Acne and Hormones

by Geoffrey Redmond, MD

Acne is Extremely Common
Almost everyone has at least a little of it at one point or another in their life. Though acne is supposed to go away after the teens, it can persist for many years. A few whiteheads or blackheads or an occasional small red pimple can usually be tolerated. However persistent or severe acne is much more troubling.

If someone has acne which is enough to bother her, it is best not to just wait to “grow out of it.” One her first visit, one of my patients said to me recently, “I’m 63 and I’ve been waiting for my acne to go away since I was 18. Though acne, fortunately, rarely lasts this long, it is still common in the thirties and forties. If you are bothered by acne, it is reasonable to seek medical help for it.

Acne is one of those conditions about which insensitive jokes are still made. Yet research has shown that acne lowers self-esteem and is extremely stressful. One study has shown that unemployment rates are higher in both women and men with acne, showing that people with acne are discriminated against. Though our society has been learning not to discriminate against  people who are physically challenged, no one speaks up for the miseries of acne.

Acne and Polycystic Ovary Syndrome (PCOS)
PCOS is a very common female hormonal disorder, one in which great advances in treatment have been made. [PCOSupport: The Polycystic Ovarian Syndrome Association Web Site] One of the four main features of PCOS is testosterone-induced skin and hair changes. These are acne, increased facial and body hair and scalp hair thinning. Other features are irregular periods, difficulty controlling weight and metabolic changes. Female acne can be a sign of PCOS. If you have some of the other features, getting worked up for PCOS is a good idea. On the other hand, many women with hormonal acne have just acne, nothing else.

Acne, the Teenage Years and Beyond
Studies show that the earlier acne appears the more likely it is to be severe, so the popular idea that acne is only a teenage problem is erroneous. Teenagers are often more bothered by acne than they let on. I work a lot with adolescents and find that though they may not admit to their parents that their acne is distressing, it is a great relief to them when treatment clears their skin.

When acne is more severe it should be regarded as a pressing medical problem, because permanent scarring may result. A few acne scars may not show, but an accumulation of scars over time can cause considerable damage to the complexion. If acne is enough to cause distress, it is best to get it treated promptly to minimize scarring.

Hormonal Testing for Acne
For more than very mild acne, hormonal testing is useful. This is the same as carried out for extra hair growth or alopecia, and consists in measuring androgens to see if elevated levels are involved in causing the acne. However, even if androgen levels are normal, they are still involved in starting the acne process. Some, but not most, women with acne, have a hormonal disorder. Evaluation by a physician experienced with these conditions is a good idea for severe acne that is not controlled by dermatological medications, or when there are also irregular periods, increased hair, or a weight problem.
Treating the Hormonal Cause of Acne
If have acne and are reading this article, it is likely that the standard measures have not cleared your skin. Fortunately, treatments directed at the hormonal cause usually work when standard ones have not.

Here’s why:
Hormonal treatments block the stimulating effect of androgens on the oil glands. Because this form of treatment stops acne before it begins, it often gives the best result. Only a few specialists are familiar with hormonal treatment and it requires blood tests, and oral medication. However, these may be well worth it if your acne cannot be controlled by standard measures. Even quite severe cystic acne which has resisted treatment for years often clears completely with properly planned hormonal treatment.

I’ll return to hormonal acne treatment shortly but want to review the standard measures first.

Skin Care for Acne
Good skin care is particularly important for women with acne. However, good hygiene, though it will help to control acne, is unlikely to take it away. For that, medication is needed as will be discussed later.
Despite what your mother and your friends may tell you, diet is not an important factor in acne. Chocolate and high fat foods do not cause acne, and eating less of these foods — though it may be good for health overall — will not solve an acne problem. Nor is acne due to poor hygiene. Basically, if you have acne it is not anything you are doing.

Anyone with a tendency to acne should only apply non-comedogenic preparations to their skin. “Comedone” is the medical term for whiteheads and blackheads so “non-comedogenic” simply means not causing breakouts. Non-comedogenic products will not feel greasy if rubbed between the fingers.

A soap-free skin cleanser, such as Purpose®, or a soap that is only slightly drying such as Clinique® for dry skin, is best. Soaps with perfume or high moisturizer content may cause problems. Astringents contain alcohol which dries the skin. Although use of an astringent may make the skin feel less oily immediately after use, it will not stop the increased oil production involved in acne and may irritate the skin. Abrasive preparations also are best avoided.

Some women with acne notice that it gets better after sun exposure. This is not a good way to control acne for two reasons. Firstly, long term sun exposure greatly increases the risk of skin cancer (including melanoma). Secondly, though the skin dries up initially after sun exposure there may be a rebound later, when oiliness actually increases. Sunbathing may therefore exacerbate acne in the long run. Use of a non-comedogenic sun screen lotion that has a Sun Protection Factor (SPF) of at least 15 is recommended. If you are in the water, it will need to be reapplied frequently, whatever it says on the package.

Another important aspect of skin care for people with acne is the use of moisturizers. Dry skin is particularly common in people who live in a northern climate. While women with acne usually have oily skin, when acne is treated, the skin often gets dryer. Some women have oiliness in some facial areas and dryness in others. Many will benefit from the use of a moisturizer, but of course it should be non-comedogenic. There are hundreds of moisturizers on the market, many of which are not really effective. Two good ones are Vaseline Intensive Care Extra Strength (not made from Vaseline which should not be put on the skin), and Mi Fine Skin. The latter was developed by a Cleveland dermatologist, Beno Michel, MD and is the best in my experience. It can be ordered by telephone (1-800-SKIN-066 or on-line I have no commercial interest in this product but my wife and I use it and have ceased to have dry skin problems.

While acne is not caused by poor hygiene, a good routine can help it. For mild acne, regular use of a skin cleanser at least twice a day, and a daily application of over the counter preparation with benzoyl peroxide, will produce some improvement. But if a regular skin care routine does not help enough, a visit to a physician experienced with acne is the next step.
Non-Prescription Acne Treatments
If acne is mild, there are simple, home treatments for acne that don’t require a prescription.
The best over-the-counter (OTC) acne medicine is benzoyl peroxide (BP). It is sold under several brand names, of which the best known are Oxy 5 and Oxy 10. These have 5% and 10% benzoyl peroxide respectively. BP is an antibacterial, and seems to dry the oiliness of the skin also Like other topicals, BP does need to be applied daily. If redness or irritation of the skin develops, BP often still works if it is put on for 30 to 45 minutes and then washed off. This works better than skipping days.

There are many other OTC acne remedies, not all of which are effective. Some contain ingredients that can irritate the skin or even make things worse. I suggest using a product which contains benzoyl peroxide without a lot of additional ingredients.

Standard Prescription Acne Treatments
Here are the most common medical treatments which most with acne have probably tried already:
Topicals such as tretinoin (Retin-A) and adapalene (Differin) which make the surface protein of the skin less sticky. Topical antibiotics such as erythromycin and clindamycin sold under a variety of brand names.
Oral antibiotics such as tetracycline, minocycline, and erythromycin. Of the oral antibiotics, I think erythromycin is most suitable for women as it does not cause the photosensitivity or yeast infections sometimes induced by tetracycline or minocycline.

Two oral contraceptives (OCs ) have been approved at this time (11/01) for treatment of acne in women who want to be on the pill. These are OrthoTriCyclen® and Estrostep®. (I was involved in the research for both and have lectured and consulted for both companies.) The number of pimples are reduced by about 50%, on average. This is a significant improvement.

However, the pill does not give adequate clearing for all women with acne. For a woman whose skin is still broken out despite use of one of these OCs, or who does not want to take an OC, there are other ways to prevent hormones from triggering it. OCs can be combined with the other acne treatments described above or with other hormonal treatments as described below.

Hormonal Treatment of Acne
Many women with marked acne do not get enough clearing with these standard acne treatments. In this situation, treatment directed at the hormonal cause may produce much clearer skin. These approaches are not often used by dermatologists, who treat most acne. If you have persistent acne and want to consider this form of treatment, you may need to see a physician with special expertise in female hormone problems who might be a endocrinologist or a gynecologist. Be sure to check first because not all doctors who deal with female hormones work with acne.
At the Hormone Center of New York, when I see a woman who has had acne which won’t go away, the first step is to measure hormone levels in order to determine the specific hormonal factors which are causing her acne. Treatment varies depending on the individual but usually involves lowering free testosterone and protecting the oil glands from this hormone. Counteracting the hormonal cause of acne often clears up the skin when the conventional measures have failed.

Oral contraceptives can be part of the treatment because they lower free testosterone. The addition of medications which block testosterone can dramatically clear the skin. Spironolactone (Aldactone®) is usually quite effective. Though often used with an OC, spironolactone can also be used by itself. Spironolactone was originally developed as a blood pressure medication. It blocks aldosterone, a blood pressure-raising hormone. Because testosterone is chemically similar to this hormone, it is also blocked by spironolactone.

Finasteride, sometimes useful for other testosterone problems in women, probably will not help acne and there is serious worry about its safety in pregnancy. This is discussed in detail in the section on treatment of unwanted hair. [Hormones and Unwanted Hair] Although birth defects have not been reported with use of spironolactone to my knowledge, they are theoretically possible since it blocks testosterone, so it is important not to get pregnant while taking this medication also.

A new OC, Yasmin® contains drospirenone, a close cousin of spironolactone, as its form of progesterone. It is not labeled for acne in the United States at this time and is equivalent to a rather low dose of spironolactone. Dose is definitely important with spironolactone; low doses are less effective.
Any acne treatment takes at least a few weeks to work. Once a breakout has occurred, healing is gradual. The best thing is to prevent the breakouts from happening in the first place. This is why acne treatments should be used all the time, not just when lesions appear.

The last resort is isotretinoin (Accutane®), a potent form of vitamin A. This drug has made a great difference for some people with bad acne but it can have serious side effects and so must be used very carefully with close monitoring. Absolute avoidance of pregnancy is essentially since fetal isotretinoin exposure can produce serious birth defects. Fortunately, once it is out of the body, isotretinoin will not affect pregnancy outcome. While isotretinoin has a place, in my experience, hormonal treatment is much easier to tolerate and often gives a better result. This is because androgen blockers not only cut down on breakouts but often give a brighter, feminine appearance to complexions which have been damaged by acne.

Acne and Extra Hair
Increases in hair growth and female acne do, unfortunately, go together because the hormonal cause of the two conditions is the same. In both cases, androgens (testosterone and related hormones) act to trigger the condition.
The initial event in acne is increased oil production. The oil is produced in the sebaceous glands which are part of the same skin structure as the hair follicles. The two are part of the same skin structure, called the pilosebaceous unit. While the sebaceous gland responds to testosterone by making more oil, the hair root responds by growing hair that is longer, thicker and darker.

The sebaceous glands respond immediately to testosterone and so acne usually appears fairly soon after levels go up. The hair follicle however may take months or years to respond so increases in hair growth generally appear at a somewhat later age than acne. Not everyone follows this pattern however.
What Causes Acne?
Acne is an androgenic disorder, like hirsutism [Hormones and Unwanted Hair], which means that it is set off by the effects of the family of hormones called androgens. These include testosterone, DHEA-S and others. Testosterone is the most important of these. While androgens are often thought of as male hormones, this is misleading because adult women have active levels in their blood. Women’s levels are only about a tenth of those found in men

The first event leading to acne is stimulation of the sebaceous (oil making) glands by testosterone. Next, the pores plug up and trap the oil inside. Bacteria grow in the trapped oil, causing the production of irritating chemicals. Finally the body’s immune system comes into play. There is both good and bad news about this immune response. While it fights the bacteria, it also causes the redness, swelling, pus-like fluid and later scarring which make acne so unsightly.

Many women notice that their acne is worse in the week before their period. The exact reason for this common pattern is not known, but obviously it is related to hormonal changes during the cycle, perhaps a rise in testosterone at midcycle.

Other Oily Face Conditions
In addition to pimples, increased oil can cause flat areas of inflammation on the skin. In the midline this is called seborrheic dermatitis; in the butterfly area of the nose and the skin next to it, the inflammation is called acne rosacea. The latter can be very embarrassing because it sometimes makes the nose red, which can be confused with the signs of excessive alcohol use.

A Final Note
For me as an endocrinologist, acne is one of the most satisfying conditions to treat. It often gets much better with the hormonal treatments described above, everyone can see for themselves how great the change has been and the person’s life can be greatly changed for the better.

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