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Testing and Natural Treatments for Hormonal Acne

Testing and Natural Treatments for Hormonal Acne

In my practice, I have a significant number of women who come to see me with concerns about hormonal acne. You may have memories of being a teenager with acne breakouts;


but why are they still occurring well into your 20’s, 30’s, or sometimes even your 40’s?


I get how frustrating this is; I struggled with hormonal acne myself, all the way until my 30’s, until I identified the root cause and addressed it using the natural methods I’ll outline in this article.


What is going on with hormonal acne?


Acne vulgaris is the medical term for acne. “Hormonal acne” is a term commonly used to describe the underlying cause of certain presentations of acne vulgaris.


Hormonal acne typically presents on the chin, jaw line, or tends to come at the same time every month in a cyclic pattern. Many women report that pimples arise just before the period, during the premenstrual phase, when estrogen and progesterone are declining.


Other women report breakouts mid-cycle, around ovulation time, when estrogen surges.


The pattern and timing of your breakouts provides information about what hormones need support in order to address the root cause of your acne.


If we zoom in on the skin of your face, the acne papules (pimples) and comodomes (black and white heads) arise on the skin due to a combination of factors:


  1. Androgens (such as testosterone) acting upon the sebaceous gland, causing increased production of sebum, which in turns contributes to a plugged follicle.
  2. Skin shedding is impaired, which exacerbates the plugged pores.
  3. The increased sebum supports the proliferation of acne-causing bacteria, most commonly Cutibacterium acnes.
  4. C. acnes causes inflammation and around the follicle and surrounding skin, contributing to the inflamed, red, and sometimes tender pimple.


To get to the root cause of the acne, however, we need to take a step back and look holistically at your whole body to understand what led to the acne-causing conditions in the first place. Often, it’s not just your skin that needs support, it’s also your hormones, digestive system and diet.


When it comes to hormonal acne, there are 4 main hormone patterns that I commonly see. Here they are, in order of most common to least common:


Androgen (testosterone) related acne. This type is due to the action of testosterone at the skin on the face, neck, chest and/or back. Typically this presents as acne pimples along the chin, jaw line, and underneath the corners of the mouth. For women who have this pattern of acne, along with other hormone imbalance symptoms such as irregular periods, and/or excess hair growth, we need to do additional testing for Polycystic Ovarian Syndrome (PCOS). More on this testing shortly.


Progesterone-related acne. The second pattern of hormonal acne I see is the acne pimples that seem to always worsen right before the period. Often these occur in the chin area, but can also occur on the cheeks or forehead. During the premenstrual time of the month, progesterone is declining sharply. This type of acne typically presents with other PMS symptoms such as moodiness, irritability, sleep disturbance, breast tenderness or bloating. This pattern can co-exist with estrogen dominance.


Insulin. Insulin is another important hormone that can contribute to acne. Insulin is the hormone responsible for managing our blood sugar levels. Chronically elevated insulin, as in insulin resistance (or “pre-diabetes”) can contribute to acne. Often it comes along for the ride with elevated testosterone in PCOS, mentioned above.


Estrogen dominance acne. This is the third type of hormonal acne I typically see. In this pattern, acne breakouts tend to occur in the first half of the menstrual cycle, or around ovulation time when estrogen surges. Check out this article for more information about this hormone pattern.


Testing and investigating hormonal acne


Importantly, in order to address and treat your acne, we have to start with identifying the root cause. When women come to see me, we start with a detailed conversation to figure out the pattern, timing, and possible triggers for their acne, so we can perform the most appropriate tests, if necessary.


As I alluded to earlier, sometimes acne is the predominant symptom of PCOS. This is especially the case if the acne is along the chin and jaw line, and other symptoms like irregular periods and excess hair growth are also present. If PCOS suspected, a panel of blood work is done to more closely examine the hormones. Typically this panel includes:


  • Total and free testosterone
  • Dehydroepiandrosterone sulfate (DHEAS)
  • Androstenedione
  • Luteinizing hormone (LH)
  • Follicle-stimulating hormone (FSH)


If you have been diagnosed with PCOS, check out this article for more information about treating PCOS using natural medicine.

It is well understood that testosterone and its metabolite, dihydrotestosterone (DHT) are important contributing factors in acne. Lesser known is the role of blood sugar and insulin on acne.


Higher-than-normal levels of insulin in the blood appear to contribute to acne too, especially in women with PCOS. This is evidenced by the increased glucose levels at the sebaceous glands in those with acne. For this reason, I will often additionally examine:


  • Fasting glucose
  • Fasting insulin
  • Cholesterol panel


Androgens, blood sugar and insulin are reliable tests we can do to examine the root cause of acne. Using blood tests for estrogen and progesterone are unfortunately less useful. The reason for this is that estrogen and progesterone fluctuate not only throughout the month, but also throughout the day (even within an hour!) This means that a blood test will only give a brief snapshot of what’s happening with these hormones.


While blood tests for estrogen and progesterone are less useful for understanding acne, the PATTERN and TIMING of your acne breakouts typically give us all the information we need to start treating your hormone imbalance. This is why taking a careful history with your naturopathic doctor is so important.


Taking a careful health and hormone history, and testing all of the above hormones (f necessary) gives us a clear understanding of the root cause of your acne, and therefore which treatments are going to work the best for you to balance your hormones and clear your skin.


Conventional treatments for acne


If you’ve seen your doctor about your acne concerns, you’ve probably discussed or perhaps tried one or more of the following common treatments. Some of these can work for reducing acne pimples, but often they are masking the problem and not treating the root cause.


1. Oral Contraceptive Pills


This is the #1 most common treatment I see women given for the acne concerns. The birth control pill will reduce the production of androgens, as well as your natural estrogen and progesterone (hence the contraceptive effect). While this may be a desirable option for some women, others are concerned about the laundry list of potential side effects, or prefer non-hormonal options. Additionally, if the true root cause of your acne is PCOS, then these symptoms will return again when you come off the pill again in the future.


2. Topical treatments


Topical benzoyl peroxide, salicylic acid, or antibiotics are common recommendations. The purpose is to kill the C. acnes bacteria and dry out the sebum contributing to the papules. I find that topical treatments sometimes help to reduce the pimples you have currently, but aren’t great at preventing future breakouts because they aren’t addressing the root cause.


3. Oral antibiotics and retinoids


Oral antibiotics are sometimes prescribed for 1-2 months to address acne. It can be effective for reducing acne inflammation, but many women are concerned about the impact on their digestive health and gut microflora. Retinoids include isotretinoin (Accutane), which can be effective, but is very harmful to fetuses and are linked to increased risks of liver damage and inflammatory bowel disease.


If you are looking for natural solutions to address the root cause of your acne, balance your hormones, and have clear skin, we can get excellent, long lasting results using diet, specific nutrients and herbal medicine.


Natural Medicine for Hormonal Acne


For many of my patients, making dietary changes to support the digestive system, healthy microflora and correct nutrient deficiencies can go a long way in supporting acne.


Combining these dietary changes with specific herbs and supplements can help to clear up and resolve acne once and for all. Here are some of the specific dietary changes and herbal recommendations that I often prescribe to my patients, depending on their acne pattern.


Refined sugar and carbohydrates. As outlined above, blood sugar and insulin levels impact your skin health. Cutting back your sugar intake, especially the refined carbohydrates and added sugar, helps to not only reduce acne but can also help to reverse insulin resistance. Using natural sweeteners such as honey or maple syrup, and sugar from fruit is okay; it’s more important to reduce your overall refined carbohydrate and sugar load from commercially baked goods, candy, soda, sweet coffee drinks, and other sources of added sugar. Typically women start to see results in about 1-2 months of reducing their overall sugar intake.


Dairy. I’ve observed that dairy is another common trigger for many women. A trial of 2 months dairy-free will often indicate whether dairy is a acne-causing food for you. You’ll notice clearer skin, and likely reduced gas and bloating. In one observational study, consumption of higher amounts of cow’s milk was associated with an increased incidence of teenage acne. Sensitivity to whey protein may also exacerbate acne, according to several case reports.


Zinc. Severe zinc deficiency can cause acne. While zinc deficiency is rare among healthy individuals consuming a western diet, zinc status appears to be marginal in the general population and even lower among people with acne. Recommended doses range from 10-30mg per day. Be sure to take with food, as zinc on an empty stomach can cause nausea.


  • Food sources of zinc: Oysters, red meat, poultry, beans, nuts, crab, lobster, whole grains, fortified breakfast cereals.


Vitamin D3. This is an important fat-soluble vitamin for the skin. Think of it as liquid sunshine. Acne is typically worse in the winter, and tends to be more severe in climates with lower levels of UV light. Sunburns are certainly not good for your skin, but lots of fresh air and a light tan from daily sun exposure generally improves the complexion. For those who live in climates with low or variable amounts of sunshine, or who have fair skin, you can get Vitamin D in liquid dropper form.


  • Sources of vitamin D: safe sun exposure, fatty fish (tuna, mackerel, salmon), grains fortified with vitamin D, cheese, beef, egg yolks.


Vitamin A. High-dose Vitamin A is an alternative option for patients considering Accutane or for those who’s acne does not respond to other treatments. Although it can be very effective in treating acne, even natural Vitamin A in high doses can pose risks. It is imperative for women using high dose Vitamin A therapy to avoid pregnancy because of possible fetal malformation; it is not a safe option for pregnant women. Also, high dose vitamin A may cause drying of lips and skin, and should not be used for longer than 3 months. This therapy works by reducing the fat (sebum) build-up in the pores. Speak with your naturopathic doctor about appropriate dosing.


  • Food sources of vitamin A: Cod liver oil, sweet potatoes, carrots, dark leafy green vegetables, winter squash, lettuce, dried apricots, cantaloupe, bell peppers, fish, liver and tropical fruits.


Vitamin B6. In women with premenstrual acne flares, treating with vitamin B6 can be helpful in reducing these symptoms. Doses range from 30-100mg of vitamin B6 per day.


  • Food sources of vitamin B6: vegetables, eggs, whole grains, fish, prok, poultry, soybeans.


Magnesium. Magnesium plays an important role in hormone metabolism and estrogen detoxification. It is helpful in the treatment of PMS acne, especially if you have sluggish bowels (i.e. bowel movements less than once a day). I recommend magnesium glycinate for the treatment of hormonal acne. Doses range from 150-400mg per day.


  • Food sources of magnesium: green leafy vegetables, avocado, banana, raspberries, nuts and seeds, legumes, seafood, broccoli, cabbage, asparagus, peas.


Indol-3-Carbinol (I3C). I3C is a compound found in cruciferous vegetables that helps the liver metabolize and excrete estrogens. This is helpful for women with PMS acne aggravations, and estrogen dominance symptoms.


  • Food sources of I3C: kale, broccoli, cauliflower, arugula, bok choy, cabbage.


Chromium. Chromium is a mineral that helps to support blood sugar balance. It’s helpful in cases of insulin resistance or PCOS.


  • Food sources of chromium: whole grains, meat, broccoli, mushrooms, Brewer’s yeast, chicken/liver, cheese, eggs, fish, corn, dairy.


Inositol. Inositol is a small molecule that is involved in cell signalling pathways. It comes in various forms, most commonly myo-inositol. Myo-inositol is very helpful for blood sugar related acne, and especially PCOS acne. Supplementation is required to get a therapeutic dose; speak to your ND about dosing that is appropriate for you.


Chaste Tree (Vitex agnus-castus). Chaste tree berry is one of my all time favourite herbs for hormone balancing. Chaste tree is particularly helpful for the type of hormonal acne that gets worse just before your period; it’s also helpful for women with PCOS-related acne. I find that chaste tree works well in combination with magnesium and vitamin B6.


I hope this article has been helpful; here are some other articles that you may find beneficial:



Yours in health,


Dr. Kathleen

Dr. Kathleen Mahannah is Naturopathic Doctor licensed by the College of Naturopathic Physicians of British Columbia.  Her practice focusses in women's health and hormone balancing using natural medicine and Hormone Therapy, particularly for women in perimenopause and menopause. Dr. Mahannah completed a Degree in Physical Education and Health from University of Toronto, and Diploma of Exercise Science from Capilano College, before obtaining her Diploma of Naturopathic Medicine. She has been practicing for over 6 years in North Vancouver, BC, Canada. Learn more about Dr. Mahannah here.

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References:


Crockett, S. (2010) Isotretinoin use and the risk of inflammatory bowel disease: a case control study. Am J Gatroenterol, 105(9): 1986-9

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