One common trope in the natural health world is that acne is caused by irritants to the gut lining and inflammation. The idea is that food toxins rub the gut lining and create a permeable gut, which in turn permits toxins to enter the bloodstream, inflame the body, and wreak havoc on the skin.
My favorite bloggers have a good point when they say that “virtually everyone who has acne has a gut issue.” Inflammations is one of the cornerstones of acne (you can read more about causes of acne other than hormones in this post).
Yet based on my own reading and experience I do not yet know if I can get 100 percent on board with that claim, having seen so many women cure their acne by fixing their hormonal issues (like myself!).
What I do know is that women experience acne at greater rates than men, that hormones can be significant contributors to acne, and that in women with any hint of hormone issues, hormones should be the first culprits targeted in the war against acne. Guts also need to be attended to. But there is only so much a healed gut can do when a woman’s hormones have jumped ship.
Hormonal Acne Presentation
When: Hormonal acne in many cases presents at certain times of the month. Popular times include 1) at ovulation, which occurs almost precisely smack in the middle of the cycle, two weeks after the first day of bleeding (read about how to pinpoint ovulation in this post), 2) the few days before a period, and 3) at the start of a woman’s period. Cyclicity is not the only way acne manifests, however. For women with hormonal problems such as PCOS and HA, hormonal acne can persist all of the time.
Appearance: Hormonal acne usually presents as cysts–which are those lovely, pus-filled, painful and inflamed red (if you’re caucasian) sacks. Hormonal acne may also present in more mild forms as comedones–those whitehead “bumps” that never break the surface–or even in some cases as smaller lesions that are not quite as angry and painful as full out cysts, and may appear more rash-like or just smaller than typical acne. Below is a photo of my own cysts back in 2011.
Location: Hormonal acne occurs first and foremost around the mouth: on the chin, below the nose, around the sides of the mouth, and sometimes up the jawline. As hormonal acne worsens, however, it can spread to the cheeks and the forehead. Other body parts can be affected, too, most especially the shoulders, back, and buttocks–where the body’s testosterone receptors are most prominent–but only in severe cases, and once it has advanced. If acne is presenting in locations on the body without being present around the mouth area, there’s a decent chance hormones are not the primary culprit (but can still be involved).
The physiological mechanism of hormonal acne
Hormonal acne is a result of increased oil production within the oil glands beneath the skin. The glands become over-burdened by the oil when this happens–there’s just too much of it–and it erupts to the surface, having to simply “go somewhere.”
Inflammation plays a role in this process (more here). The worse inflammation is, the more irritated the oil gland can become, and thus the more red, and the more painful. Yet hormonal eruptions do not occur first without an oil problem. This is the reason no amount of washing will ever completely eliminate hormonal acne (but can definitely be helped by antioxidant cleansers, serums, or creams or, my favroite, topical probiotics). It comes from underneath. The only way to fix it is from the inside out.
What causes increased oil secretion
In the case of hormonal acne, the primary drivers of oil secretion are androgens (male sex hormones), specifically when they are elevated relative to other hormones, particularly estrogen. When skin cells detect higher levels of androgens in the blood, their DNA responds by up-regulating oil production.
The most prominent androgen is testosterone. Testosterone-driven acne is most obvious in women with PCOS, who often only find out they have PCOS once they experience acne and ask their primary care doctors or dermatologists about a cure. Acne is one of the clearest indicators of PCOS and of the underlying hormonal imbalance for this reason. This is also, interestingly, why men on steroids often experience acne around the mouth area. Excess testosterone causes cystic, hormonal acne, plain and simple.
Testosterone spikes at ovulation. If you experience regular acne in the middle of your menstrual cycle, then testosterone is almost unquestionably to blame.
Yet testosterone is not the only androgenic culprit. Another androgen, called DHEA-S, causes oil production as well. DHEA-S is produced primarily in the adrenal glands. It is a stress hormone. Whenever a woman is under any degree of stress, her body decides if it wants to produce normal sex hormones like progesterone and estrogen, or if it wants to produce stress hormones like DHEA-S.
For this reason, Hypothalamic-Pituitary-Adrenal (HPA) Axis dysregulation is usually the first place to look to as the origin of DHEA-S problems. Women with high stress levels, dysregulated HPA axes, or hypothalamic amenorrhea often experience increased DHEA-S levels. Some women with PCOS do as well, depending on their etiology. (See my post on the inter-related nature of HA and PCOS).
The presentation of elevated DHEA-S is less well-defined and understood than testosterone, but it is still crucial in understanding the relative balance between androgens and female sex hormones in the body. Moreover, because it is produced by the adrenal glands, it speaks volumes to the amount of stress upon a woman’s HPA axis. It is incredibly helpful for me diagnosing the source of women’s hormonal problems. If DHEA-S is elevated, I know that stress is a major problem for us to tackle.
It is also important to note that hormonal balance is maybe evn more important for the skin than the absolute amount of certain hormones like testosterone. Therefore, even if testosterone is normal, low estrogen can cause acne. This is often the case in menopausal women.
Estrogen is one of the most potent anti-acne molecules in the female body. It has the power to off-set high testosterone levels in the blood, for one. This occurs because estrogen increases levels of sex-hormone-binding-globulin (SHBG), which in turn binds testosterone. For another, there are many estrogen receptors in the skin, so estrogen directly performs a balancing and soothing function at the site of acne.
In normal, healthy women, estrogen levels drop off in the week prior to the menstrual cycle. In some women this happens to a more extreme degree (especially when compared to estrogen’s counterpart, progesterone), so for them acne can flare up around this time.
Because hypothalamic amenorrhea (missing menstrual cycles due to low body fat, restrictive diet, excess exercise, or stress) is characterized by low hormone, and particularly low estrogen levels, this is one of the main and most helpful ways women with hypothalamic amenorrhea cure their acne. Because menopause significantly decreases estrogen levels, this is also the primary reason women in menopause can see a re-emergence of hormonal acne after decades of clear skin.
As a final cause of hormonal acne, progesterone can also play a role. Progesterone, in high doses, acts as an inflammatory agent, and in this way causes acne to flare up. Progesterone levels are highest during the days leading up to menstruation, which explains why many women experience outbreaks at this time.
Since estrogen and progesterone play such a crucial role in skin health, it’s no wonder that acne is a common side effect of hormonal birth control pills, and also that many other women experience cleared skin while on the pill. Whether a certain variety of the pill causes acne for you or not, however, is entirely dependent upon your own body chemistry and how your body reacts to external hormones. Know only that if you noticed a change in your skin while experimenting with birth control methods, this is most likely why. You may want to consider a birth control method tbat has a different kind of progesterone in it, or one that has a different progesterone-estrogen balance, to see if it helps relieve your acne.
Aggravators of hormonal acne
Stress: Stress plays an important role. It acts as an inflammatory agent, especially if cortisol levels remain high for a long time. Stress also decreases production of healthy, skin-supporting hormones like estrogen, and increases production of acne-causing stress hormones like DHEA-S. Stress is not necessarily the cause of hormonal acne, but does exacerbate it, and prevent proper healing.
Heat. Heat is inflammatory, and also causes sweat, which can clog pores.
UV Rays. The sun’s rays are some of the most potent acne inflamers out there. Protect the skin on your face with at least an SPF of 20, or consider wearing a hat in the summer months.
Inflammatory foods: grains, dairy, nuts, and omega 6 vegetable oils can all contribute to poor gut health and inflammation.
Dairy: While already mentioned for being inflammatory, dairy deserves special mention because it is a highly hormonal food. Pregnant cows produce several hormones like insulin-like-growth-factor that promote acne in the body, and can cause androgen production to rise. Dairy products also contain progesterone, which can be inflammatory. I have seen enormous success with women with hormonal acne eliminating dairy for their skin. Many people at least anecdotally least respond to dairy with acne more strongly than any other food.
Phytoestrogens: soy and flax are the primary phytoestrogens to be concerned about, with legumes and nuts coming in a distant second place. Phytoestrogens (“phyto estrogen” is greek for “plant estrogen”) have the power to act as estrogens in the body. This may sound like a good thing for acne, but this role is ambivalent and should be treated with caution, especially with the skin. Different estrogen receptors read different kinds of phytoestrogens differently, such that phytoestrogens usually perform estrogen-lowering effects in skin tissue despite what they do in other locations.
Low carbohydrate diets: Having sufficient glucose stores is important for skin healing, and can speed the recovery of acne lesions. Glucose is also helpful for preventing hypothyroidism.
Poor sleep: Sleep both enables healing and promotes healthy hormonal production.
Hypothyroidism: Without sufficient levels of T3, the active form of thyroid hormone, in the blood, a woman’s skin cells lack the ability to heal properly. Many women who suffer hypothyroidism suffer chronic acne.
Dealing with hormonal acne
The best thing you can do for hormonal acne is get blood work done and figure out precisely whatyour problem is. Unfortunately not all of us can afford this, so it’s okay to guess. Nevertheless, the better an idea you have of what is going on in your body, the more specific you can be about what to do to fix it.
In general, hormone dysregulation that leads to acne can be broken down into a few broad categories:
1) high testosterone from PCOS (specifically the overweight and insulin resistant type of PCOS),
2) low estrogen from low body fat levels, chronic restriction, or living in an energy deficit,
3) low estrogen from menopause,
4) high progesterone from general hormone imbalance, possibly related to PMS,
5) any of these conditions worsened by stress or hypothyroidism, and
6) any combination therein.
The solution to all of these problems is to correct the hormone imbalance. I have discussed methods of doing so above and elsewhere. (See my manual for overcoming PCOS, and some of my work on hypothalamic amenorrhea.) For most sufferers of hormonal acne, testosterone is elevated due to insulin resistance and PCOS. The solution, then, is to eat an insulin sensitizing diet, to exercise, and to decrease stress. For other sufferers, DHEA-S may be too high, so stress should be a big factor to examine. And for many others, low estrogen relative to testosterone is the primary problem, and modes of increasing estrogen levels should be examined. These include weight gain, stress reduction, and improved sleep quality. For women with menopause, it may just “take time” or perhaps medical interventions are appropriate, depending on the severity of the problem.
There are drugs designed to help with hormonal acne. Spironolactone and flutamide are the two primary ones that come to mind (though I don’t recommend taking either of them), as well as birth control.
The reason birth control pills are helpful for acne is because they enforce hormone regularity on a woman’s system. The precise pill that is helpful for each woman varies by her particular condition– but in general, BCPs are comprised of estrogen and of progesterone. BCPs can for that reason 1) raise estrogen levels–which either corrects an estrogen deficiency or helps balance the activity of runaway testosterone–and they can also 2) restore proper balance between estrogen and progesterone, which is important for keeping progesterone levels within their proper parameters. Some BCPs also contain anti-androgenic substances, such as drospirenone, which is an added benefit for women who are living with androgen excess (but poses some health risks). In all cases, I do not generally recommend that women get on BCP, as it can cause worse hormonal dysregulation in the long run (sort of like handicapping a delicate hormonal system), and does not solve the underlying problem.
Flutamide acts in a similar way to spironolactone, but less effectively, and with more side effects. So spironolactone is typically the drug of choice.
Spiro has been hailed by many acne sufferers as God’s gift to womankind: it decreases testosterone activity. For many women this begets truly miraculous effects. Yet one should step cautiously with spironolactone. If a woman’s primary problem is not testosterone excess, spironolactone will very likely do more harm for her skin than good. (Check out the panicked discussion forums at acne.org to see what I’m talking about.) Moreover, even for those who have testosterone excess as their primary problem, spironolactone merits caution for a variety of reasons. First, spiro usually induces an infamous “initial breakout” which can last anywhere from weeks to months. This isn’t always the case– sometimes women improve immediately. Sometimes they never really do (I never did: in fact, my acne got worse on spiro.) But the typical case is for women to see an initial worsening of their acne, followed by relief in the upcoming months, especially if they increase their dosages.
Secondly, spiro cannot be taken by pregnant women because it induces birth defects, so women cannot stay on spironolactone indefinitely. This is problematic because spironolactone acts as a bandaid on the hormone problem, and does nothing to fix it whatsoever. What spiro does simply is block testosterone receptors. In most cases, if the underlying problem is not addressed while a woman is taking spironolactone, her acne will return once she comes off of the drug. This is why I recommend that women only consider taking spironolactone if they want a “quick fix” while they work on their diet and exercise in order to improve their PCOS.
Finally, spironolactone has a couple of other health concerns. First, it lowers blood pressure, since spiro is actually a blood pressure lowering drug proscribed “off label” for acne. Secondly, it acts as a diuretic, so women on it need to drink water constantly, may not be able to consume alcohol anymore, may have dysregulated salt cravings, and may never actually be properly hydrated. And finally, spiro acts as a potassium-sparing diuretic, such that women cannot eat potassium rich foods, lest they risk the chance of becoming hyperkalemic, which can lead to sudden death. It hospitalized me. An imbalance of electrolytes in the blood is no laughing matter, so women on spiro should limit their potassium rich foods as well as get their potassium levels checked periodically. Potassium rich foods include melons, bananas, potatoes, avocadoes, tomatoes, and leafy greens, among others.
For these reasons, spiro can help, but it cannot be relied on long term. It does not get at the root of the issue–drugs rarely do–and the true path to hormonal help is diet and lifestyle modifcation.
As a final note, bio-identical hormone supplementation can be helpful for women going through menopause. Estrogen patches can release small amounts of hormone into the bloodstream, and can lessen acne considerably. I do not think this is necessarily detrimental to a woman’s health, if it is in fact the case that her estrogen levels have simply dropped off during menopause. However, it does, in my opinion, make it difficult for estrogen levels to rise and hormone balance to re-establish itself on its own. This is a decision best left to the individual and to her doctor.
Hormonal acne is terrible, and for many women can seem incessant, and never ending. Girls are assured growing up that they will eventually out-grow their acne, yet many women see it persist throughout their twenties and thirties, and some actually do not even see the acne manifest until their twenties and thirties. Some women do not even see acne appear until after the birth of their first children, as their progesterone and estrogen levels are flying all over the map.
For this reason, drug interventions can serve as decent placeholders in moving forward. It can help the pain and awkwardness of acne while diet and lifestyle fall better into place. Yet there are downsides to medication, and large ones. Medication is only ever a band-aid, and it can be a band-aid that in the long run leads to more harm than good. Playing with hormones is like playing with fire. Sometimes things can go horribly wrong. For this reason, meds may be best left alone, depending on the circumstance and the level of risk a woman is willing to bear. It is entirely possible as well as supremely healthy to cure acne from the inside out with good diet and lifestyle practices alone. It may take experimentation and patience, but don’t all good things, in the end?
January 2014 Update: For an even more thorough blog post on the causes of acne and overcoming it, see the new post on acne, here.
For more information on hormones and hormone balance, see my book, Sexy by Nature.
For my favorite resource out there on overcoming acne, see Seppo Puusa’s Clear for Life.