Everyone has a similar story. It’s your first date with that someone you’ve been eyeing in class, or an important job interview, or the senior prom, or your wedding day, and drat! – you wake up with a red angy baby Mt. Vesurius on your chin, nose or cheek.
As teenagers, everyone has to put up with zits from time to time. For some individuals, it’s just an annoying occasional occurrence, for others with serious and chronic outbreaks, it can take over their lives, leading to constant embarrassment, loss of self-esteem, social isolation, and in the worst cases, horrific scarring on the face, chest, back and psyche. Acne vulgaris typically heralds the start of our hormonal rite of passage into adulthood, the time when the slumbering pre-pubescent endocrine machinery starts crankng up with a vengence. Girls sprout breasts and curves, grow pubic hair, and begin having monthly visits from their “friend”. Boys grow facial and pubic hair, gain muscle, and start having frequent erections – some welcome and some quite inopportune.
“Robert, why don’t you come up to the blackboard and demonstrate to the class how to solve this quadratic equation.”
“Do you mind calling on someone else? PLEASE! I must have been daydreaming. Didn’t catch a thing you were saying…”
The Role of Male Hormones (Androgens) in Acne of Both Sexes
By the time most people are in their mid to late 20’s, their adult bodies have begun to settle down into a more or less predictable endocrine pattern, moreso, however, for men than women. The male hormonal milliue is downright boring compared to that of a women. Normal female hormonal fluctuations that occur before menstruation and during pregancy can result in pimples that appear like cloclwork throughout a woman’s reproductive life and into the perimenopausal years. Even though males produce 40 to 60 times more testoterone than women, ovaries do produce it and the female body also produces other androgens that can exacerbate acne. The reason women get cyclical acne is less about total concentration of androgenic hormones and more about the ebb and flow and relative amounts of androgenic hormones compared to estrogen and progesterone throughout the 28 day cycle.
Unfortunately, real life acne isn’t nearly as cute as the Madison Avenue version.
In most cases, hormonal acne presents at specific times of the month – at ovulation, a few days before a period, or when a period starts. For women with hormonal problems such as polycystic ovarian syndrome) and hypothalamic amenorrhea, hormonal acne can persist all of the time.
Hormonal Acne Presentation
Appearance: Hormonal acne can present as cysts, pus-filled, painful inflamed “sacks” just below the skin surface, or as comedones, whitehead “bumps” that never break the surface, or smaller lesions that are not quite as angry and painful as full out cysts, or more lie a rash that is smaller than typical acne lesions.
Location: Hormonal acne occurs first and foremost around the mouth, on the chin, below the nose, around the sides of the mouth, and sometimes up the jawline. As hormonal acne worsens, however, it can spread to the cheeks and the forehead. Other body parts can be affected, but typically in advanced severe cases. If acne is presenting in locations on the body without being present around the mouth area, there’s a decent chance hormones are not the primary culprit.
Evolution of an Acne Eruption
The evolution of an acne lesion takes time. Two to three weeks elapse before it becomes visible on the surface of the skin.
- A normal folliclewith hair shaft and sebaceous gland. The gland produces sebum, the oily substance that keeps skin moist and pliable.
- Follicular Keratinization – Excess skin cells, or corneocytes, build up on the surface of the skin, clogging the pore opening.
- Sebaceous Activity – An increase in androgen hormones elevates sebum production which mixes with dead skin cells, causing a blackhead, or comedone.
- Inflammation – An inflammatory response causes redness, swelling, and tenderness.
- Propionibacterium Acnes (P. Acnes) – Anaerobic bacteria (meaning it can survive without survive without oxygen) that lie deep within the pore act upon the sebum which greatly increases inflammation, leading to pustules (pimples) and cysts.
Other Contributing Factors
Nodulocystic acne is the most difficult type to
manage and has a strong familial component,
often running in families generation after generation.
Heredity: Severe acne has the most evidence for a heredity linkage.
Food: While pizza, chocolate, greasy and fried foods, and junk food may not be good for overall health, they don’t cause acne or make it worse. Studies show dairy products and high glycemic foods can trigger acne. The dairy products contain hormones related to lactation and pregnancy in the cow. High glycemic foods trigger insulin spikes that effect rates of androgen synthesis.
Oily skin: Some individuals have more “oily” skin than others and may be more prone to acne breakouts. Cosmetics: Most cosmetic and skin care products are not pore-clogging (“comedogenic.”) Water-based or oil-free cosmetics are best.
Pressure: In some patients, pressure from helmets, chinstraps, collars, and the like can aggravate acne.
Drugs: Some medications may cause or worsen acne, such as those containing iodides, bromides, or oral or injected steroids (either the medically prescribed or type bodybuilders or athletes take). Occupations: In some jobs, exposure to industrial products like cutting oils may produce acne.
Occupations: In some jobs, exposure to industrial products like cutting oils may produce acne. 
Workers exposed chronically to industrial oils and non-hygienic conditions are at high risk for acne.
I stumbled on your blog when I was looking for information about Nerium. A reader asked me about it and I was particularly unimpressed with the thin to nonexistent science section of their website. Glad to hear I wasn’t the only one.
I’m quite sad that you as doctors don’t put more emphasis on the role of diet in acne. A few days back I wrote about a recent Russian study that, yet again, showed a connection between diet and acne. In the post I mentioned all the acne-diet studies in the past 2 decades have shown a connection. The only studies that don’t show a connection are the 2 very poor studies in the 1969 and 70 (names of the authors escape me) that started the myth that diet doesn’t affect acne.
I know that from the scientific standpoint the evidence is less than rock solid. That said, I constantly hear from people who have been to a doctor after doctor who tells them diet has no effect on acne and they shouldn’t worry about it. Many write back later that their skin has gotten much better when they make simple dietary changes.
I do think this deserves more coverage than a small sideline comment about high glycemic index foods and dairy.
I’m not sure if you are familiar with research done by Dr. Whitney Bowe? If not, you might find her papers regarding the gut-skin axis and sebum peroxidation in acne (you can find them from PubMed) as interesting research material for your follow up post. You titled this one as part 1, so I’m assuming you are going to follow up with at least part 2.
Another great educational article. Here is an example of how through and up to date the docs are; by mentioning the food aspect: Studies show dairy products and high glycemic foods can trigger acne. The dairy products contain hormones related to lactation and pregnancy in the cow. High glycemic foods trigger insulin spikes that effect rates of androgen synthesis.
This is current information based on the side effects of putting hormones in our food supply, I would not limit this list to dairy, but all meat as well.
Acne is tough to treat but can be done………Thanks for carrying the water….