Acne is considered by many to be a right-of-passage that must be endured on the way to adulthood. And, the research says this may be true. It is estimated that nearly 85 percent of people develop acne at some point between ages 12 and 25, regardless of country of origin.1

However, aestheticians know that acne is no longer just a skin condition isolated to the teenage years. Today, there is an increasing number of individuals whose acne continues well into middle age, as well as those whose skin remains clear through their teenage years only to experience the initial onset of acne in their late 20s or 30s. There are many theories as to why this is happening, including stress and diet, but the prevailing factor is hormones. And, the reality is, hormonal acne affects women much more than men. In fact, according to the American Academy of Dermatology, more than 50 percent of women between the ages of 21 and 30, 26 percent of women ages 31 to 40, and 12 percent of women ages 41 to 50 have clinical acne.

THE ROLE OF HORMONES IN ACNE DEVELOPMENT

To fully understand how hormones impact acne, it is vital to first recognize the four direct causes of the condition:

1. The sebaceous glands create an excessive amount of sebum.
2. The cells of the hair follicle are abnormally sticky and do not shed properly. This is referred to as follicular hyperkeratinization.
3. There is a prevalence of acne bacteria. Formerly known as Propionibacterium acnes, the bacterium that causes acne has recently been reclassified as Cutibacterium acnes.
4. Inflammation is present, which can both trigger acne and be a side effect of it.

While hormones are not a direct cause of acne, they are a trigger – and a major one, at that. During puberty, hormone levels spike. However, it is the increased levels of androgen hormones, specifically, that cause acne – hormones that are present in both males and females. When these hormones bind with androgen receptors in sebaceous gland cells, the glands are signaled to become larger and increase production of sebum. Combine this increase in sebum with dead skin cells that are collecting around the pores (follicular hyperkeratinization) and the result is clogged pores that lead to the formation of whiteheads and blackheads – comedones that can be extracted. Clogged pores, however, present a hospitable environment for acne bacteria due to the absence of oxygen, which leads to bacterial proliferation. When bacteria invade the pore, inflammation and infection can result. Acne of the inflammatory variety is typically characterized by red, swollen, and sometimes painful pimples that cannot be extracted. In severe cases, deep acne nodules and cysts may develop.
At the end of puberty, hormone levels stabilize and persistent acne subsides in most individuals. While men are generally spared acne’s wrath after their mid-20s, most women continue to experience occasional acne breakouts until full menopause is reached. Breakouts can accompany hormonal fluctuations during menstruation, pregnancy, and early menopause. The main culprit here is varying levels of estrogen – the female hormone that acts in opposition of androgen in the sebaceous gland and slows the production of oil.
Cyclical acne occurs prior to menstruation as estrogen levels drop, causing androgens to be temporarily higher in the body. This leads to higher production of sebum.
Acne during pregnancy is typically at its worst during the first trimester when progesterone levels are substantial. While the role of progesterone in the development of acne is not well understood, there is suspicion that, like androgens, it may stimulate the sebaceous glands.2 An additional hypothesis is that progesterone provides the skin with a tightening effect, thereby causing pores to minimize, trap sebum, and clog
more easily.
Acne accompanying menopause occurs due to the natural decline in estrogen levels, while androgen levels remain constant. This explains why, for some individuals, acne becomes an issue in middle age. It is also the reason for other annoyances of middle age, such as the occasional chin hair.

ADDITIONAL CAUSES OF ACNE

It stands to reason that nearly all acne is hormonal in nature. However, there are conditions in which acne is triggered by other factors. Among them are: the use of comedogenic makeup or skin care products that block pores; the use of products that contain irritating ingredients, resulting in acne tied to an allergic reaction; frequently holding a phone against the skin; and the friction caused by hats, sports equipment, and so forth. Acne that develops due to heat or friction is called acne mechanica.
Diet can also influence the development of acne, especially the consumption of high-glycemic foods that spike blood sugar, and can also increase hormones that impact sebum levels.3 Consumption of dairy has also been implicated, as hormones present in milk are believed to trigger the factors that cause acne.4
Another factor is stress. The exact mechanisms by which psychological stress aggravate acne are not fully understood. However, research suggests that sebaceous glands have receptors for neuropeptides that are released during times of stress. When they bind, sebum production and
inflammation increase.5

IDENTIFYING HORMONAL ACNE

To determine if acne is hormonal, it is vital to first take an inventory of client lifestyle factors, like diet and stress levels, and recognizable hormonal fluctuations. Often, a suspected connection to acne can be pinpointed through this exercise, presenting an opportunity to test elimination of controllable factors, like foods, before moving on to more serious intervention. It is through this exercise that professionals may also be able to identify hormonal occurrences at play. For example, if breakouts worsen in conjunction with menstruation or if the client is approaching menopause, hormones are likely a factor.
Hormonal acne often bears visible characteristics that allow it to be identified. Breakouts that appear primarily on the lower face and along the jawline tend to be hormonal. Additionally, blemishes due to hormones tend to be inflamed cysts that lie below the skin and can be tender or painful. If a client’s acne is characterized by comedones, hormones are likely not the cause.
When acne is simply unexplainable – that is, diet and lifestyle factors do not seem to be at work and hormonal fluctuations are not obvious – deeper investigation by a physician may be warranted. This is because, in rare cases, acne may be the sign of a hormonal abnormality, such as adrenal hyperplasia, polycystic ovarian syndrome (PCOS), Cushing’s Syndrome, and more. This is especially of concern when the client is also experiencing excess facial or body hair, infrequent periods, and a deepening of their voice.

COMBATTING HORMONAL ACNE

The first rule of acne treatment, whether it is hormonal or otherwise, is straightforward: the intensity of treatment should match the severity of the acne. In other words, clients should avoid pursuing a prescription-strength approach to their breakouts if the condition is mild. In fact, in nearly all cases, it is wise to begin with a topical approach to acne treatment and ramp up as needed.

Homecare
With any client experiencing acne, a necessary first step is the development of a comprehensive homecare regimen using products formulated with high-quality ingredients that are proven to benefit acne-prone skin. The most commonly used ingredient in the treatment of acne, benzoyl peroxide is an old standby that has been used for decades. This ingredient is a must for those with acne because of its ability to kill acne bacteria. However, side effects are common, including dryness and peeling. Therefore, it is recommended that clients begin with products that feature a low strength and work up in concentration as skin adjusts.
Salicylic Acid: A beta hydroxy acid, salicylic acid works to soften and exfoliate dead skin cells, thereby unclogging pores and normalizing the skin cell renewal cycle. While alpha hydroxy acids, such as glycolic acid, are also beneficial in the treatment of acne, salicylic acid is ideal because it is oil-soluble and, as such, can penetrate clogged pores more readily.
Zinc Pyrithione: Another acne ingredient that has been in use for decades, zinc pyrithione is an antibacterial that is effective on acne bacteria. It also helps to regulate sebum levels.
Retinol: A derivative of vitamin A, retinol dissolves built-up layers of dead skin cells to unclog pores and keep them clear. What is more, it has anti-inflammatory benefits.
Aloe Vera: Because many acne-fighting ingredients can have a drying effect on the skin, it is vital that acne treatments include ingredients to nurture the skin. Aloe vera is a dream ingredient because it helps to reduce inflammation, has antibacterial properties, improves skin hydration, and aids in the healing of damaged skin.
Additionally, to minimize the potential for dryness which can cause acne symptoms to worsen, use of a hydrating toner throughout the day is beneficial.
The client’s progress should be monitored closely, as acne skin care products can take several weeks to begin showing positive results. In fact, acne symptoms may worsen before they improve as the skin adjusts to use of the products. It is very common for acne sufferers to throw in the towel when this happens, whereas hanging in there for a few additional days could reveal clearer skin.
Once the skin has begun showing improvement, it is vital to watch for a leveling off to occur; that is, the point at which acne shows no further improvement. If and when that happens, frequency of use of acne treatments and chemical exfoliators can be gradually increased and acne products with higher potencies can be introduced. An example of this would include switching to a cleanser with a higher percentage of benzoyl peroxide.

Professional Treatments
As the client’s skin adjusts to use of an acne homecare regimen, the introduction of professional treatments may accelerate healing. Consider supplementing the client’s regimen and professional treatments with regular salicylic acid chemical peels, deep cleansing, exfoliating facials, and high-
frequency treatments.

Prescription Medications
For severe or stubborn cases of acne, clients should be advised to see a dermatologist who can prescribe medications that have been proven effective in the treatment of acne.
Hormonal Therapies: In the case of hormonal acne, physicians often prescribe medications intended to bring hormone levels into balance. The most common medications used for this purpose are combination oral contraceptives, several of which have been FDA-approved to treat acne. Among them is Ortho Tri-Cyclen, which reduces androgen levels while increasing levels of estrogen. However, birth control use is accompanied by potential risks, including blood clots, heart attack, and stroke. What is more, oral contraceptives are not an option for those who are pregnant or trying to
become pregnant.
Anti-androgens: Anti-androgens, such as spironolactone, block the effects of androgens on the sebaceous glands, while glucocorticoids, including dexamethasone, suppress androgen production. Like oral contraceptives, these anti-androgens come with side effects ranging from dizziness and weight gain to hypertension and osteoporosis.
Antibiotics: Oral antibiotics, like tetracycline, are often prescribed to kill acne bacteria and reduce inflammation. However, bacterial resistance is a common risk, which is why antibiotics are typically prescribed for only a short period of time.
Retinoids: Isotretinoin (Accutane) and tretinoin (Retin-A), vitamin A derivatives, are the most commonly prescribed medications for acne and are considered among the most effective treatments available. Retin-A is used topically and is effective in unclogging pores and keeping them clear by encouraging proper shedding of cells.
Accutane is taken orally and works by addressing all of the direct causes of acne: it reduces sebum levels, kills acne bacteria, reduces inflammation, and normalizes cellular turnover. However, use of this medication also comes with serious risks, which is why it is best reserved as a last resort for moderate to severe acne. Side effects include dry skin, liver damage, and, if pregnant, birth defects. In fact, most physicians require patients to take a blood test to verify they are not pregnant before beginning use of isotretinoin and to participate in the iPledge safety program to ensure pregnancy does not occur while using the medication. If working with a client who is currently or has recently used isotretinoin, it is vital that chemical peels, dermabrasion, or laser treatments are not performed until they have not used the medication for at least six months. This is because isotretinoin compromises the skin’s ability to heal and regenerate.

Dietary Changes and Supplementation
Given research findings that point to a link between acne and diets high in refined carbs or dairy, many clients will find improvement in their acne symptoms after adopting a diet that includes antioxidant-rich foods like green vegetables and berries and is low in white flours, sugar, starchy vegetables, and milk. What is more, research has pointed to the benefit of certain supplements in the reduction of acne symptoms, including omega-3 fatty acids, zinc, and chromium, among others.6,7,8

By its very nature, hormonal acne can be unpredictable, stubborn, and difficult to treat. Because of this, it is important to remind clients experiencing hormonal acne that it is certainly possible to improve the condition of their skin; however, hormonal acne stands to return as long as hormonal fluctuations are occurring, and depending on the age of the client, that can last for many years. For that reason, a long-term relationship between the aesthetician and client is essential. By taking the time to understand the various factors that contribute to the development of hormonal acne and, in turn, educating clients about the causes and triggers that may be responsible for their breakouts, a professional will be proven a trustworthy ally in their fight against acne, resulting in improved compliance with their homecare regimen and greater openness to lifestyle modifications that can improve their skin.

References
1 Ewadh, MJ, KA Shemran, and KJ Al-Hamdany. “The Correlation of Some Hormones with Acne Vulgaris.” International Journal of Science and Nature 2, no. 4 (2011): 713-717.
2 Arora, MK, A Yadav, and V Saini. “Role of Hormones in Acne Vulgaris.” Clinical Biochemistry 44, no. 13 (2011):1035-40.
3 Smith, RN, NJ Mann, A Braue, et al. “A low-glycemic-load diet improves symptoms in acne vulgaris patients: a randomized controlled trial.” American Journal of Clinical Nutrition 86, no. 1 (2007): 107-15.
4 Adebamowo, CA, D Spiegelman, FW Danby, et al. “High school dietary intake and teenage acne.” Journal of the American Academy of Dermatology 52, no. 2 (2005): 2017-14.
5 Jovic, A, B Marinovic, K Kostovic, et al. “The Impact of Psychological Stress on Acne.” Acta Dermatovenerologica Croatica 25, no. 2 (2017): 133-41.
6 Jung, JY, HH Kwon, JS Hon, et al. “Effect of dietary supplementation with omega-3 fatty acid and gamma-linolenic acid on acne vulgaris; a randomised, double-blind, controlled trial.” Acta Dermato-Venereologica 94, no. (2014):521-6.
7 Micaelsson, G, L Juhlin, and A Vahlquist. “Effects of oral zinc and vitamin A in acne.” Archives of Dermatology 113, no. 1 (1977): 31-6.
8 Dreno, B, P Foulc, A Reynaud, et al. “Effect of zinc gluconate on propionibacterium acnes resistance to erythromycin in patients with inflammatory acne: in vitro and in vivo study.” European Journal of Dermatology 15, no. 3 (2005): 152-5.

Ahmed Abdullah is a board-certified plastic and cosmetic surgeon and is CEO and founder of Lexli International, Inc. A recognized expert on the restorative and medicinal effects of aloe vera, Abdullah is the lead formulator of the Lexli line of aloe-based skin care. He is a member of the International Aloe Science Council (IASC) and has served on its board of directors. Abdullah is a diplomat of the American Board of Surgery and the American Board of Plastic Surgery. He earned his medical degree from Northwestern University in Chicago and completed his residency at the University of Texas Medical Branch in Galveston, Texas.