Hormonal acne: What you need to know
The rise in androgen levels can trigger a process of higher sebum production, changes in skin cell activity, inflammation, and colonization of the hair follicles by a bacteria known as Propionibacterium acnes (P. acnes). This can lead to acne.
Acne lesions or zits of varying severity typically affect the face and upper body. Acne is a common and treatable condition.
What is acne?
Mild acne affects many people during adolescence, and it can persist through adulthood.
Acne is a condition of the skin.
It happens when the body makes excess sebum, an oil that stops the skin from drying out, and this clumps together with dead skin cells in a pore. Where the clogging occurs, an acne lesion or zit can form.
The lesions in the skin formed by acne include comedones, which can be open or closed plugs that form at the base of hairs.
Other types of lesion include:
These four types of lesions, of increasing size and severity, form when bacteria become involved with the plugs. The bacteria cause an inflammatory response from the immune system.
Acne is the most common skin condition in the United States. The American Academy of Dermatology (AAD) estimate that at any one time, there may be as many as 50 million people in the United States who have acne.
What is hormonal acne?
Hormonal acne is not a term used in medical research or by doctors, but it may be used on the internet, in glossy magazines, or by people selling natural remedies.
This article assumes hormonal acne simply to mean acne. One reason people may call it hormonal acne is to link it to the fact that it is most common in teenagers going through the hormonal changes of puberty.
Acne symptoms can include:
Whiteheads and blackheads are not inflamed and do not cause pain or swelling. If they become inflamed, they can become cysts or pustules. Inflamed lesions can be painful, sore, and red. The lesion and the area around it may be raised.
Lesions often appear on the:
They are more likely to appear on the forehead than the other parts of the face, such as the cheeks, because sebum levels are higher in this area.
Acne is thought to affect 80 percent of people between the ages of 11 and 30 years, and especially from 14 to 19 years. Some people continue to experience acne after the age of 30 years.
During pregnancy and around menopause, hormonal changes can again cause acne to affect women.
There are four main factors behind the formation of acne lesions. Hormones are one major factor, which may be why some people call it hormonal acne.
The four components of acne involve the units at the base of hairs in the skin:
1. Production of the hormone testosterone rises during puberty. This causes greasy skin because it increases production of sebum, the oily substance secreted at the base of hairs to protect and lubricate the skin
2. The hair follicles become blocked, forming comedones or "clogged pores." The overproduction of skin cells that would usually be pushed up and lost from the surface also adds to this process.
3. The comedones can be made worse by bacterial infection.
4. The immune system reacts to the bacteria, resulting in inflammation.
Not all acne is inflammatory. Simple comedones — blackheads and whiteheads — may not be inflamed. Pimples called papules, pustules, nodules, and cysts — in order of rising severity — are inflamed.
The role of hormones in acne formation
Acne may be known as hormonal acne because one major causative factor is the hormone testosterone.
Testosterone levels go up in the teenage years as part of puberty. This causes male development in boys and gives muscle and bone strength in girls.
The hormone also has the effect of increasing sebum production at the base of hairs. This is because the glands that secrete the oil are sensitive to testosterone.
Other hormones play a part in acne, too. For women, hormonal changes relating to pregnancy or the menstrual cycle can also trigger acne. Falling estrogen levels may increase the risk of acne around menopause.
Conditions that affect hormone levels, for example polycystic ovary syndrome (PCOS) can trigger acne.
Acne in menopause
According to the AAD, growing numbers of women are reporting acne beyond their teenage years and into their 30s, 40s, and 50s. Most cases of adult female acne are mild to moderate.
Most adult female acne is persistent, continuing on from puberty after the age of 24 years, but between 20 and 40 percent of cases start after puberty.
It is not clear why this is so, but some life changes can cause a flare-up.
Hormonal fluctuations can lead to acne in pregnancy and around the time of menopause.
Researchers note that women who experience acne around menopause usually have androgen levels within the normal range, but falling estrogen levels.
It may be this imbalance that gives rise to acne flares. As hormone reach a "tipping point," the new hormonal ratios lead to additional stimulation of the sebaceous glands, triggering outbreaks.
Severity of acne
Severe acne is when inflammation occurs and there are many lesions. Medication may be prescribed.
Acne can be mild, moderate, or severe.
Existing classfications suggest that:
Mild acne involves mostly blackheads and whiteheads and does not usually need any help from doctors. There are fewer than 20 comedones, or 15 inflammatory lesions, or a total of 30 lesions.
Moderate acne involves both inflamed and non-inflamed lesions, some of which may leave scars. Tthere are 20 to 100 comedones, or 15 to 50 inflammatory lesions, or a total of 30 to 125 total lesions
Severe acne features widespread inflamed lesions. It can impact both appearance and self-esteem, and it can cause scars.
All forms of acne can be distressing.
Even mild acne can affect a person's self esteem. This is not only due to its appearance, but also the fact that it often affects young people when they begin developing relationships.
Myths about what causes acne
There are many myths about the causes of acne.
There is no evidence that any of the following cause acne:
- poor hygiene
- chocolate and other diet factors, including nuts or greasy foods
- masturbation or sex
Some research has found weak links between acne and milk products – and especially skim milk.
There is also evidence linking acne with diets that contain lots of foods with a high glycemic index. These include simple carbohydrates, found in white bread, chips, and white potatoes, and sugary drinks.
These foods can increase blood sugar levels, and this may have an impact on hormone levels that then impact the risk of developing acne.
Herbal medicines are examples of complementary and alternative treatments for acne. These are usually harmless, but there is a Examples used include tea tree oil and clove basil.
Practical tips for people with acne
People should avoid picking or touching spots, but wash the skin gently twice a day.
- gentle daily washing no more than twice a day and after sweating
- using mild soaps or cleansers and warm water, not hot water
- not using harsh or exfoliating scrubs
- avoiding scrubbing, picking, or scraping pimples, as doing so can make them worse and can cause inflammation
- people should avoid makeup, or use water-based cosmetics that are marked as non-comedogenic sparingly
- where possible, avoiding environments with high humidity that cause excessive sweating
Over-washing is not good for acne.
Too much washing and scrubbing can remove oil from the skin and irritate it more. The skin can respond by producing more oil and so worsening the acne.
Acne is treated according to severity. Mild acne can be treated with over-the-counter products as well as with medicines offered by doctors.
There is no quick-fix treatment for acne. All treatments take weeks to show effect.
Mild acne treatments available without prescription include antibacterial skin cleansers. There is no evidence that acne is caused by poor hygiene, however.
Benzoyl peroxide is a topical drug available over-the-counter that may help. Other non-prescription drugs are available but with less evidence for good effect.
While using medications to treat acne, people should avoid direct sunlight and tanning beds, as the skin may be more sensitive to UV light at this time.
Various products for treating acne are available for purchase online.
Treatment for moderate and severe acne
Doctors can help people whose acne involves more severe pimples that may lead to scarring.
Moderate acne may be treated with oral antibiotics. Examples are:
Antibiotics for acne typically need to be continued for 3 months for full results. Topical antibiotics as well as the oral antibiotics may be prescribed as well.
Severe acne may require prescription treatment, for example, the drug isotretinoin.
This is an oral treatment that needs to be taken for 16 to 20 weeks. It is very effective against severe acne, but it has side effects, and its use has to be monitored.
It is crucial not to use isotretinoin if you are planning on becoming pregnant or if you are or could be pregnant, as there is a risk to the unborn child.
Women must have a pregnancy test before starting the medication and use reliable contraceptives before and during its use.
Sexually active women of childbearing age must use two forms of contraception before, during, and after treatment with isotretinoin.
People with severe acne who need to use isotretinoin must be referred to a dermatologist who is registered with the U.S. Food and Drug Administration (FDA) monitoring program for the drug.
Cystic acne and triamcinolone
The most severe form of acne is cystic acne, which may be treated with a corticosteroid injection called triamcinolone. This injection into the lesion aims to reduce scarring caused by the inflammation.
A dermatologist may recommend or use one or a combination of the following:
- lasers and light therapy
- chemical peels
- drainage and extraction to remove a cyst
An injection with medication can decrease the size of a large cyst if there is a need to do so quickly.
Hormonal therapy for adult women with acne
Treatment for acne in adult women is the same as for other people. Further options include hormone therapy.
These include the contraceptive pill as it can help to clear acne in women. Those approved by the FDA contain ethinyl estradiol.
An oral contraceptive can be used alone or with an anti-androgen medication.
Oral contraceptive pills should not be used by those with certain health conditions.
- a history of breast cancer
- previous heart attack or stroke
- a history of blood clots
- uncontrolled hypertension
- abnormal vaginal bleeding
As with isotretinoin, those using hormonal therapies will need regular monitoring to ensure the safety of the treatment.
When to see a doctor
A doctor who specializes in skin conditions called a dermatologist needs to be seen for severe acne.
People are advised to see a doctor and perhaps a specialist dermatologist if:
- they have a lot of acne
- there are severe lesions
- there is a risk of scarring
- acne could affect pigmentation
If the presence of acne affects a person's daily functioning, they should also seek help.
Is it a good idea to use a chemical peel as a treatment for acne?
Chemical peels are effective in the treatment of acne but are best when used alongside other treatments as well.
Multiple treatment modalities are typically best and most effective in the treatment of acne, as rarely is there a single treatment that will completely rid an individual of acne.
Medium to deep peels are especially helpful with scarring that is caused by acne.Cynthia Cobb, APRN Answers represent the opinions of our medical experts. All content is strictly informational and should not be considered medical advice.