Hormones, Diet, and Acne
Hormonal acne is a big topic. Truthfully, we could write an entire book just on the complex interplay of your endocrine and integument (AKA skin) systems. We frequently talk about the skin as being its own mini-endocrine system. Intrinsically, the body can create its own hormonal issues through conditions like PCOS, thyroid disease, and obesity leading to more severe acne. Extrinsically, hormone supplementation (testosterone and progesterone in particular), IUDs, certain diets, and medications can also contribute to hormonally driven acne.
‘Classic’ Hormonal Acne
The most commonly discussed hormonal acne is acne vulgaris in cis-gender female patients. The underlying driver of these breakouts is a higher amount of pro-inflammatory androgens including testosterone, androstenedione, DHEA, among others. Additionally, insulin and insulin-like growth factor have been found to be important players in hormonal and diet driven acne (we will come back to this when we talk about diet).
Polycystic ovarian syndrome (PCOS) is the most common disease in which androgens and insulin resistance combine to produce the inflammatory lesions of hormonal acne. However, it is important to know that hormonal acne can present in those without PCOS as well. Other indications of PCOS and hormonal acne can include androgenic alopecia (AKA female or male pattern hair loss), hirsutism (unwanted hair growth on the chin, cheeks, or other body surface areas), and acnathosis nigricans (a thickening and darkening of skin on the back, armpits, and neck).
What does hormonal acne look like? It looks very similar to other acne lesions with red bumps or papules, sometimes deeper and more painful under the skin - jawline area is commonly affected. Most commonly, female patients may report worsening of their acne around the time of their menstrual cycle as another clue to diagnosis. And remember, many women without other underlying health issues may also have hormonal acne.
The Role of Diet, Exercise, and Wellness in Acne
Diet and exercise interplay directly with our endocrine system. Specifically, insulin and insulin-like growth factor (IGF) play a central role. Foods with a high glycemic index (think processed grains and processed sugars), dairy, and whey protein all seem to have a role in increasing amounts of IGF in they body. IGF appears to have a pro-inflammatory impact on the skin and may contribute to inflammatory acne lesions. For dairy, stick to dairy products with fat (whole milk and creams) and avoid skim - skim products were found to be more responsible for acne. More broadly, it is important to note that diet can affect multiple inflammatory skin diseases including eczema, psoriasis, and hidradenitis suppurativa. Thus, diet is a critical factor to a patient’s success.
Now, it is also importatnt to emphasize that I do not endorse restrictive diets or unsustainable changes to your diet. It is important to live your life and find a balance that works for you! We all enjoy the occasional sweet treat or cheese, and you can still do this and achieve results that will make you happy.
Exercise is also beneficial to a treatment plan as it 1) increases insulin sensitivity 2) can contribute to reductions in stress. Stress is a constant (for all of us) but finding stress-reducing activities can help to lower cortisol (our stress hormone) which improves insulin sensitivity and may further drive down insulin levels.
Hormone Supplements and Skin: Testosterone Replacement Therapy (TRT), Testosterone Supplementation Therapy (TST), and Progesterone Implantable Uterine Devices (IUDs)
Certain hormonal supplements can also be triggering. Hormone supplementation and exposure is common for cisgender and transgender patients. For all patients taking testosterone either as a replacement or supplement, acne is common and expected. Testosterone contributes to increased sebum production and inflammation - the building blocks of acne. Similarly, progesterone has also been shown to increase sebum production and contribute to acne - we see this most frequently in the setting of progesterone IUDs.
Thankfully, hormonal acne is responsive to treatments. A topical regimen including prescription retinoids and topical antibiotics can help decrease the severity of the lesions. In my experience, patients frequently will need oral prescriptions treatment to get to their desired outcome.
Spironolactone can be a fantastic and safe option for female patients, including those utilizing an IUD. For those on testosterone, oral antibiotics and isotretinoin (AKA accutane) can be therapeutic avenues. Ultimately, the best treatment is one designed to you and your unique needs. If you are suffering from hormonal acne, please come see a dermatologist! If you are in North Dakota, and struggling with hormonal acne or acne after testosterone supplementation, you can schedule here.
