The Mechanisms and Pathogenesis of Hormonal Acne (Acne Excoriée)

Hormonal acne (sometimes known as acne excoriée or “picker’s acne”) is a specific breed of acne that almost exclusively effects people born biologically female. It is characterized by tender bumps that are often large and can occur deep in the skin. These bumps often appear to be “headless” and are commonly labeled as cystic acne lesions.

mụn-trứng-cá-nội-tiếtHormonal acne almost exclusively appears on the jaw line, chin, and lower cheeks unlike common acne, which tends toward the T-zones of the face (forehead, nose, and upper cheeks). It’s difficult to cover with cosmetics and is almost always a point of embarrassment, shame, and pain for those who suffer from it.

It affects roughly 25% of the biologically female population and is actually increasing in prevalence.

It is often unaffected by topical products that are marketed to help acne sufferers due to the cause being the fluctuation of female hormones. Fortunately, there are treatments that can help, so let’s talk a bit about what actually causes hormonal acne, some things to try before seeing your doctor, and what you can expect when seeing a doctor for hormonal acne.


Recognizing the Cyclical Nature of Hormonal Acne

Before I get into the meat of this post, I first want to talk a bit about the cyclical / re-occurring nature of hormonal acne.

Acne is often a chronic disease, with hormonal acne affecting nearly one in every four women throughout their lifetime. This prolonged course of outbreak, healing, and relapse is not only frustrating, it is also psychologically and socially damaging to the sufferer. These effects are often swept aside or neglected all-together, leaving sufferers to feel ostracized and silenced. Of course, this pattern just re-inforces itself: sufferers feel dismissed, neglected, or lied to, which leads to feeling like it should not be discussed at all, which leads to feeling isolated and ashamed, which leads to feeling dismissed, neglected, or lied to… and so on, until you find yourself avoiding outings with friends, dates, or mirrors.

Worse, hormonal acne is physically painful, which creates a constant reminder of the lesions that you feel are ruining your very life. Anxiety, depression, and social withdrawal are not uncommon and have all been reported in individuals with acne and acne scarring. Physical scars and persistent hyperpigmentation are not uncommon and often expensive or difficult to treat, which can mean that even after the acne is gone, the memory is still there.

If you have found yourself suffering from acne, regardless of whether it is hormonal acne or not, it is important to remember that you are not alone and that the right doctor can change your life. Please do not feel ashamed of your skin to such an extent that you are reluctant to see a medical professional.

And if you are feeling anxious, depressed, withdrawn, or suicidal, I urge you to speak to a therapist. Some insurers, while not accepted in office, will refund you a percentage of the amount of mental health visits after a deductible is met (for example, my last insurer would cover up to 70% of each visit if I mailed them a claims form and the receipt for my therapy visit). Therapists are there to listen – without judgment – to whatever you are going through, and merely provide guidance on how to overcome the painful feelings within.


The Formation of Hormonal Acne

As anyone with hormonal acne knows, it is a disease that is cyclical in nature, meaning it comes and goes. To understand why this is, I’ll be talking very briefly about the menstrual cycle.

Understanding the Menstrual Cycle

The length of the average menstrual cycle is about 30 days and consists of four different stages:

  1. Menstruation: The first day of the menstrual phase is the first day of your period. You may feel low energy, and your skin may begin to clear up as your period begins or starts to end.
  2. Follicular: The last day of your period is when the body begins to prepare for ovulation, the next stage of your menstrual cycle. Your estrogen spikes, your skin begins to clear, and you may have more energy.
  3. Ovulation: The egg is released into the Fallopian tube and travels into the uterus. You’re still riding high on estrogen during this time. You may feel very motivated and full of energy, and your skin might “look it’s best.”
  4. Luteal: The egg moves down the Fallopian tube towards the womb. Your body begins to produce progesterone to build the lining of the uterus. If the egg is not fertilized, estrogen and progesterone begin to drop and your body begins to break down the uterine lining. Your skin will start to break out, you may feel easily irritable, feel the most anxious or sad, and your breasts may swell.
acne

The hormones of the menstrual cycle, visualized

This temporary imbalance of hormones is what is often at the root cause of hormonal acne. More annoyingly, as a biological woman ages, her estrogen levels drop while androgens remains the same, making hormonal acne more likely. Of course there can be other drivers at play, the most common being polycystic ovarian syndrome or PCOS – a hormonal disorder among women of reproductive age.

Hirsutism.jpg

Hirsutism

Before you panic, PCOS has many symptoms other than hormonal acne. It is frequently accompanied by hyperandrogenism (excessive androgen hormones); excessive hair growth (hirsutism) around the face, chest, and neck; irregular periods; oily skin; infertility; obesity; and hair loss on the crown of the head that spreads outwards.

 

There are other diseases that can result in hormonal acne, such as growths on the adrenal or pituitary gland, but these are all extremely rare. Please see a doctor if you have any of the other signs of hyperandrogenism mentioned above.

The Role of Androgens in Hormonal Acne

While the pathogenesis of acne is constantly evolving, it is widely accepted that the key factors that play a role in the development of acne are follicular hyperkeratinization, microbial colonization with p. acnes, sebum production, and inflammation. I talked a bit about this in my post on retinoids.

To quote directly from the-dermatologist.com, which has a wonderful explanation the role of hormones in acne:

• Sebum is largely under hormonal control, and we know that androgen stimulates sebum production and proliferation by binding to the androgen receptor. In addition, 5-alpha reductase type I enzyme activity is present at the sebum site. This activity converts less potent androgens, such as testosterone and also androsterone, into dihydrotestosterone (DHT). This more potent hormone has a greater effect on sebum production. We also know that sebum levels remain relatively constant far into the adult years, so why does acne seem to spontaneously resolve in many people? In addition, why is it that some people who have oily skin don’t develop acne? This reiterates the idea that acne is multi-factorial.

We also know estrogens have an inhibitory influence — they increase the sex hormone binding globulin, which is what “soaks up” testosterone. Estrogens also feed back into the hypothalamus and pituitary glands. This decreases the release of gonadotropin-releasing hormone, and subsequently, gonadotropins. So, less androgen is secreted from the ovaries and adrenal glands.

Total testosterone is not the important value — free testosterone is more important. In general, the higher your sex hormone binding globulin, the lower the amount of free testosterone. The levels of free testosterone in males is 9 to 30 nanograms per deciliter, and in females it’s 0.3 to 1.9 nanograms per deciliter. So, again, if sebum was the only factor contributing to acne development and testosterone was the cause of this excess sebum, then all men, and no women, would have acne. Obviously, this isn’t the case.

In individuals with hormonal acne, the sebaceous glands seem to be particularly sensitive to DHT. Why these DHT-sensitive sebaceous glands tend to be concentrated in the jaw is not very well understood. However, it is well known that increased sebum excretion and alteration of lipid composition are all events associated with the development of acne.

Of course, as mentioned, acne is multi-factorial.

Insulin-like Growth Factor (IGFs) in Hormonal Acne

Another thing to consider is insulin-like growth factor, a hormone triggered by high glycemic loads, which can cause increased sebum production in some people.

Unfortunately, all of the studies performed on low glycemic load (LGL) diets have been small and relatively inconclusive. In the article “Dietary Regimes for Treatment of Agne Vulgaris: A Critical Review of Published Clinical Trials,” the authors note:

We found only 6 studies which performed an actual clinical intervention; all concerning HGL and/or chocolate, and only 3 of these gave significant results … Two of the studies showed a decrease in lesion counts with an LGL diet. Fulton’s trial from 1969 was the first clinical trial regarding dietary habits and acne (Effect of chocolate on acne vulgaris, Fulton, 1969). This study has later been criticized (Chocolate and acne: how valid was the original study, Goh W.). … This is an area that requires further research; in particular studies with larger sample sizes are required.

In short, your mileage may vary.

Dairy and Hormonal Acne

Dairy has gained a bit of a bad name in recent years. Fortunately for dairy-lovers everywhere, the data suggests that skim milk is the only dairy worth watching out for.

According to the American Academy of Dermatology (Guidelines of Care for the Management of Acne Vulgaris, 2016), a 2005 study of 47,355 adult women were asked to recall their diets as well as whether they had been diagnosed with acne. The strongest positive association with acne was with skim milk. “Specifically, women who consumed >2 glasses of skim milk a day had a 44% increased risk of reporting acne,” the researchers noted. Two follow-up studies were conducted, one on boys and one on girls, which again associated the intake of skim milk.

In another study involving 88 Malaysian subjects 18 – 30 years old, the frequency of milk and ice cream consumption was “significantly higher in patients with acne compared to controls. … No association was found with cheese or yogurt.” (Source)

This was replicated once more in 2012, when a study involving 563 Italian subjects, 10-24 years old, found “that the risk of acne was also increased with milk consumption. The association was more pronounced with skim milk, and again, no association was seen with cheese or yogurt.” (Source)

Treatment of Hormonal Acne

Some of the treatments for hormonal acne mimic those of traditional acne, such as retinoids. However, there are some distinct differences that are unique to hormonal acne, namely in the treatment of hormones (or rather, the blocking of androgens with anti-androgens).

Retinoids and Antibiotics

Retinoids are usually one of the first lines of treatment, usually in combination with other medications. You can read all about retinoids and combination treatments in two of my posts, which go further in detail about the how and why for these treatments:

Birth Control (Combination Oral Contraceptives)

Combination oral contraceptives (COCs) were first approved by the FDA in 1960. “They work by preventing ovulation and pregnancy by inhibiting gonadotropin-releasing hormone, and subsequently, follicle-stimulating and luteinizing hormones.” (Source) In the absence of these hormones, ovulation does not occur. To quote the American Academy of Dermatology once again:

There are currently 4 COCs approved by the FDA for the treatment of acne. They are ethinyl estradiol / norgestimate, ethinyl estradiol / norethindrone acetate / ferrous fumarate, ethinyl estradiol / drospirenone, and ethinyl estradiol / drospirenone / levomefolate. The mechanism of action of COCs in the treatment of acne is based on their antiandrogenic properties. These pills decrease androgen production at the level of the ovary and also increase sex hormone binding globulin, binding free circulating testosterone and rendering it unavailable to bind and activate the androgen receptor.

A 2012 Cochrane metaanalysis assessed the effect of birth control pills on acne in women and included 31 trials with a total of 12,579 women. Nine trials compared a COC to placebo, and all of these COCs worked well to reduce acne. The progestins included in these 9 trials were levonorgestrel, norethindrone acetate, norgestimate,
drospirenone, dienogest, and chlormadinone acetate. Seventeen trials compared 2 COCs, but no consistent differences in acne reduction were appreciated based on formulation or dosage of the COC. Only 1 small study compared a COC to an oral antibiotic; no significant difference in self-assessed acne improvement was identified.

The risks of birth control should be weighed against the risk of the condition being prevented. For example, a meta-analysis evaluated 25 publications reporting on 26 studies that focused on oral contraceptives and venous thromboembolic events (VTEs, such as venous thrombosis). The analysis conclused that all COCs increase the risk of VTE compared to placebo. To put the risk into perspective, the baseline risk in non-pregnant, non-users of COC is 1-5 per 10,000. Users have a risk of 3-9 per 10,000. Pregnant women are at an increased risk, with 5-20 per 10,000, with postpartum women at a risk of 40 and 65 per 10,000.

Spironolactone

Perhaps the most effective and common treatment for hormonal acne is spironolactone, a potent antiandrogen medication that decreases testosterone and inhibits testosterone and dihydrotestosterone (DHT) in skin. It has not been approved by the FDA for treatment of acne. There are multiple studies backing it’s effectiveness however.

Two small, placebo-controlled prospective studies showed statistically significant improvement in acne severity and sebum production at doses ranging from 50 to 
200 mg daily. A retrospective chart review of 85 patients treated with spironolactone 50 to 100 mg daily, either as monotherapy or as adjunctive therapy, revealed that 66% of women were clear or markedly improved with favorable tolerability at 
these lower doses. (Source)

Spironolactone is well-tolerated, with the most common side effect being diuresis (frequent urination). Those taking spironolactone may be advised to avoid high-potassium foods, such as low-sodium processed foods and coconut water. Some doctors may order potassium testing for those taking spironolactone.

Isotretinoin (Accutane)

The last resort drug, oral isotretinoin has been used in the United States for the treatment of acne for over 30 years. It is prescribed in cases of treatment-resistant acne or acne that produces severe distress to the patient.

The side effects are well-known to most acne-sufferers as well as prescribers. The most prevalent side effect is extreme dryness, particularly of the mucous membranes and lips. Other side effects that have been noted include inflammatory bowel disease (IBD), depression/anxiety/mood changes, cardiovascular risks, bone mineralization, concerns of scarring, and S aureus colonization.

The AAD on IBD:

While 2 studies have shown a potential relationship, more recent analyses suggest no association between IBD and isotretinoin ingestion. The most convincing article suggesting an association between isotretinoin and UC was directly refuted by a later analysis of the same database. Therefore, the work group agrees with
the position statement of the American Academy of Dermatology that the ‘‘current evidence is insufficient to prove either an association or causal relationship between isotretinoin use and IBD.’”

On depression/anxiety/mood changes:

Changes in mood, including depression, suicidal ideation, and suicide have been reported sporadically in patients who are taking isotretinoin. To date, no studies to suggest an evidence-based link between isotretinoin and depression, anxiety, mood 
changes, or suicidal ideation/suicide exist. Multiple studies have shown no evidence of depression from isotretinoin on a population basis.

On the contrary, most studies have shown isotretinoin to improve or have no negative effects on mood, memory, attention, or executive functions. However, given the prevalence of depression, anxiety, and suicidal ideation/suicide in the general population, and especially the adolescent population who may be candidates for isotretinoin therapy, the prescribing physician should continue to monitor for these
symptoms and make therapeutic decisions within the context of each individual patient.

Fortunately, hormonal acne often requires a much lower dose than traditional Accutane treatments, which has a decreased rate of side-effects and increased rate of tolerability and satisfaction.

Isotretinoin is often only prescribed in combination with an oral contraceptive due to the high rate of congenital malformations. Because of this, iPLEDGE (US only), a risk-management program, was implemented. The FDA has since mandated that all patients receiving isotretinoin treatment enroll in and adhere to the iPLEDGE program. Regardless, roughly 150 isotretinoin-exposed pregnancies still occur in the US each year.

Isotretinoin is very lipophilic (oil-loving) and should be taken with food.


Caring for Hormonal Acne at Home

Whatever route you take, it is important to stick with a bland routine that does not aggravate inflammation in the skin. Simple moisturizers, cleansers, and sunscreens are often recommended.

Reducing stress, a herculean task, seems to help many people who suffer from hormonal acne. While entirely anecdotal, meditation is an excellent way to relieve and manage stress for many people who suffer from chronic illnesses.

Getting ample sleep, limiting sugar intake, and other inflammation-reducing practices may also help you.

Whatever you decide, it is important to keep in mind that hormonal acne comes from within, which means that it often needs to be treated from within by a doctor. I’ve been asked from countless women what I recommend for their hormonal acne and unfortunately, my answer is always the same: You often cannot treat it topically. It must be treated internally.

Do you suffer from hormonal acne? If so, what has helped you? Let me know in the comments below!

 

 

2 thoughts on “The Mechanisms and Pathogenesis of Hormonal Acne (Acne Excoriée)

  1. I have known or read about people who swore that this food or that food or “just wash your face” cured their acne, and this is the first post I’ve ever seen that a) described my acne (apparently hormonal, and not in the “oh dear I got one tiny pimple every month” kind of way) and b) convinced me to try drinking less milk.

  2. Hi! Just wanted to come by and say thank you for your blog – I can tell each article is painstakingly researched – I try to do the same with my posts, and it takes a lot of time and effort, so I appreciate your work!

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