Hormonal-type acne is fairly responsive to proper dietary changes. In this section, we’ll go over the most important dietary changes for hormonal-type acne.
Avoid hormonal bombs
Some foods are, to use the scientifically accurate term, hormonal bombs. It means just what it sounds like. These foods have a substantial and direct effect on acne-relevant hormones.
Sugar is perhaps the worst food for people with hormonal-type acne. Sugar stimulates insulin release that both, directly and indirectly, causes problems for the skin. Sugar is also somewhat inflammatory. I’ll go over the details of what sugar does to your body in the sugar part of the diet section.
As far as your body is concerned, there’s no difference between so-called natural sugar and refined sugar. Natural sugar is sugar in fruits and other whole foods whereas the white stuff in grocery stores is refined sugar. All sugar is broken down and metabolized the same way (except for fructose). That said, natural sugar comes ‘packed’ with fiber that slows down absorption and nutrients that help the body to process the sugar. So natural sources of sugar, like fruits, usually aren’t bad for your skin as added sugars.
Before we get too alarmist, let’s take a step back and apply some common sense. Yes, sugar is bad for your skin, and yes, you should avoid it. But this doesn’t mean you have to cut sugar completely from your diet. That would be highly impractical and unnecessary for most people.
I recommend that you either avoid or significantly reduce sugar-rich foods, such as:
- Sugars, syrups, and sweeteners
- Sodas and other ready made drinks
- Fruit juices; stripped of fiber, the sugars will be absorbed as quickly as from sodas
- Dried fruits
- Candies, nougats, and chocolate
- Cookies, cakes, pies and bakery products
- Jams, preserves, and marmalades
- Jell-O and jellies
- Breakfast cereals (muesli is usually lower in sugar than other cereals)
- Canned fruits
- Sauces and instant gravies – often contains tons of hidden sugars
- Ice cream
- Frozen yogurt
Also, get into the habit of reading the labels on packaged foods in grocery stores. Food manufacturers find sneaky ways of loading their products with sugar – they know that anything with sugar will sell.
Avoiding the biggest sugar bombs is probably enough for most people, and there’s no need to go out of your way to cut all sugar from your diet.
Fresh fruits are perfectly ok in moderation. But you do want to be careful with bananas and other fruits that contain a lot of sugar. It’s ok to have a few bananas a day, but you don’t want to regularly eat 5 to 10 bananas a day.
White flour and refined carbohydrates
Much of what we said about sugar can also be said about white flour, white foods (like white rice), and other refined carbohydrates. These foods act like sugars in the body. Often they are broken down and absorbed even faster than sugar and thus spike insulin higher than sugar.
While I don’t think glycemic index is a very useful concept to guide your dietary choices (more on why in the glycemic index page of the diet section), it’s a good idea to keep white foods and other high GI bombs to the minimum. In my books, they are no different from sugar.
Along with sugar, dairy products are common dietary culprits in hormonal-type acne. Studies have shown that people who drink milk are more likely to have acne than those who don’t.
Most likely this happens because milk has been demonstrated to increase the levels of many acne-causing hormones. Milk stimulates the release of insulin and IGF-1 hormones. These hormones deliver a triple punch to skin that’s prone to hormonal-type acne:
- Directly stimulate sebum production and skin cell growth.
- Stimulate the release of androgen hormones.
- Make the skin more sensitive to androgen hormones by removing FOXO1 proteins from the skin. FOXO1 proteins repress androgen receptors in the skin and thus reduce skin’s sensitivity to androgens.
Phytoestrogens are plant substances that mimic the natural estrogen hormones. They bind to estrogen receptors in cells and trigger some of the same effects.
Since hormonal-type acne is linked to androgens, and estrogens help to balance androgens, in theory, phytoestrogens could reduce acne. However, the problem is that phytoestrogens are much weaker than real estrogens – sometimes thousands of times weaker. What happens is that they end up blocking the real estrogens and thus lowering the overall estrogenic effect in the body.
A brief example to illustrate the point. Let’s say that there are in total 100 estrogen receptors in the body. Think of estrogen receptors as docking sites for estrogens, and once an estrogen hormone docks, it triggers ‘estrogenic action’ in the cell. Let’s say that real estrogens trigger 100 units of estrogenic action per active estrogen receptor and phytoestrogens only trigger 1 unit.
If real estrogens activate all the 100 receptor sites, you’ll get 10,000 (100 x 100) units of ‘estrogen action’. Let’s say that phytoestrogens block 20 of those sites; then you’ll only get 8020 (80 x 100 + 20 x 1) units of estrogen action.
And that’s not all. The human body uses an enzyme called aromatase to convert androgen hormones into estrogens. Phytoestrogens can block that conversion, and by doing this, they worsen the androgen-estrogen imbalance. Studies show 20 to 30% reduction in estrogen levels after a month on a phytoestrogen-rich diet.
While there’s no data to show how phytoestrogens affect acne, they can have a negative effect on hormonal balance and that way aggravate acne. I would treat them as suspect foods.
Countless foods contain phytoestrogens, but you can reduce your phytoestrogen intake by 95% or more just by avoiding these four foods (and anything made of these):
- Sesame seeds
- Chia seeds
These three foods contain orders of magnitude more phytoestrogens than other foods. So just avoiding those three should be enough.
For more details, please see the phytoestrogens page in the diet section.
A 2015 paper reviewing the effect of various macronutrients on insulin resistance concluded the following:
In summary, most studies of SFA enriched diets have demonstrated increased insulin resistance.
Deer, J., Koska, J., Ozias, M. & Reaven, P. Dietary models of insulin resistance.Metab. Clin. Exp. 64, 163–71 (2015). https://www.ncbi.nlm.nih.gov/pubmed/25441706
The authors reviewed ten different studies examining the effect of various amounts of saturated fat on insulin resistance. 8 of the 10 studies showed that consuming saturated fats caused more insulin resistance than other types of fats (excluding trans-fats).
This doesn’t mean you have to avoid animal foods, but it’s a good idea to limit them a bit and focus more on plant-based fats from whole foods. Avocados, nuts and seeds, and olive oil are good sources of plant-based fats.
Advanced glycation end products
Dietary AGEs are another potential factor in hormonal acne. Unfortunately, no studies have looked at the relationship between AGEs and acne, but a few studies have linked AGEs to polycystic ovary syndrome (PCOS). While most women with hormonal acne don’t have cystic ovaries, acne and PCOS feature similar hormonal disturbances. And measures that help PCOS patients likely also help women with hormonal-type acne. Not to mention that women with PCOS also often have acne.
A handful of studies has linked AGEs to PCOS. These studies show that AGE levels correlate with testosterone levels. That is, women with higher blood levels of AGEs also tend to have higher testosterone levels. Whether AGEs directly or indirectly increase testosterone and other androgen levels is still unknown.
However, in 2014 Greek researchers conducted an interesting study that showed increasing or reducing AGEs in the diet also affected testosterone levels.
In the study, the researchers put 23 women with PCOS through 3 2-month diet phases: low-calorie diet (LC), normal calorie diet with high AGE content (HA) and normal calorie diet with low AGE content (LA). Here are the estimated dietary AGE exposures for each diet phase:
- Baseline (before the study): 10.9
- LC: 9.6
- HA: 16
- LA: 5.7
This image shows how each dietary phase affected androgen, insulin, and oxidative stress levels. In the graph, FAI means free androgen index, which measures abnormal androgen levels. In each case, the higher the value, the worse it is for the skin.
That graph should be fairly self-explanatory. Each acne-relevant factor was increased during the HA diet phase and reduced during the LA phase. It’s a bit hard to see from the graph, but the FAI is about 15% lower in the LA phase compared to the baseline. And you can see the massive difference in oxidative stress (inflammation) between high and low AGE diets.
Here’s the authors’ conclusion:
The main finding of the present study is that changes in dietary AGEs parallel changes in insulin sensitivity, oxidative stress and hormonal status.
We can’t conclude from this that dietary AGEs caused these changes. Rather, it’s low AGE style diet that caused them. During the HA phase the participants were asked to eat a lot of protein foods cooked in high temperature (grilled, broiled, baked) as well as nuts and sodas. Fried foods were not allowed at all.
During the LA phase, they were asked to limit red meat, poultry, and fish consumption and to cook at lower temperatures (steaming, boiling, poaching, stewing). They were also encouraged to eat more pasta, legumes, and boiled vegetables.
Given that the diets during the different phases were quite different, it’s not possible to lay all the blame on AGEs, and that’s why I said that it’s low AGE style diet that caused the improvement.
We still don’t know why AGEs affect testosterone and androgen levels. Scientists speculate it comes down to oxidative stress. AGEs accumulate in and cause damage to tissues. This can cause insulin resistance and trigger androgen release from adrenals and ovaries/testes.
For more detailed discussion of AGEs, what they are, how to avoid them, and how they affect health, see the AGE page in the diet section.
When you eat can be as important, even more important, than what you eat. This is especially true for hormonal-type acne.
In a nutshell, evolution has shaped the human body to process foods at certain times and to be at rest at other times. Our hormones go through daily cycles that affect our ability to digest and process food. For more detailed explanation, please see the meal timing page of the diet section.
But let’s see what proper meal timing can do for acne-relevant hormones.
In a 2012 study researchers gave healthy participants 3 identical meals to be consumed as breakfast, lunch, or dinner. The results showed that insulin levels were about 30% lower after breakfast as compared to the same meal eaten as dinner. And because your body processed carbohydrates better early in the day, the carbohydrates have less of an impact on acne-causing hormones than the same about of carbs eaten in the evening.
This was nicely demonstrated in a 2013 study where researchers divided 60 lean women with PCOS into two groups: breakfast diet (BD) and dinner diet (DD). Both groups consumed otherwise identical diets, but the BD group consumed most of their calories in the morning and DD in the evening. Here’s the caloric breakdown for both groups:
- BD: 980 kcal (55%) / 640 kcal (35%) / 190 kcal (10%) (breakfast / lunch / dinner)
- DD: 190 kcal / 640 kcal / 980 kcal
Here are the improvements in acne-relevant parameters after 90 days. Positive values mean things got better.
Source: Jakubowicz, D., Barnea, M., Wainstein, J. & Froy, O. Effects of caloric intake timing on insulin resistance and hyperandrogenism in lean women with polycystic ovary syndrome. Clin. Sci. 125,423–32 (2013). https://www.ncbi.nlm.nih.gov/pubmed/23688334
In a nutshell, there were significant improvements in all acne-relevant parameters in the breakfast group while there was no before/after change in the dinner group.
Overemphasizing these results is hard. These improvements are comparable, perhaps even better, than what’s seen with prescription drugs and rigorous exercise programs. And yet, these women didn’t have to stick to a restricting diet. The only thing they changed was to eat most of the calories in the morning, i.e. in tune with the metabolic rhythms of the human body.
Other studies have come up with similar findings, but there’s no point to go through all of them. The take home message is that eating most of your calories early in the day and keeping dinner and evening meals as light as possible seems to reduce many of the hormones linked to acne.
I don’t mean that you can’t eat anything in the evening. It’s ok to eat in the evening if you are hungry. Just make sure to get most of your calories in early.
If you want to take this a step further, and I’m not sure it’s necessary, you could restrict carbohydrates in the evening. Given that insulin sensitivity peaks in the morning, it’s better to eat most of your carbohydrates early and make sure evening meals are predominantly fat and protein.
Macronutrient ratio refers the ratio of carbohydrates, fats, and proteins in the diet. It’s expressed as the percentage of total calories coming from carbohydrates, fats, and proteins.
A lot has been written about the supposedly perfect macronutrient ratio for humans. “Expert” opinions vary wildly. Some people claim fat is the enemy and promote low-fat diets, while others demonize carbohydrates and advocate minimizing them.
The truth is that science hasn’t yet uncovered the optimal macronutrient ratio. Probably because it’s likely no such thing exists.
The results from studies comparing different diets with different macronutrient ratios are best described using the highly scientific term ‘meh’. In other words, when both diets consist of healthy foods it doesn’t matter whether you eat carbohydrates or fat.
That said, we know that carbohydrates, and proteins to some degree, cause the pancreas to pump out insulin. As discussed elsewhere in the course, insulin stimulates the skin cells directly and triggers a release of other acne-relevant hormones. So it makes sense to do your best to maintain stable and low insulin levels.
Keeping that in mind, I do think it’s a good idea for people with hormonal-type acne to moderate carbohydrates. There’s no need to go low carb, but carbohydrate moderation is sensible.
My current guideline is to limit carbs to around 30 to 40% of your total calories. Though, this is anything but a hard and fast rule. The other dietary recommendations discussed here will probably help your skin much more.