is no a quick fix, unless you are wanting to go on a hormonal contraceptive that will 'band-aid' the real issue. It takes time to resolve underlying gut conditions, support healthy ovulation, and reduce androgen levels and normalise sebum production.
References
1. Saowska-Przytocka et al. (2022). Doi: 10.5114/ada.2021.107101
2. Kim et al. (2017). Doi: 10.5021/ad.2017.29.1.20
3. Hasrat & Al-Yassen (2023). Doi: 10.7759/cureus.34241
4. Escamilla-Cruz etal. (2023). Doi: 10.1007/s13555-023-00974-4
5. Briden (2019) Period repair manual: Every women’s guide to better periods
6. Schachner et al. (2023). https://doi.org/10.111/jocd.15946
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