Acne affects around 50% of teens & adolescents and 20-25% of women aged 35-50. By definition, hormonal acne refers to skin breakouts caused by hormonal fluctuations. They tend to occur most commonly around puberty but can also occur around the time of your period or much later in adulthood, for example, during menopause.

Most common locations tend to be around the T-zone (forehead, nose and chin) or around the lower jaw area. 

Does this mean I have a hormone imbalance?

No, not necessarily. PCOS is a common cause of hormonal acne that is caused by a true imbalance of masculine or androgenic hormones such as testosterone or DHEA. But in many cases of hormonal acne, there are no hormonal abnormalities detected. It appears that genetic predisposition makes some women susceptible to acne flare-ups during the normal hormonal fluctuations that occur during our menstrual cycle. Diet also appears to play a significant role. 

Why do my hormones fluctuate?

In PCOS, the increased levels of testosterone or DHEA are thought to stimulate excessive sebum production from your sebaceous or sweat glands, increasing the risk of blocked pores. Testosterone may also increase the activity of a bacterium called Cutibacterium acnes which can cause inflammation around hair follicles. 

Even in normal menstrual cycles, there are big fluctuations in estrogen and progesterone- both hormones are low in the early part of your menstrual cycle, during and shortly after your period. By mid-cycle, around ovulation, these hormones are on the rise. Progesterone levels peak about a week before your next period. Increased progesterone levels can raise body temperature and cause increased sweating which can trigger premenstrual skin breakouts as the sweat and sebum build up combines to block pores. 

How does diet affect acne? 

Eating sugary or high glycemic index foods such as soda, sugary cereals, candy, white bread etc causes increased production of insulin in our body. Insulin is necessary to move sugar from your bloodstream and into your organs and muscles where it can be used as fuel for energy. However, too much insulin production can also trigger production of other hormones such as insulin-like growth factor (IGF1). This hormone can cause hyperkeratinization of your skin and increased sebum production which can cause acne. 

Many population studies have shown that acne is significantly more widespread in urban communities eating a refined, western diet compared to rural populations. This holds true even when comparing similar gene pools. For example certain populations did not historically have acne: the Canadian Inuit, South African Zulus, Japanese Okinawans etc. The appearance of acne in these groups in more recent generations has been attributed to their adoption of Western diets, including processed foods, dairy, and refined sugars

Should I limit dairy consumption if I have hormonal acne? 

Milk and many dairy products appear to have a similar effect of raising levels of IGF1 and this causes blockage of pores and acne. Skim milk appears to be worse than whole milk in this regard because whey proteins are added to skim milk in order to maintain a proper consistency. Whey proteins are acidifying and play a role in comedogenesis. 

Why does my dermatologist recommend antibiotics to treat acne? 

For the same reason that skin can also respond to certain kinds of probiotics!

Bacterial cells outnumber human cells in your body by a ratio of around 10:1. The vast majority of bacteria are harmless or useful. Only 1% or less can cause harm. This is no different for skin problems. For example, Propionibacterium acnes (P.acnes) is a bacterium that normally grows on your skin. However, abnormal increases of this bacteria can cause skin inflammation, alteration of sebum and hyperkeratinization, all of which can provoke acne. Taking a daily probiotic targeted for skin can help maintain a healthy flora and prevent overgrowth of bad bacteria. In some cases of moderate to severe acne, your dermatologist may prescribe a course of antibiotics to get rid of any bacterial superinfection before starting topical treatments for acne. 

Treatment of hormonal acne: 

An anti-inflammatory diet that is low in refined sugar, dairy and processed foods works best to fight inflammation in your skin.

Your doctor may recommend topical treatments like retinoids, salicylic acid, or benzoyl peroxide for mild acne. Prescription medication options for moderate to severe hormonal acne include Accutane (oral isoretinoin), antibiotics, oral contraceptives (for women) or anti-androgen drugs like spironolactone.