One common trope in the paleosphere is that acne is caused by irritants to the gut lining and inflammation. The idea is that food toxins create a permeable gut, which in turn permits toxins to enter the bloodstream and wreak havoc on our skin. Several advocates have a good point when they say that “virtually everyone who has acne has a gut issue” — yet based on my own reading and experience I do not yet know if I can get 100 percent on board with that, having seen so many women’s acne cured by fixing their hormonal issues. 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 should 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 ~week three of the cycle (which can be discerned by body temperature variations) (with the menstrual cycle starting on day one of blood flow), 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 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.
Location: And in terms of 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, 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.
The physiological mechanism of hormonal acne
Hormonal acne comes from up-regulation of 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 can exacerbate this process. The worse inflammation is, the more irritated the oil gland can become, and thus the more red, and the more painful. Yet eruptions do not occur first without an oil problem. This is the reason no amount of washing will ever clear up hormonal acne. It comes from underneath. The only way to fix it is with interventions in the bloodstream.
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, in the blood. 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 hormonal acne, plain and simple.
Yet it is not the only androgenic culprit. Another androgen, called DHEA-S, causes acne production as well, though DHEA-S serves the female body less as a male sex hormone and more as a precursor hormone. DHEA-S is produced primarily in the adrenal glands. From there, DHEA-S acts as a building block for virtually all other hormones. For this reason, 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 dysregulation and stress upon a woman’s HPA axis. DHEA-S increases oil production when present in disproportionately high amounts.
Because hormonal balance is in large part what cells detect when determining how much androgen is floating in a woman’s bloodstream, low estrogen (relative to androgen levels) is also a significant driver of hormonal acne. Estrogen has the power to off-set high testosterone levels in the blood. This occurs via increased testosterone binding activity, which estrogen enables by increasing the activity of sex hormone binding globulin (SHBG). For this reason, if low estrogen levels are restored–either in women with PCOS or HA or some mixture of the two–then testosterone levels are mediated and hormonal acne decreases. Because hypothalamic amenorrhea often sends estrogen levels into the basement–particularly if a woman has low body fat levels–this is the primary mechanism by which 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, progesterone can also play a role in hormonal acne. Progesterone, in high doses, acts as an inflammatory agent, and in this way causes acne to flare up. Progesterone levels being highest during the days leading up to menstruation explains why many women experience outbreaks at this time.
Moreover, testosterone levels peak at ovulation, while estrogen levels simultaneously hit their low, which is why the other common time for women to experience cyclic breakouts is at the start of week three of their cycles.
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, and then also if a woman then enters into adrenal fatigue, which triggers a chronically inflamed state. Stress may also dysregulate DHEA-S production. For this reason, stress is not necessarily the cause of hormonal acne, but does exacerbate it, and prevent proper healing.
Heat. Heat is inflammatory, and also causes us to sweat, such that pores become clogged.
Inflammatory foods: grains, dairy, omega 6 vegetable oils.
Dairy: While being inflammatory, dairy is also the most androgenic of foods. Pregnant cows produce a protein that inhibits normal testosterone processing in the human body, such that testosterone can rise beyond normal levels with high dairy intake. This is true of women with pre-existing hormonal imbalances, yet it is also true of the general population. Many people at least anecdotally least respond to dairy with acne more strongly than any other food.
Phytoestrogens: soy, flax, legumes and nuts in high quantities. While phytoestrogens have the power to act as estrogens in the body, this role is ambivalent and should be treated with caution, especially with the skin. Different estrogen receptors read different kinds of phytoestrogens differently, such taht phytoestrogens usually perform estrogen-lowering effects in skin tissue.
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 hormonal production (and as such helps restore hormonal rhythm and balance).
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 way forward with hormonal acne is to get blood work done and work through the primary imbalances. In general, hormone dysregulation that leads to acne can be broken down into a few categories: 1) high testosterone from PCOS (specifically overweight and insulin resistant 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 as a result of an overactive pituitary and estrogen dominance, 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 posts on PCOS causes and treatment options, 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, 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 spironolactone, which is an added benefit for women who are living with androgen excess. 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 women as God’s gift to womankind. For many women it 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. 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 a few cases, it cures women. Yet in very many 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. As a final note, 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, and may not be able to consume alcohol anymore. 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–I swear to God–lead to sudden death. It’ll probably lead to muscle weakness first, but 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 bananas, potatoes, avocadoes, tomatoes, and leafy greens.
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 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. One point I did not even touch on above is that playing with hormones is like playing with fire. Sometimes things can go horribly wrong– on spironolactone and BCPs alike some women suffer weight loss or significant weight gain, increased acne, and significant–even frightening and life-threatening–mental health disturbances. For this reason, meds may be best left alone, depending on the circumstance and the level of risk a woman is willing to bear. On the other hand, there is in all cases a natural, food-based solution. What it takes is time, experimentation, good blood work, and patience. As in all things.
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.