Acne is such a bummer. Whether you are a teenager and hear it’s common during these years, or an adult wondering why you are still get acne – everyone just wants clear skin! Our hormones that are responsible for causing acne go through such a rapid increase during puberty which is why acne tends to be worse during this stage of our lives. Eventually, these hormones should level out and find their balance but sometimes they don’t.
A lesson on our skin.
Our skin is an organ that acts as a protective layer for us. It contains keratin which makes up our hair, skin, and nails. We also have pores which contains a hair follicle and a sebaceous gland which secretes oil and sebum to lubricate and protect the skin. On top of the skin we will find Cutibacterium acnes (C. acnes) (formerly called Propionibacterium acnes, or P. acnes) – a very common bacteria that finds a home in sebum rich areas such as the face, chest, and back. When pores get clogged with oil, sebum, dead skin cells, dirt, and C. acne, it creates the perfect storm for acne to develop.
How do hormones play a role in acne?
Men and women make the same hormones, but where we differ is how much we make of each. Men make more hormones that as a collective we call the “androgens”, the two main ones being testosterone and dihydrotestosterone (DHT), while women produce more estrogen and progesterone. Testosterone and DHT are the biggest culprits in hormonal acne for both men and women, with DHT being 5-10 times stronger than testosterone1.
The way androgens cause acne is through their role in stimulating oil and sebum production in the sebaceous glands. When androgens promote more oil and sebum to be made, there is a more likely chance for pores to get clogged. This is believed to be the number one mechanism as to why acne develops.
How does hormonal acne present?
Breakouts in hormonal acne are more likely to occur 1-2 weeks before your menstrual period. Break outs predominantly occur on the bottom of your cheeks, jawline, chin, neck, chest, and back. Although there are different types of acne, most hormonal acne presents as red raised bumps (papules, pustules), or deeper cystic acne.
Natural treatments for hormonal acne.
Naturopathic medicine offers various ways to balance your hormones and improve skin. A combination of plant medicine, vitamins & minerals, dietary changes and topical skin care products are often recommended in treatment plans designed for each individual person.
Plants:
Some plants are able to create an anti-androgen effect in the body by lowering the production of androgens. Plants such as white peony (Paeonia lactiflora), saw palmetto (Serenoa repens), nettles (Urtica dioica), and spearmint (Mentha spicata) are commonly used in acne botanical formulas for their anti-androgen effects3.
Vitamins & Minerals:
Zinc: Zinc works as an anti-inflammatory and has skin healing properties. Also, when applied topically zinc demonstrates an anti-bacterial effect by reducing the amount of C. acnes on the skin4.
Vitamin D: Vitamin D also has an anti-inflammatory effect on acne by reducing inflammatory proteins that are involved in the development of acne5. Studies show that men and women who experience acne tend to have lower levels of vitamin D compared to those who don’t suffer from acne5.
Vitamin E: rapid shedding of skin (hyperkeratinization) in the sebaceous gland will create a microcomedone under the skin weeks before it turns into an acne lesion6. Vitamin E is shown to manage hyperkeratinization and reduce the development of comedones (small flesh colored acne lesions; papules)7. Hyperkeratinization is the second mechanism in the development of acne.
Diet:
Omega 3 Fatty Acids: the Eicosapentaenoic acid (EPA) in fish oils have an anti-inflammatory effect as well as the ability to lower insulin-like growth factor. These two cellular processes are very common in the development of acne. A 2022 study by German Dermatologists involving 100 patients found that 94% of people with acne have below normal levels of omega-3 fatty acids8. One interesting fact is that there are certain populations in Papa New Guinea and Paraguay that have no reported cases of acne. This is believed to be due to the absence of a western diet – no processed foods, no refined sugars, low glycemic index, and high in omega 3 fatty acids9.
Dairy: consuming dairy can cause unexpectedly high insulin levels, which leads to inflammation and increased androgen levels. Some people may also have a food sensitivity to 2 proteins found in dairy – whey and casein. A small study found that whey protein products have caused acne flairs in teenagers10.
Insulin: insulin gets release when we eat sugar or carbohydrates that break down into glucose. When insulin is released in higher amounts, various studies have demonstrated that this increases androgens. One study found that testosterone still remained elevated 24 hours after administering insulin via IV11. This suggests we should be mindful of our intake of sugar, bread, pasta, and other carbohydrates if we suffer from acne.
Topicals:
Topical use of Vitamin B3 (niacinamide, sometimes called nicotinamide) has reduced sebum production, works as an anti-inflammatory, and may have an anti-bacterial effects on C. acnes12. Topical products will contain up to 10% niacinamide in a serum.
If you want to explore acne further or learn which products are right for you, book an appointment with me!
Dr. Stephanie Liebrecht, BSc, ND
Naturopathic Doctor
Resources
1. Ebede, T. L., Arch, E. L., & Berson, D. (2009). Hormonal treatment of acne in women. The Journal of clinical and aesthetic dermatology, 2(12), 16–22.
2. Grant, P., Ramasamy, S. (2012). An update on plant derived anti-androgens. International journal of endocrinology and metabolism, 10(2), 497–502. https://doi.org/10.5812/ijem.3644
3. Gupta, M., Mahajan, V. K., Mehta, K. S., & Chauhan, P. S. (2014). Zinc therapy in dermatology: a review. Dermatology research and practice, 2014, 709152. https://doi.org/10.1155/2014/709152
4. Alhetheli, G., Elneam, A., Alsenaid, A., & Al-Dhubaibi, M. (2020). Vitamin D Levels in Patients with and without Acne and Its Relation to Acne Severity: A Case-Control Study. Clinical, cosmetic and investigational dermatology, 13, 759–765. https://doi.org/10.2147/CCID.S271500
5. Lall, N. (2018). Medicinal Plants for Holistic Health and Well-Being. Academic Press.
6. Keen, M. A., & Hassan, I. (2016). Vitamin E in dermatology. Indian dermatology online journal, 7(4), 311–315. https://doi.org/10.4103/2229-5178.185494
7. Abstract 314 submitted to the EADV Spring Symposium: ‘Deficit of Omega-3 fatty acids in acne patients. Retrieved from: https://eadvsymposium2022.org/hope-for-europes-23-million-acne-sufferers/
8. Bowe, W. (2014). Food for Thought: A Closer Look at Diet and Acne. Practical Dermatology, p 39-44.
https://assets.bmctoday.net/practicaldermatology/pdfs/pd0914_CF_Diet.pdf
9. Silverberg N. B. (2012). Whey protein precipitating moderate to severe acne flares in 5 teenaged athletes. Cutis, 90(2), 70–72.
10. Pateguana, N., & Janes, A. (2019). The contribution of hyperinsulinemia to the hyperandrogenism of polycystic ovary syndrome. Journal of Insulin Resistance, 4(1), 3 pages. doi: https://doi.org/10.4102/jir.v4i1.50
Walocko, F. et al. (2017). The Role of Nicotinamide in Acne Treatment. Dermatologic Therapy, 30(5), e12481. Retrieved from: https://doi.org/10.1111/dth.12481
Estrogen Detoxification: Roles of the Liver & Gut
Our body is always in a state of hormone production and excretion. Once a hormone has completed it’s function, it is broken down and excreted by the gut or kidneys. Estrogen follows this same process, which we call estrogen detoxification or estrogen metabolism.
First let’s spend one minute talking about our active estrogens. There are 3 main forms of estrogen: estrone (E1), estradiol (E2), and estriol (E3). Estradiol (E2) is the prominent form of estrogen in menstrating women. It is important in fertility, bone health, cardiovascular health, and more! Estrone (E1) is the main estrogen during menopause, and estriol (E3) increases during pregnancy.
Estrogen detoxification occurs in 3 phases – in the liver Phase 1 & Phase 2, and Phase 3 in the gut via the microbiome (gut bacteria).
Phase 1 Detoxification
During Phase 1, estrone and estradiol are first converted into 3 different metabolites known as 2-OH-E1, 4-OH-E1, and 16-OH-E1.
Phase 1 detoxification results in 70% of 2-OH-E1, 10% of 4-OH-E1, and 20% of 16-OH-E1.
The 2-OH-E1 form of estrogen is considered the safe form, and is the preferred pathway of detoxification. 4-OH-E1 has the highest ability to damage DNA and contribute to the development of breast cancer, therefore we should go down this pathway the least. The 16-OH-E1 will help to maintain bone mineral density, but can also influence the development of breast cancer.
DIM (Diindolylmethane), I3C (indole-3-carbinol), and cruciferous vegetables such as broccoli, cauliflower, kale, cabbage, brussels sprouts, and bok choy all support the safe 2-OH-E1 pathway. Coffee is able to support Phase 1 detox, while a diet high in sugar and alcohol can inhibit it.
Phase 2 Detoxification
This phase prepares the 2-OH-E1 and 4-OH-E1 to be excreted out of the body. Through a process called methylation, the liver makes these metabolites water soluble to be safely excreted byt the colon and kidneys.
B Vitamins (B12, B6, folate) and magnesium are used to help Phase 2 detoxification. Cosmetic products that contain phthalate esters such as lotion and creams, nail polishes, hair products, deodorants, and fragrances can disrupt Phase 2 detoxification. Coffee inhibits Phase 2 detox.
Phase 3 Detoxification
Once estrogen is prepared and ready to be excreted, it enters the kidney’s for urination or leaves the liver via bile and makes its way into the colon to be excreted by stool.
A collection of gut bacteria called the estrobolome are capable of metabolising estrogen. They do this by producing an enzyme called beta (β)-glucuronidase, which takes the estrogen ready for excretion and sends it back into circulation. This leads to higher levels of estrogen in the body creating an estrogen dominance hormone imbalance. Calcium D-glucarate inhibits the activity of β-glucuronidase and can be found in supplement form. Eating a diet rich in fiber and fermented foods will support a healthy gut microbiome.
Hormone Testing
In depth hormone testing can provide insight into your detoxification pathways of estrogen. As a naturopathic doctor, I use one of the original comprehensive hormone testing kits called a DUTCH test by Precision Analytical. It provides information on each of the 3 main estrogens E1, E2, and E3, as well as how each of the 3 phases of detoxification are working.
Dr. Stephanie Liebrecht, BSc, ND
Naturopathic Doctor