Hormonal Acne
Intro
Hormonal acne (and other chronic skin issues) is one of the most common reasons why people choose to see me for naturopathic medical care. As a licensed naturopathic doctor (ND), I seek to identify & treat the root cause of a person’s symptoms by carefully listening to their health story and thoughtfully ordering & reviewing lab work. In this blog post, you will learn:
What hormonal acne is
Some of potential causes of hormonal acne
Conditions that look like hormonal acne
Labs that can identify root causes of hormonal acne for more-targeted management of hormonal acne
Some integrative & naturopathic options for managing hormonal acne
Some over-the-counter skincare ingredients that address factors that contribute to acne
1) What is hormonal acne?
Hormonal acne (aka acne vulgaris) is a common skin condition that affects around 80% of people aged 11-30 years old, with symptoms usually resolving before their 30s. There are various root causes of acne and there are many skin conditions that can look like acne. But, the pattern and appearance of their skin symptoms helps doctors understand what skin condition someone is experiencing.
Pattern & appearance of hormonal acne
For hormonal acne, we see a connection between menstrual cycles and acne in addition to the location of their acne. Hormonal acne tends to worsen 1 week before menstruation and reduces severity during or immediately after bleeding. Hormonal acne usually appears along the jawline, and can appear as:
Non-inflammatory: Open comedones (blackheads) and closed comedones (white heads)
Inflammatory: Papules, pustules, nodules, or cysts
How acne vulgaris develops
Acne vulgaris develops because of hormones, sebum (aka oil) production, bacteria in pores, and pore plugging. What we see in acne vulgaris is that androgens (such as testosterone) play a significant role in the development of acne. We also know that other hormones can contribute to acne by increasing androgenic activity or directly stimulating oil glands in pores (read below). Androgens have been shown to cause over-production of sebum, and bacteria (specifically Proprionibacterium acnes) feed on sebum, which then stimulates inflammatory and immunological reactions. Stimulation of these reactions causes the area around the pore to rise and become red, lead to papules. And, if there is a larger inflammatory and immunological response, people can experience pustules, nodules, or cysts.
Pore plugging happens because of hyperkeratinization, which is when skin cells are over-produced in the pore. When this takes takes place, it causes a plug in the pore that leads to the production of comedones.
2) What causes hormonal acne?
Androgens: Testosterone, DHT, and other weaker androgens (DHEA, androstenedione, etc.) have been shown to play a large role in activating oil production in pores that lead to the development of acne.
Progesterone: Progesterone inhibits the production of DHT, and it could be suggested that sub-optimally low levels of progesterone may play a role in the development of acne.
Insulin & blood sugar dysregulation: Blood sugar dysregualtion leads to higher levels of insulin in the system. And, insulin has been shown to increase growth hormone, which then increases levels of androgens.
Stress: When physical or emotional stress is recognized by the brain, the hypothalamus sends out corticotropin-releasing hormone, which then stimulates the production of cortisol from the adrenal glands through a cascade of biochemical reactions in addition to stimulating the conversion of DHEA to testosterone.
Medications: Steroids have been shown to play a role in the development of acne by increasing the skin’s pro-inflammatory response.
& more
3) Conditions that look like hormonal acne
There are skin conditions that can look like hormonal acne, but will have different patterns & appearance. Some conditions that can look like hormonal acne are:
Bacterial folliculitis: Abrupt onset of acne-like lesions and spreads because of scratching or shaving
Perioral dermatitis: Usually found around the mouth, on the chin, and around the nose
Pseudofolliculitis barbae: Lesions that look like acne and are usually found on areas that are often shaved
Rosacea: Usually appears as redness with broken capillaries, but will not have comedones
Seborrheic dermatitis: Greasy yellow in appearance
& more
4) Lab work: identifying root causes
To identify the root cause and rule out conditions that can look like acne vulgaris, labs should be completed. Additionally, identifying the root cause will help with more-targeted treatment of acne from a naturopathic medical perspective.
Some conventional labs that can be ordered are:
Testosterone (free and total)
Androstenedione
DHEA
SHBG
Prolactin
17-Hydroxy progesterone
Luteinizing hormone (LH)
Fasting and postprandial insulin
Serum cortisol
Functional lab work that I sometimes recommend to patients can include:
Dried urinary test for comprehensive hormones (DUTCH): Helps me understand sex hormone levels and imbalances and potential causes of hormone imbalance by giving levels of detoxification hormone metabolites and hormone precursors. This functional lab ultimately helps me better-understand root causes of hormonal acne.
Comprehensive stool analysis: Helps me understand if microbiome imbalance and post-biotics are playing a role in sex hormone imbalance.
5) Integrative management
As mentioned earlier, naturopathic medical treatment is about identifying and treating the root cause of symptoms. Licensed ND’s are trained in integrative medicine, meaning we are trained in conventional/pharmaceutical care AND natural care. Since licensed ND’s are trained in various treatment options, licensed ND’s are able to personalize treatment plans given their patient’s symptoms picture, treatment preferences, and treatment goals.
pharmaceutical Management
Licensed ND’s may recommend pharmaceutical management for acne when symptoms are severe, if the patient prefers pharmaceutical therapy, and/or if the patient prefers faster results. Also, when licensed ND’s do prescribe pharmaceuticals, they may prescribe concurrent vitamins, minerals, and other supplements to take to prevent drug-nutrient depletions and to optimize overall health and wellbeing. It should be noted that state scope of practice differs from state to state, and that licensed ND’s may not have prescriptive rights in some states that would allow them to prescribe pharmaceuticals.
Some pharmaceuticals that may be prescribed for acne vulgaris are:
Topical pharmaceuticals: First-line treatment for mild acne vulgaris includes topical benzoyl peroxide or a topical retinoid, such as Adapelene. These may also be combined with topical antibiotics.
Oral antibiotics: For moderate to severe acne and inflammatory acne, oral/systemic antibiotics (doxycycline and minocycline) may be recommended - usually done in combination with other antibiotics to prevent drug resistance.
Hormonal birth control: Combined oral contraceptives are recommended for females with inflammatory acne.
Isotretinoin: For severe nodular acne when topical pharmaceuticals and oral antibiotics have failed.
Spironolactone: Spironolactone reduces the production of DHT.
& more
Natural Management
Licensed ND’s may recommend natural management for acne vulgaris when severity of acne is mild-to-moderate and/or if the patient prefers natural therapy. Natural therapy is more likely to address the root cause of a patient’s symptoms when compared to pharmaceutical therapy since natural treatments with a naturopathic doctor involve supporting the foundations of health and wellness (diet and lifestyle medicine) and supporting organ function. It should be noted that natural therapy can take longer than pharmaceutical therapy, but since natural management does better-address the root cause, natural management tends to be longer-lasting compared to pharmaceutical therapy once treatment is withdrawn.
Some root-cause, natural management options for acne vulgaris are:
Insulin resistance/blood sugar dysregulation: Consumption of low-glycemic foods with protein have shown to cause lower levels of insulin, specifically those in females with polycystic ovarian syndrome (PCOS), which has been shown to have roots in insulin resistance. In addition to this, the combination of consumption of low glycemic foods and exercise can increase insulin sensitivity. Beyond these foundational aspects, there are some minerals and herbs that a licensed naturopathic doctor may recommend to support insulin sensitivity, such as inositol, berberine, cinnamon, and chromium.
Low progesterone: After labs reveal sub-optimally low levels of progesterone, a licensed naturopathic provider may foundational recommendations, such as dietary recommendations to support nutrient status as undernourishment has been shown to lead to low progesterone, and lifestyle medicine that includes optimizing exercise activity as it has been shown that those with high levels of physical stress, such as athletes, have lower levels of progesterone. Beyond that, there are some herbs that a licensed ND may recommend to optimize progesterone levels, such as chaste tree berry, black cohosh. Vitamin C has also been shown to help support luteal phase progesterone levels in females. To learn more about low progesterone, click here to read my blog about it.
Stress/Hypothalamic-pituitary-adrenal (HPA) axis dysfunction: Preventing hypoglycemia will be one of the easiest and most-foundational strategies your licensed ND may recommend to support optimal HPA axis activity. A licensed ND may also recommend nervine herbs to soothe the nervous system and adaptogenic herbs to help the body adapt to to emotional and physical stressors, such as ashwagandha, asian ginseng, rhodiola, and schisandra.
Gut microbiome: Literature suggests that the gut microbiome could play a role in higher levels of androgens. Beta-glucuronidase is an enzyme that is made by the bacteria in the gut, and this enzyme has the potential to reactive testosterone metabolites, which could be reabsorbed into the system. It has been that some strains of bacteria found in the intestines have the ability to produce testosterone. There are various options that can be recommended by a licensed ND that will help balance out gut microbiome imbalance (aka dysbiosis).
Hyperkeratinization & sebum production: Targeted Vitamin A oral supplementation may be recommended by a licensed ND to address skin hyperkeratinization and oil production found in acne vulgaris. Vitamin A has been shown to balance skin cell division to prevent hyperkeratinization, limit sebum production, and limit the development of P. acnes. This treatment may be recommended if all other root-cause natural treatments have failed to produce results.
& more
6) skin care Ingredients for Acne
The most-accessible way people first address acne vulgaris is by going to the drugstore or to a beauty store for skincare products. But, I do recommend that people first speak to their trusted skin providers to see what is actually worth their while before buying or trying anything new. The reason why is that some skincare products may be ineffective or may worsen acne. There are some skincare ingredients that have the potential to address some of the factors that play a role in the development of acne (read: they do not address the root cause).
5 skincare ingredients that address factors that Play a role in Acne:
Glycolic acid: Glycolic acid is an alpha-hydroxy acid (AHA) derived from sugarcane that has been shown to inhibit P. acnes and have anti-bacterial activity against P. acnes in a pH dependent manner where pH of 3-4.5 being effective.
Salicylic acid: Salicyclic acid is a beta-hydroxy acid (BHA) that has been shown to have exfoliative properties that address hyperkeratinization found in acne vulgaris.
Azelaic acid: Topical azelaic acid addresses hyperkeratinzation and inhibits P. acnes in non-inflammatory and inflammatory acne.
Niacinamide: Niacinamide has been shown to reduce sebum production in addition to inhibiting inflammation due to P. acnes. Additionally, a 4% preparation of Nicotinamide (another form of niacinamide) has been shown to be as effective as topical Clindamycin 1% in the treatment of acne vulgaris.
Retinoids: There are various over-the-counter topical retinoids, such as retinyl esters, retinol, and retinaldehydes, and are commonly used for acne since they have been shown to address hyperkeratinization in acne.
TAKEAWAYS & SUMMARY
Hormonal acne can be thought of as being primarily rooted in androgen activity. And, there are various root causes of increased androgen activity, as explained in this blog post. From a naturopathic medical perspective, treating hormonal acne means identifying the root cause with the use of lab work & treating the root cause with integrative therapies that may include pharmaceutical and/or natural options. There are pros and cons to various treatment options, such as length of treatment, duration of acne management, and more - and all of these can be explained throughly by a licensed naturopathic doctor. There are also skincare ingredients that are important to take note of when treating acne, and can address factors that lead to the development of acne, such as excess oil production, hyperkeratinization, and more.
I hope you found this blog post helpful, especially if you are on the journey of healing hormonal acne from within. If you found this blog post helpful and informative, make sure to share this with your wellness community! And for the month of May here on my blog, I will be focusing on more skin topics, such as skin barrier disruption, melasma, and more!
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