In high school, when everyone was complaining about pimples and hormonal breakouts, I slid by with perfect skin. I thought I was somehow immune to the acne of my peers, but instead, I got hit hard with acne in my 20s. As a med student, I immediately jumped at trying all of the typical solutions—the pill, Retin A, spironolactone (a drug originally designed for high blood pressure!), and even cortisone injections. No cream or pill helped me clear up my cystic acne and I started to develop scarring.
What I didn’t realize at the time was that I should have been looking to the root cause, and what was on the inside, instead of trying to solve the problem by covering it up. Eventually I discovered that my skin issues were actually related to food sensitivities I had developed in adulthood. I’ve seen many members at Parsley Health struggle with similar issues and time and time again I’ve often uncovered a food allergy, sensitivity or hormonal issue that is causing their cystic acne. Today, I want to dive in and talk more about hormonal acne.
Acne affects nearly 50 million Americans annually with billions of dollars spent on treatments each year. However, many of these treatments are focused on only treating the acne topically rather than the underlying root cause that may be bringing it on. One of the root causes of cystic acne is often hormones.
Hormonal acne is any acne that occurs due to hormonal fluctuations. It’s common during puberty, because androgens, a group of hormones that include testosterone and other “male hormones,” naturally increase production during this time. But hormonal acne can happen any time there are fluctuations in hormone levels, which is why up to 85 percent of women will see acne increase days before their menstrual cycle .
The most common cause of hormonal acne is an excess amount of androgens and increased systemic inflammation . Both can lead to an increase in sebum production, and this is where the major problem starts. Sebum is oil produced by your skin via the sebaceous glands, also known as the oil glands. It serves to protect your skin and lock in moisture. However, if its production increases above normal limits and your skin cell turnover rate remains the same, your pores will quickly become clogged. When this happens, the sebum can’t leave the pore, so as a result it becomes inflamed and a pimple forms in its place. Since most of your oil glands are located on the face, chest, back, and shoulders, these areas are most prone to hormonal breakouts. So what causes excess androgens and chronic inflammation in the first place? Here’s what we know.
Androgens are one of the major hormone-related culprits when it comes to acne. They’re produced by the ovary and adrenals and have been specifically linked to many forms of acne. Androgen production can increase for a few different reasons:
PCOS : Women with PCOS have higher than normal levels of androgens in their system. This is why acne , when paired with a number of other symptoms, such as an irregular menstrual cycle, serves as a strong indicator of the syndrome.
Menopause: During menopause, hormones are constantly in flux. Women most commonly experience a decrease in estrogen paired with an increase in testosterone. Since estrogen directly combats the effects of testosterone, and levels are low during menopause, there’s nothing to put up a defense against the sudden spike in testosterone. As a result, testosterone levels will continue to increase along with sebum production.
Your monthly menstrual cycle: When you have your period , your levels of estrogen and progesterone are at their lowest, both of which are shown to reduce sebaceous gland acitivty . With neither of these hormones around to balance the testosterone lingering in your system, you’ll likely experience an influx of breakouts around this time of the month. It’s why 85 percent of women will see their acne increase in the days leading up to their period.
Another common cause of hormonal acne is inflammation . Simply put, systemic inflammation is the chronic activation of our immune system caused by dietary and lifestyle factors that can play a major role in disrupting internal hormonal balance.
Some dietary and lifestyle factors that are commonly linked to increasing inflammation and subsequently, the occurrence of acne include:
Nutrition: Studies show that dietary intake, specifically of inflammatory omega-6 fats such as linoleic acid, may have a direct impact on acne development. For example, diets rich in refined foods such as processed grains, fried foods, breads, and potato chips, boost internal inflammation by providing excess linoleic acid through the diet—one of the main components in sebum. With an overproduction of sebum on the skin, acne is more likely to develop.
Stress: Inflammation caused by chronic stress has been linked to the aggravation of acne . The stress response boosts production of certain hormones, such as cortisol and corticotropin-releasing hormone (CRH), which increases inflammation and accelerates the body’s production of sebum. Studies show that skin with acne has higher levels of stress hormones, such as CRH, when compared to normal, acne-free skin. In essence, the more stress you experience, the more likely the resulting inflammation may contribute to hormonal breakouts.
Environmental factors: Common environmental interactions with the skin such as air pollutants and cosmetics have been shown to have inflammatory and hormonal effects on the body and the skin. Cosmetics can negatively alter the skin’s microbiota balance especially in the oil glands, thus triggering inflammation and the onset of a breakout. Similarly, air pollutants such as ozone, nitrogen dioxide, and sulfur dioxide can have harmful effects on the skin and increase oxidative stress, which boosts inflammation and alters the normal functions of the skin, leading to an uptick in acne.
A healthy omega-3 to omega-6 ratio of 1:1 can provide you with a number of cardiovascular and neurological benefits, but when the ratio shifts to favor omega-6 then you might run into trouble. Since omega-6 fatty acids on their own are inflammatory, a ratio high in omega-6 can impact the inflammation in your skin. It’s because of their proinflammatory effects that the connection has been made to inflammatory acne . Rebalancing your ratio to favor omega-3 fatty acids will help counteract omega-6’s inflammatory properties and can have a therapeutic effect on hormonal breakouts.
Consider cutting back on the amount of food you eat with a high glycemic index, such as honey, rice, cereal, and white bread. These foods digest quickly, so they spike your blood sugar and insulin levels. Studies show that a low glycemic diet can help to reduce inflammation, stabilize insulin levels and positively influence sebum production, so reducing your intake of these foods can help combat your hormonal acne.
Most evidence-based studies agree that dairy can be a common trigger for acne. While the exact mechanism is unknown, researchers theorize that dairy’s role in acne is likely due to the artificial hormones dairy cows are treated with or the growth hormones that naturally exist in cow’s milk. These hormones may throw off our own hormonal balance and contribute to acne. Others believe it is the common combination of refined foods and processed sugars with milk products in the Western diet that regularly disrupt insulin levels and cause hormonal breakouts in those that are prone. Despite the lack of consensus on the connection, many people with acne find that reducing or eliminating dairy helps them reduce acne and improve skin quality . If you’re regularly experiencing breakouts, it might be worth experimenting with the removal of dairy to assess its effects on your skin.
If you’re an adult and experiencing acne for the first time along with other signs of excess androgen production, such as menstrual irregularities or infertility then you might have a hormonal imbalance . Consider getting a hormone test to check your total androgen levels and serum testosterone. At Parsley Health, our doctors regularly recommend these tests for members who exhibit some of the above symptoms.
Tea tree oil is the best option when it comes to treating hormonal acne naturally. While it does have a slower onset, one study found tea tree oil just as effective as traditional topical agents, such as benzoyl peroxide. Participants that followed a tea tree regimen also experienced less side effects than their benzoyl peroxide counterparts.
Hiding acne under a layer of makeup? The products you’re using could actually be contributing to your breakouts. As many as 62 percent of acne cases are triggered by cosmetic products. Look for products that specify the product is non-comedogenic or non-acnegenic to ensure it won’t aggravate your acne further.
Probiotics can help reduce inflammation further by feeding your microbiome with good bacteria that will support your immune function. Taking a probiotic also helps ensure your microbiome is healthy , a sign of good health. In addition to an oral probiotic, topical probiotics are also being researched for their benefits in which bacteria are applied directly to the skin to help restore microbial balance and improve conditions at the site.
When you’re stressed your body releases cortisol in hopes of bringing you back to equilibrium, but high levels of cortisol can increase your likelihood of immune dysfunction, inflammation, and hormone imbalances. Research shows that managing stress reduces inflammation in the body, so it can also help manage hormonal breakouts. The quickest and most effective way to reduce stress is through a regular self-care routine. Activities such as a daily meditation or gratitiude practice, restorative exercise, journaling or deep breathing are just a few examples of easy ways to help keep your stress in check.
Dr. Robin Berzin is the Founder and CEO of Parsley Health, America's leading holistic medical practice designed to help women overcome chronic conditions. She founded Parsley to address the rising tide of chronic disease in America through personalized holistic medicine that puts food, lifestyle, and proactive diagnostic testing on the prescription pad next to medications. Since founding Parsley in 2016, Dr. Berzin has seen 80% of patients improve or resolve their chronic conditions within their first year of care, demonstrating the life-changing value of making modern holistic medicine accessible to everyone, anywhere. Parsley is available online nationwide.
Dr. Berzin attended medical school at Columbia University and trained in Internal Medicine at Mount Sinai Hospital in New York City. Her book, Prescription for Happiness: How to Eat, Move, and Supplement for Peak Mental Health, was published by Simon Element in January 2022.