Getting diagnosed with a cancer is perhaps one of the most horrifying things. Often it means you are going to die slowly and there’s not much you can do about it. Similarly hearing a doctor describe your acne as hormonal can feel equally bad. Why? Because hormonal acne is often seen as something that’s out of your control.
But just because your acne is hormonal doesn’t mean it’s out of your control. Because acne formation relies heavily on two hormones: insulin and insulin like growth factor 1 (IGF-1), both of which depend heavily on what you eat. Similarly prudent application of topical treatments can mitigate the damage androgens do to your skin.
I hope that after reading this post you’ll understand the role hormones play in your acne, and what you can do about it.
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Acne formation process and the role of hormones
To understand the role hormones play let’s briefly walk through the acne formation process. I’ll point out which steps are affected by hormones and which are not.
Excessive sebum production is perhaps the key characteristic of acne. Sebum production in the skin is handled by cells known as sebocytes. They are a bit like water balloons in that they gobble fatty acids and grow bigger and bigger. Once they mature they make their way into the hair canal where they burst and spill the sebum. Hormones stimulate the growth of sebocytes and thus sebum production.
Blockage of the hair canal (follicle) by dead skin cells is another key characteristic of acne. Cells known as keratinocytes are the most common cells in the outer layer of the skin. They form the walls of the hair canal. In a healthy skin they die and separate and are pushed out of the skin by the growing hair. In an acne-prone skin this process goes haywire for two reasons.
- Excess growth of skin cells.
- Condition known as hyperkeratinization. Keratin is a protein that binds these cells together, and when you have too much of keratin the bonds between the cells are stronger. So when the cells die they are more likely to stick together and block the hair canal.
There’s a good reason to believe hormones affect both of those. It’s known that hormones accelerate the growth of skin cells (thus more dead skin cells to eliminate), and researchers suspect that hormones up-regulate keratin levels (and thus hinder separation of dead skin cells).
Once the hair canal is blocked by a sticky mixture of sebum and dead skin cells it starts to swell as more and more dead skin cells are pushed into the area. Oxygen levels plummet at the blocked pore, and this creates an ideal environment for P. Acnes bacteria to thrive.
Inflammation results as the immune system attacks the bacteria in the blocked pore. Acne patients have markedly stronger inflammatory response to P. Acnes bacteria than people with healthy skin. There’s good reason to believe this is regulated by hormones, especially in men.
To summarize, hormones affect all the primary causes of acne: sebum production, skin cell growth and separation and inflammation.
The culprits: Insulin, IGF-1 and androgens
Now that we understand how hormones affect acne, let’s see which hormones are to blame. This discussion could get very complicated very quickly, as different hormones have somewhat different effects on different cell types in the skin. But we don’t have to worry about what. So, in the interest of keeping things simple we can say that the primary hormones behind acne are:
- Insulin is a storage hormone (among other things). It takes glucose (sugar) and amino acids (protein) from bloodstream to the cells. Eating carbohydrates and protein (to lesser extent) will cause insulin levels to increase.
- Insulin like growth factor 1 (IGF-1) is a growth hormones. It often goes hand in hand with insulin, so anytime insulin increases so does IGF-1.
- Androgens are male sex hormones, of which testosterone is the best known. Other acne-relevant hormones are dihydrotestosterone (DHT) and dehydroepiandrosterone (DHEAS).
Let’s review what these hormones do.
Insulin and IGF-1
While these are separate hormones I’ll clump them together as they go hand-in-hand. Studies have repeatedly shown a connection between acne and IGF-1 levels. There are also studies that show higher rates of insulin resistance in acne patients as compared to people with healthy skin. Insulin resistance means the cells don’t respond to insulin and the pancreas has to pump out more to compensate. And more insulin of course also means more IGF-1.
Here’s how these hormones affect the skin:
- IGF-1 stimulates the growth of sebocytes and thus increases sebum production. One study demonstrated correlation between IGF-1 levels and facial sebum production.
- Make skin cells grow faster
- Stimulate the synthesis of androgens in the testes and ovaries
- Make the skin more sensitive to androgens
So while insulin and IGF-1 act on the skin directly their primary effect on acne comes from the fact that they multiply the effect of androgens.
Acne belongs to the group of hyperandrogenic diseases, which means conditions characterized by excessive production of androgens. Other such conditions are polycystic ovary syndrome and male pattern baldness, and that’s why they can appear together with acne.
Here’s how androgens directly affect acne:
- Increase sebum production, much like IGF-1 does
- Stimulate the growth of skin cells
- Hinders separation of dead skin cells
- Increase inflammation. Testosterone and DHT up-regulate inflammatory response to injury. This not only makes the pimple bigger and more painful but also slows down healing of the wound.
Androgens may affect acne also indirectly by weakening the skin barrier function. Healthy skin barrier retains moisture and prevents entry for bacteria and other pathogens. And weaker skin barrier function makes the skin just that much more prone to acne.
Studies have shown that acne-prone skin has markedly weaker skin barrier function than healthy skin, and it’s likely androgens play a role in this. Interestingly topical application of caffeine can correct this, and that’s probably the reason Exposed Skin Care includes caffeine in their products.
Multiplier effect: conversion of testosterone to DHT
The human skin is not just a passive organ. It actively processes and creates hormones. One example of this is the conversion of testosterone to DHT, which is up to 10 times more potent testosterone.
An enzyme called 5-alpha reductase is responsible for this conversion. Here comes yet another difference between acne-prone and healthy skin. In acne-prone this enzyme is much more active. IGF-1 further stimulates this conversion and makes a bad situation even worse.
Luckily there are substances known as 5-aplha reductase inhibitors. They inhibit the conversion and reduce sebum production. Green tea is an example of such substance, and that’s why one study showed 70% reduction in sebum production after applying green tea cream. See the green tea and acne page for more details.
Summary so far
Acne is a primarily androgen-mediated condition, but IGF-1 acts as an accelerant in this process. And while there’s not so much you can do to affect androgen levels, you can control hormonal acne by maintaining stable insulin and IGF-1 levels.
Studies measuring the levels of these acne-causing hormones have found similar levels between acne patients and those with healthy skin. So it’s not the absolute levels of these hormones that cause acne, but how acne-prone skin reacts to them. One example is the increased conversion of testosterone to DHT.
And this is where genes come into play. Because of genetic factors acne patients are deficient in nuclear transcription factor FoxO1. Sebum production and skin cell growth are out of control in acne patients. FoxO1 acts like a break to these processes, and it’s malfunctioning. It reduces sensitivity to androgens by suppressing androgen receptors and regulates cell growth and inflammation. Thus there’s a good reason to believe that the less FoxO1 is present in the skin the more prone to acne it is.
Insulin and IGF-1 can make the situation even worse by further reducing FoxO1 levels.
For more information, please see the genes and acne page.
Diet and hormonal acne
What you eat can show up on your skin, and one way this happens is through hormones. Studies link acne to Western-style diets (high in sugar and calories), and given what we know this is not a surprise. Eating sugar and refined carbohydrates causes the pancreas to release large amounts of insulin and IGF-1. Over time this type of diet leads to insulin resistance and chronically high levels of these acne-causing hormones.
Eating minimally processed low glycemic index foods can reverse the situation, and this has been now demonstrated in several studies.
But it’s not only sugar that gives you pimples; dairy products are also to blame. What’s the role of milk? To help baby cows grow. So it’s not a surprise milk has plenty of IGF-1 and other growth hormones. These hormones make their way into your blood and eventually to your skin where they stimulate sebum production and skin cell growth.
Summary and take-home messages
- Hormones affect all the steps in the acne formation process. They increase sebum production and skin cell growth, hinder separation of dead skin cells and increase inflammation.
- The hormones responsible are: insulin, insulin like growth factor 1 (IGF-1) and androgens.
- Androgens have a more profound effect on the skin whereas insulin and IGF-1 multiply the damage androgens cause.
- Acne patients may have higher levels of these hormones but that’s not always the case.
- Genes make acne-prone skin more sensitive to these hormones.
- There’s not much you can do about androgen levels, but you can control insulin and IGF-1 levels with proper dietary and lifestyle choices, and that’s the key to controlling hormonal acne.
- Caffeine improves barrier function in male skin.
- Testosterone Perturbs Epidermal Permeability Barrier Homeostasis
- Androgen receptor–mediated inhibition of cutaneous wound healing
- Increased Prevalence of Metabolic Syndrome in Patients with Acne Inversa
- Insulin resistance and acne: a new risk factor for men?
- Mild insulin resistance during oral glucose tolerance test (OGTT) in women with acne.
- Elevated serum insulin-like growth factor-1 (IGF-1) levels in women with postadolescent acne.
- Adrenal androgen abnormalities in women with late onset and persistent acne.
- Correlation between serum levels of insulin-like growth factor 1, dehydroepiandrosterone sulfate, and dihydrotestosterone and acne lesion counts in adult women.
- Role of hormones in acne vulgaris.
- Acne and systemic disease.
- Role of insulin, insulin-like growth factor-1, hyperglycaemic food and milk consumption in the pathogenesis of acne vulgaris. (PDF)
- Human Skin: An Independent Peripheral Endocrine Organ (PDF)
- Correlation of facial sebum to serum insulin-like growth factor-1 in patients with acne
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