Published September 11 2017
The National Institute of Arthritis and Musculoskeletal and Skin Diseases define acne as a disorder resulting from the action of hormones and other substances on the sebaceous glands and hair follicles (1) [1]. Acne is a common skin condition and mostly affects teenagers and young adults. It is further estimated that 80% of people between the age of 11 and 30 have acne outbreaks at some point. However, a small percentage of older adults have acne as well. In this article I’ll discuss the relationship between the different types of hormone imbalances that can cause acne, including thyroid hormone imbalances.
While I will briefly talk about the relationship between acne and thyroid health in this article, much of this information will also benefit those who have acne in the absence of a thyroid or autoimmune thyroid condition. As a result, if you know of a friend or family member who has acne, please feel free to pass this information along.
What Are The Causes of Acne?
While the exact cause of acne can vary depending on the person, here are some of the more common factors which can lead to acne:
- High androgen levels. Elevated sebum excretion is involved in the development of acne. And high levels of androgens can lead to changes in sebaceous gland functions, which in turn lead to an increased production of sebum.
- Different types of medications. Certain types of medications can lead to drug-induced acne. This usually is characterized by a sudden onset of acne lesions after taking medications, and some of the drugs that can play a role include corticosteroids, anabolic steroids, testosterone, halogens, isoniazid, lithium, and some new anticancer agents (2) [2].
- Genetic factors. Acne does appear to run in families. One small study involving identical and non-identical twins showed that genetics play a big role in sebum excretion, while environmental factors plays a greater role in the development of acne lesions (3) [3].
- Using birth control pills. Pills that include both an estrogen and progestin usually don’t exacerbate acne, and in fact can help with many cases of acne by decreasing androgen levels and sebum production. On the other hand, progestin-only birth control pills can exacerbate one’s acne condition.
- Stress. The research shows that sebaceous glands can act as independent endocrine organs, and thus can respond to changes in androgens in a similar manner as the hypothalamus-pituitary-adrenal (HPA) axis (4). Corticotrophin-releasing hormone (CRH) is involved in the stress response, and it also regulates sebaceous gland function (4) [4], and this may explain the relationship between stress and skin conditions such as acne.
- Eating foods which spike insulin levels. I’ll talk more about the relationship between diet and acne later in this article, but a few different studies show a correlation between insulin resistance and acne (5) [5] (6) [6]. As a result, the frequent consumption of foods with a high insulin index (i.e. dairy, refined sugars, etc.) can lead to the development of acne.
What Are The Different Types of Acne?
Acne Vulgaris. This is a medical term for common acne which includes the presence of whiteheads, blackheads, and other form of pimples on the skin. Breakouts often occur on the face, chest, back, and the shoulders. Although I’ll briefly discuss other types of acne below, the main focus of this article will be on acne vulgaris.
Acne Rosacea. While the spots in acne rosacea are similar to those of acne vulgaris, the main difference with this type of acne is that there are no blackheads. Moreover, it’s accompanied by a red rash on the cheeks, forehead, nose, and chin. Primarily, acne rosacea affects women over 30 and it’s the second most common type of acne after vulgaris.
Cystic Acne. This is a more severe type of acne, and it involves large, red, pus-filled lesions that are usually painful to touch.
Acne Conglobata. This is a rare condition that is often resistant to therapy, and usually presents as numerous acne lesions, papules, pustules, nodules, abscesses, and draining sinus tracts that involve the chest, back, and buttocks (7) [7]. This type of acne can lead to permanent scars and at times skin damage.
The Four Main Pathways of Acne Vulgaris
Since acne vulgaris is the primary type of acne I’m focusing on in this article, I’d like to briefly discuss the four main pathways involved in the development of this type of acne:
1. Excess sebum production by androgen-mediated stimulation of sebaceous glands. The sebaceous gland is considered to be an important endocrine organ embedded in the skin (8) [8]. Sebum is a product of the sebaceous gland, and it is a mixture of lipids composed mainly of triglycerides, wax esters, squalene, free fatty acids and smaller amounts of cholesterol, cholesterol esters and diglycerides (8). Elevated levels of sebum play a role in the development of acne.
2. Abnormal keratinization of the follicles leading to plugging and comedone formation. Keratins are a diverse group of structural proteins that form the intermediate filament network responsible for maintaining the structural integrity of keratinocytes (9) [9]. So what does this mean? Well, essentially keratins are a type of protein that help epithelial cells maintain their structural integrity, but these epithelial cells are compromised when someone has acne vulgaris.
By the way, a comedo is simply an enlarged and plugged hair follicle. If the comedo stays beneath the skin, it is called a closed comedo, and it produces a white bump called a whitehead (10) [10]. A comedo that reaches the surface of the skin and opens up is called an open comedo, or a blackhead (10). Multiple acne lesions are known as comedones.
3. Propionibacterium acnes colonization. Propionibacterium acnes is a gram-positive bacterium that forms part of the normal flora of the skin, oral cavity, large intestine, the conjunctiva and the external ear canal (11) [11]. Although this bacteria is associated with the development of acne vulgaris, it also can lead to infections of the bones and joints, mouth, eye, and brain (11) [11]. Propionibacterium acnes may play a role in other conditions, including inflammation of the prostate leading to cancer, SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome, sarcoidosis and sciatica (11) [11].
4. Inflammation of the follicle and surrounding dermis. Inflammation seems to be a factor both in the early stages and later stages of acne (12) [12]. While Propionibacterium acnes can play a role in the development of inflammation, the inflammatory process can also occur even in the absence of this bacteria (12) [12]. Since inflammation plays an important role in the development of acne, anti-inflammatory drugs are sometimes recommended.
The Relationship Between Acne Formation and Hormones
Hormones can play a major role in the formation of acne. Let’s take a look at the individual hormones that can play a role in the development of this condition.
DHEA. This hormone is produced by the adrenal glands, and it converts into testosterone. As a result, if someone has elevated DHEA levels, along with elevated testosterone levels, then this would indicate an adrenal source of the androgens. And if the elevation is extremely high (i.e. >8,000 ng/mL) then this usually indicates the presence of an adrenal tumor.
Testosterone. In women with elevated testosterone levels and normal or low DHEAS levels, this usually indicates an ovarian source of the hormone.
Dihydrotestosterone (DHT). Like testosterone, DHT is an androgen that can lead to increased sebum production, and therefore can play a role in the development of acne.
Estrogen. Although too much estrogen isn’t a good thing, healthy levels of estrogen can help with acne by increasing SHBG, which will result in lower levels of free testosterone. Estrogen can also reduce the size of the sebaceous gland, which in turn will reduce sebum formation.
Progesterone. This hormone will inhibit 5α-reductase, which is necessary for the conversion of testosterone to DHT.
Insulin. When talking about a hormonal cause of acne, many focus solely on the sex hormones. However, insulin is a hormone as well, And insulin stimulates the growth and maturation of sebaceous glands. In addition, insulin inhibits the production of SHBG and leads to an increased production of androgens by both the adrenals and ovaries. This is how eating a poor diet can lead to acne, as certain foods result in an increased secretion of insulin, which in turn causes the excess production of androgens and sebum. Not surprisingly, eating a lot of refined foods and sugars on a frequent basis will increase the risk of developing acne.
Can Thyroid Hormone Imbalances Cause Acne?
There is no direct correlation between hypothyroidism and acne, and I also didn’t find a correlation between hyperthyroidism and acne. However, I did come across a study which looked at the relationship between acne and thyroid autoimmunity in adult women (13) [13]. The study showed that those with acne had higher levels of thyroglobulin antibodies, although they didn’t have elevated TPO antibodies. The authors concluded that thyroid autoimmunity is likely to be more frequent in adult acne patients.
The Flaws Of Hormone Testing
Although androgens are essential for the formation of acne, many women with acne present with normal serum levels of androgens. This includes the serum levels of DHEAS, testosterone, and DHT. While the levels might be high in some people with acne, this isn’t always the case. However, even when the hormone levels are normal, treatment designed to lower androgen levels can help with many cases of acne.
If the blood tests are negative, when should a hormonal cause of acne be suspected? Well, if a woman presents with acne that is severe, associated with hirsutism (the presence of hair in a male-like pattern), or irregular menstrual periods (14) [4], then a hormone imbalance is the likely cause. Other signs include cushingoid features (i.e. facial puffiness), increased libido, presence of acanthosis nigricans (dark, coarse and thickened skin with a velvety texture), and androgenetic alopecia (14) [4].
Conventional Treatment Methods For Hormone-Based Acne
Unfortunately the medical treatment of choice for acne usually comes down to taking one of the following drugs:
Benzoyl peroxide. This is a form of topical therapy for acne vulgaris, as it can greatly reduce Propionibacterium acnes and inflammatory acne lesions, and it also is effective in reducing noninflammatory acne lesions (15) [14]. Benzoyl peroxide is equally effective at concentrations of 2.5, 5.0 and 10%, although a concentration-dependent irritant dermatitis can occur when taking higher concentrations (16) [15].
Salicylic acid. The ability of salicylic acid to exfoliate the stratum corneum makes it a useful peeling agent for patients with acne (17) [16]. Over the counter salicylic acid acne treatments include concentrations of 0.05% to 5%, and adverse reactions are usually limited to a mild, local irritation (18). Studies have shown that salicylic acid is superior to benzoyl peroxide in reducing the total number of acne lesions (18) [17] (19) [18].
Topical and oral antibiotics. These include clindamycin, doxycycline, erythromycin, and tetracycline. Topical antimicrobials work via both antimicrobial and non-antimicrobial mechanisms (20). Clindamycin seems to be more effective when compared to erythromycin and tetracycline, although the propionibacterial species is becoming more resistant to clindamycin and erythromycin (20) [19].
Topical retinoid medications. These include tretinoin (Retin-A), adapalene (Differin), and tazarotene (Tazorac). Topical retinoids expel mature comedones, reduce microcomedone formation, and exert anti-inflammatory effects (21) [20]. They can be effective for most types of inflammatory and non-inflammatory acne, and unlike topical and oral antibiotics, long-term use of topical retinoids doesn’t result in bacterial resistance (21).
Isotretinoin. This is an oral retinoid, also known as Accutane, and it has been considered to be a major pharmacological breakthrough for treating severe and recalcitrant cases of inflammatory acne (22) [21]. However, side effects are common, including dry skin, dry eyes, cheilitis, muscle pain, increased serum triglycerides, and elevated liver enzymes (22) [21].
Azelaic acid. This is a topical cream that is used in the treatment of mild to moderate acne vulgaris (23) [22]. One study showed that it was equally effective as a topical retinoid (tretinoin cream), and was better tolerated with fewer side effects (24) [23].
Oral contraceptives. I briefly mentioned earlier how birth control pills that contain estrogen can help with acne, although shortly I’ll explain why oral contraceptives usually is not a good option for the treatment of acne.
Androgen blockers. An example is Spironolactone, which decrease the androgen levels, and as a result, will decrease sebum production.
Glucocorticoids. These cause the suppression of androgen production, and they also have anti-inflammatory effects. With regards to suppressing androgen production, glucocorticoids accomplish this by suppressing the adrenals, which of course isn’t a good thing. While taking low doses of glucocorticoids for severe cases of acne might be indicated in some cases, I would try to avoid these whenever possible.
5α-reductase inhibitors. This enzyme catalyses the conversion of testosterone into the more potent androgen dihydrotestosterone (DHT), which in turn leads to increased sebum production, and thus is a factor in the development of acne. And so drugs which inhibit this enzyme can reduce the conversion of testosterone to DHT, and thus can help in some cases of acne.
Why Not Take Oral Contraceptives For Acne?
Oral contraceptives are commonly recommended for acne, especially when PCOS is confirmed or suspected. As I briefly mentioned earlier, a combination of estrogen and progestin are used, and the way they work is by decreasing androgens, and this in turn will decrease sebum production. In addition, the estrogen in the oral contraceptive will increase the levels of sex hormone-binding globulin (SHBG), which will result in decreased levels of free testosterone.
While all of this might sound great, oral contraceptives of course don’t do anything to address the cause of the high androgens. In addition, oral contraceptives commonly cause side effects. First of all, they suppress the endocrine system, which is why they are such an effective contraceptive. In addition, they can also result in nutrient deficiencies. Some of the potential nutrient deficiencies caused by oral contraceptives include vitamins B2, B6, B12, vitamin C and E and the minerals magnesium, selenium and zinc (25) [24].
What Natural Treatment Options Are Available For Acne?
So what can someone do in order to address the cause of acne, and not rely on prescription and over-the-counter drugs? These are some of the main things you need to do:
- Eliminate dairy. Although dairy isn’t the only culprit, it is one of the main foods that can lead to acne. And as I discussed earlier, this has nothing to do with having a dairy allergy or sensitivity. Instead, since dairy has a high insulin index it will increase insulin levels and insulin-like growth factor (IGF-1), which in turn will stimulate the growth and maturation of sebaceous glands.
- Avoid other insulin-spiking foods. In addition to avoiding dairy, it’s important to minimize your consumption of other foods that can spike insulin levels. Of course avoiding refined sugars is a very good idea. Other foods with a high insulin index include bread and white potatoes.
- Improve the health of your adrenals: Earlier I mentioned how the sebaceous glands act as independent endocrine organs, and how corticotrophin-releasing hormone (CRH) regulates sebaceous gland function. While improving your stress handling skills alone probably won’t be sufficient to eliminate acne, you still don’t want to underestimate the role of stress management.
- Reduce inflammation. Inflammation can be a culprit, and while eating well and managing stress will help greatly in reducing inflammation, there are other things you might need to do. For example, vitamin D can help to reduce inflammation, and one small study showed that a vitamin D deficiency was more common in patients with acne (26) [25].
- Take turmeric and lauric acid. As I mentioned earlier, Propionibacterium acnes is one factor in the development of acne. Both curcumin and lauric acid (found in coconut oil) have antimicrobial properties, and one study showed that these can be an alternative treatment for acne vulgaris (27) [26]. Another study also showed that lauric acid can be an effective antimicrobial for Propionibacterium acnes (28) [27].
- Use essential oils. Essential oils can provide some wonderful benefits, and this includes helping with acne vulgaris. One study involving 124 patients with mild to moderate acne concluded that tea tree oil reduced the number of inflamed and noinflamed acne lesions, and had far fewer side effects when compared to a 5% benzoyl peroxide lotion (29) [28]. Tea tree oil has been shown to be effective against P. acnes (30) [29], and other essential oils that can be effective in treating acne include Plai oil (31) [30], Thymus quinquecostatus (32) [31], rosemary (33) [32], and Abies koreana (34) [33].
10 Other Natural Acne Remedies To Consider
In addition to the natural treatment options listed above, I figured that I’d include some additional “natural acne remedies” to consider. However, you really do need to incorporate the basics first. For example, if someone eats a poor diet consisting of a lot of foods that spike insulin, then they probably won’t experience good results with the following remedies.
1. Apple Cider Vinegar (ACV). Apple cider vinegar has both antifungal and antibacterial properties to help prevent skin infections and acne. Moreover, ACV removes excess oil from your skin and helps to balance your skin’s PH levels. The hydroxyl acids present in ACV aid in the removal of dead skin cells and with time, you’ll notice a healthier and glowing complexion.
Directions: Take a cotton ball and dab some unfiltered apple cider vinegar. Apply this directly to your skin to absorb oil. Leave this on for 10-20 minutes and wash it off with some warm water. Use a chemical free moisturizer afterwards. You can also create a toner by mixing one part of ACV to three parts of distilled water. This natural toner reduces the appearance of acne scars, age spots, and pimples.
2. Tea Tree Oil. I mentioned essential oils earlier, including the antimicrobial properties of tea tree oil. Research also shows that it’s able to absorb excess oil when applied to the skin. Lotions and gels with 5% tea tree oil may be as effective as those containing 5% benzoyl peroxide. Although this treatment may work slowly, it has fewer side effects. If you have severe acne, look for a minimum concentration of 15% and 5% for mild acne.
Directions: Apply the oil directly to your blemishes using a cotton swab. If the scent is overbearing or you find it too strong, you can add the oil to your homemade face wash, moisturizer, scrubs, or even toner.
3. Honey. Honey contains natural enzymes that act as an antimicrobial agent and help in rejuvenating the skin. High quality honey like Manuka honey works as a natural mask to remove dirt from the pores. Honey can help fight acne by acting as an antibacterial agent.
Directions: Take a small amount of honey and apply it directly to your pimples. Rinse off your face with warm water after 15-20 minutes.
4. Aloe Vera. You’ve probably heard of the many benefits of aloe vera, and this can potentially reduce the inflammation associated with acne. The natural herb not only relieves sunburns, but it also prevents infection of acne sores and allows them to heal quickly. Furthermore, the gel can extract the dirt and oil that mainly cause acne.
Directions: Take a part of an aloe vera plant and extract the gel. Apply this gel directly to your face and neck. Allow it to stay overnight and rinse it off in the morning.
5. Papaya. Papaya contains a proteolytic enzyme called papain that can prevent future breakouts and help with acne. Also, the papain efficiently cleanses the skin, dissolves the oils, and leaves you with smooth skin.
Directions: Mash a part of the papaya to make a paste. Apply this paste on the affected area. Let the mask stay on for 15 minutes and rinse off with cold water. You can also use the raw juice to reduce inflammation and soothe soreness caused by acne. Alternatively, you can consume the fruit to reap the same benefits of a smooth, acne-free skin.
6. Green Tea Extract. Drinking green tea can help to reduce acne by decreasing sebum production (35) [34]. However, when used topically it can also help with this.
Directions: Dip a cotton ball in a glass of cooled green tea and apply this on the infected areas for a few minutes. Wash off with lukewarm water to reveal a smooth and glowing skin.
7. Lemon. Beauticians commonly recommend lemon as a way to brighten up dull skin. But did you know that you can also use lemon to treat acne? According to Mayo Clinic, this citrus fruit contains alpha hydroxy acid that works to unclog pores and remove dead skin cells,
Directions: Squash the juice from a lemon and use a cotton ball to apply this juice directly to the affected areas. Leave this for 10 minutes and rinse with lukewarm water.
8. Willow Bark Extract. Willow Bark contains salicylic acid, and I mentioned earlier that this is an acne-fighting exfoliant. What’s more, this also works as an anti-inflammatory when applied to the skin and reduces the appearance of acne scars. Salicylic acid is found in many acne treatments, and it’s been shown to treat acne better than benzoyl peroxide.
Directions: Consume a part of the willow bark extract to experience a rejuvenated and smooth skin.
9. Oatmeal. Oatmeal is a less known, but another natural treatment option for acne. Oatmeal reduces the itching, redness and works as an agent to treat acne.
Directions: In a cup, put two tablespoons of oatmeal (preferably gluten free!) and add some water to make a paste. Place this paste on the affected area and leave it for 15 minutes. Rinse off your face with cool water.
10. Sandalwood oil. Sandalwood is a renowned traditional herb that was used by Chinese herbalists to treat different skin conditions. This oil has anti-inflammatory benefits that help relieve acne. The astringent properties present in sandalwood oil also induces contractions in your skin, making your skin tighter and smooth. If you are worried about aging, sandalwood oil is high in antioxidants which reduce damage caused by free radicals which are responsible for aging.
Directions: Take a cotton swab and put some sandalwood oil on it. Apply this directly to acne prone areas. You can add a base oil or dilute it first with water.
In summary, acne is a common skin condition, and there are numerous factors that can lead to its development. While genetics is a factor, some of the other causes include high androgen levels, different types of medications, birth control pills, stress, and eating foods which spike insulin levels. The hormones which play a role in the development of acne include DHEA, testosterone, dihydrotestosterone, estrogen, progesterone, and insulin. Although I couldn’t find any evidence of a direct relationship between thyroid hormone and acne, thyroid autoimmunity does seem to be more common in adult acne patients. While numerous medications can help with some cases of acne, natural treatment options can also be beneficial, and should be an option to consider.