The underlying causes of acne
Acne vulgaris is a common yet complex inflammatory skin disease. It is multifactorial, and is characterised by hormonally driven sebum overproduction, follicular hyperkeratinisation and chronic inflammation. In adolescents, puberty and genetics play an integral role, with up to 85% of adolescents experiencing some form of acne and its associated symptoms. This may be because androgen, sebum and growth hormone levels peak during the adolescent period.
In adulthood, elevated androgen levels may increase sebum production, abnormal follicular keratinisation and desquamation, leading to the formation of follicular plugs and subsequent blockage.
What is an Androgen?
A male hormone that promotes male characteristics: free testosterone, total testosterone, and dehydroepiandrosteronsulfate (DHEA-S).
What is Androgen excess:
- High Androgens on a blood test, or
- Physical signs of androgen excess
- Best test: Free testosterone (blood)
- Other tests: total testosterone, androstenedione and DHEAS
- If Total testosterone is measured, then we need SHBG – which is a protein that binds to testosterone and oestrogen. SHBG is typically low with PCOS.
Androgen excess physical signs:
- Facial, body hair (long & dark) on chin, cheeks, belly, and around nipples is the most reliable sign of androgen excess. Not peach fuzz, or a few strands.
- Acne – especially hormonal acne on chin. This can be a sign of androgen excess in adults. (NB: This is not reliable indicator in teenagers). Acne can either aggravated or initiated by increased androgen levels
- Hair loss and thinning – androgenic alopecia
What causes Androgen excess?
- Hormonal birth control with ‘high androgen index’. These are birth control methods that have certain progestins, such as those containing desogestrel. They can cause hair loss (by shrinking follicles), acne, weight gain (as progestins interferes with insulin), high blood pressure, nutrient deficiencies and reduced thyroid function.
- Certain medications
- High prolactin
- Rare pituitary or adrenal diseases
- Insulin (hyperinsulinemia)
In healthy women 80% of testosterone is bound to SHBG. This prevents free testosterone from wrecking havoc in our bodies. The levels of SHBG increase and decrease based on cnditions and medications.
SHBG is increased by:
- Thyroid hormone
- Oestrogen-containing preparations
SHBG is decreased by:
- Synthetic progestins (norethindrone, norgestrel, desogestrel, norgestimate)
- Growth hormone
Although sebum androgens are viewed as the major trigger for acne, emerging evidence suggests insulin-like growth factor (IGF-1) also plays a kay role. Hyperinsulinemia (excess insulin) promotes hyperandrogenaemia (excess androgens) through binding of insulin to the insulin-like growth factor -1 (IGF-1) receptor. Insulin mimics the action of insulin growth factor 1 (IGF-1) which augments androgen production by the ovaries. Since insulin decreases levels of SHBG, the circulating levels of free testosterone are also increased.
IGF-1 levels increase during puberty, and increasing prevalence of acne is being linked to the western diet, and specifically high-glycaemic foods, which enhance IGF-1/insulin signalling and stimulate sebum production, keratinocyte proliferation and sebaceous gland hyperplasia.
Post pill acne
Steroid drugs in some form of hormonal birth control work well to clear acne. Synthetic oestrogen and the progestins drospirenone (different from androgen index birth control) suppress sebum (skin oil) to childhood levels. In response your skin upregulates sebum and the upregulation continue after the pill is stopped. So, this result is more sebum than ever before. At the same time coming off the pill can trigger the ovaries to temporarily make more androgens to kick back into action. Double whammy! This peak 6 months after then improves.
Oestrogen and progesterone are both good for the skin. Acne is almost never about oestrogen and progesterone. Acne is about underlying conditions such as insulin resistance and inflammation.
Removing diary, sugar and taking zinc.
- Sugar: this reduces insuin growth factor or IGF-1. IGF-1 is the perfect storm for acne because it increases sebum, keratin, and inflammation
- Avoid cows diary – reduces inflammation and IGF-1 hormone.
- Address digestive problems: such as IBS and SIBO as they generate inflammation and worsen acne.
- Address histamine intolerance: fermented foods and cheese – can worsen acne.
- Zinc: Reduces keratin and therefore keeping pores open. Zinc also kills bacteria, reduces inflammation and lowers androgens.
- Berberine: is a natural antibiotic, and kills bacteria that kills acne. Also reduces inflammation IGF-1 (not safe for long term use)
- DIM (diindolylmethane) – a phytonutrient derived from vegetables such as broccoli. This blocks androgen receptors. 100mg per day
How to reduce Androgens
- Peony and licorice (inhibit production and blocks receptors). Reduces serum testosterone.
- Vitex – lowers prolactin induced androgen excess (not typical in PCOS)
- Zinc (30g) – normalises hormones (will not push testosterone below normal)
- Magnesium for insulin sensitivity.
- Quit sugar
- Reduce carbs
- Micronized progesterone: inhibits 5-alpha reductase and blocks androgen receptors.
Hormones fluctuations during pregnancy and menstruation can also exacerbate.