Expert talks

Hormonal acne explained by a gynaecologist

For teenage girls and women alike, hormones and acne are a real problem. Dr Odile Bagot, Gynaecologist, explains the causes of hormonal acne and how to treat it.

What exactly is hormonal acne?

This is a common question. Is acne caused by hormonal imbalances? Why does acne start during puberty? Can hormonal acne be prevented? What is the link between acne and pregnancy? What about acne and menopause? How can we treat hormonal acne? Does the birth control pill affect it? When talking about hormones, it’s not always easy to understand.

Dr Odile Bagot, a gynaecologist based in Strasbourg (France) and author of the Mam Gyneco blog, gives us some insights into what causes hormonal acne.

Dr Odile Bagot, Gyneacologist.

Hormonal acne starts at the end of childhood when the ovaries or testes start functioning. Although this pathology usually starts and finishes during puberty, it can continue into adulthood.

Dr Odile Bagot, Gyneacologist.

Sometimes, it disappears or recedes, only to flare up later on. More rarely, hormonal acne can be triggered in adults, mostly women.

Acne takes different forms depending on your age:

adolescent acne makes a ‘T’ shape covering the forehead, nose, around the mouth and the chin. It is accompanied by oily skin.
acne in adults usually forms a U shape, following the lines of the chin and sometimes the neck. It is often associated with body acne.

Late-occuring acne tends to appear after 25, and usually ends once you reach 40, but it is not always the case.

Mini-guide: hormones

Androgens: collective name for all male hormones present in men and, in smaller quantities, in women.
Testosterone: a hormone that belongs to the androgen group. Produced in the testes, it is associated with sexuality and fertility in men. In women, it affects the libido and is produced in the ovaries and adrenal glands.
Progesterone: female hormone secreted by the ovaries that enables the embryo to develop in the uterus, regulates the menstrual cycle and plays an important role during pregnancy.
Oestrogen: female hormone secreted by the ovaries and, in very small quantities, in the testes. In women, it has an impact on breast development and sexual desire, but also on skin hydration, bone solidity, the cardiovascular system, brain and digestive system.

There is always a hormonal element to acne, but it is by no means the only factor

Lots of endogenous factors have a role to play, including personal predispositions like family genetics, resistance to antibiotics and the level of male hormones – that is to say, androgens. Other exterior factors can also have an impact on acne including stress, tobacco, some cosmetics, pollution and, in particular, endocrine disruptors. All together, these are referred to as the exposome.

Hormonal acne: excess of male hormones?

Yes, hormonal acne is connected to male hormones, but not necessarily in excess. This is why hormone boosters – that women sometimes demand – are often ineffective as levels are usually normal.

Male hormones (androgens) are produced in the testes and adrenal glands, but also by the ovaries - women also have testosterone as a perfectly natural part of their hormonal landscape.

Because the androgens and testosterone circulating in the blood aren’t very active: only 2% of circulating testosterone is bioavailable in the blood.

The remaining 98% is captured by protein carriers, which transport them to the cutaneous cells where they are transformed and become active. For example, testosterone is transformed into DHT (dihydrotestosterone), a far more powerful hormone. This full process needs to take place to have a visible impact on the skin. This is why adding androgens to the blood is usually ineffective.

Hormonal acne is related to androgens, though, isn’t it?

The effect of androgens on the skin depends on 3 elements:

The level of androgens circulating, in other words, the amount of testosterone in the blood. Biological hyper-androgens with clinical signs like hirsutism (significant excess body hair) or alopecia (baldness) are rare. Polycystic ovaries are, however, more common – this leads to excess hair, acne, spaced out periods and, sometimes, high levels of testosterone.
Protein transporters that capture the androgens, and in particular, testosterone. The more you have, the more androgens you capture, and the less bioavailable testosterone there is on your skin.
Transformation of androgens into active androgens. This transformation takes place in the sebaceous follicle to produce sebum and in the hair follicle for hair growth. We refer to this as androgenic sensitivity and, of the three, it has the biggest impact on the appearance of acne.

To sum up, free androgens have two main effects:

Increase sebum secretion
Make the skin thicker

What is the role of oestrogen in hormonal acne?

Lots of women notice a correlation between acne and their periods. They have acne before their periods, during the pre-menstrual phase, which is a classic characteristic of hormonal acne. Dr Odile Bagot shines more light on the role of the two female hormones: oestrogen and progesterone .

Oestrogen has a beneficial effect on acne, directly reducing the amount of sebum produced by the sebaceous follicle and indirectly increasing the production of proteins that capture androgens, thus lowering the level of bioavailable testosterone.

Women’s menstrual cycle is divided into 2 phases:

The follicular phase that culminates in ovulation at around day 14, characterised by increased oestrogen secretion. The skin is usually radiant.
The luteal phase after day 14, when more progesterone is produced – this doesn’t necessarily have an androgenic effect. But as the level of oestrogen gradually decreases, acne often reappears or gets worse - sebum is secreted and the skin is oilier.

During ovulation, in the middle of the cycle, oestrogen has a positive overall effect on acne.

We don’t really know why acne appears during the premenstrual period, but it does. Just like during the early months of pregnancy. The only common denominator is the increase in progesterone. The hypothesis is therefore that progesterone has an impact on acne, but this has not yet been proven.

Dr Odile Bagot, Gynaecologist

How can you reduce hormonal acne?

Dr Odile Bagot suggests 3 levers with a potential impact on hormonal acne.

Address external factors: stress, diet, weight, pollution and endocrinal disruptors
Address the consequences on the skin: local treatments, prescribed treatments and an adapted skin care routine
Address the problem at hormonal level with an impact on androgens by taking the birth control pill

Acne is most common during the first trimester and then stabilises.

The acne that occurs during pregnancy can have several causes:

The high level of progesterone at the beginning of pregnancy
Stopping a birth control pill that was beneficial for acne
Stopping an anti-acne treatment during pregnancy

Acne doesn’t have an impact on the baby, but most anti-acne treatments aren’t recommended during pregnancy. You also need to be careful about what you apply to your skin, avoiding products with parabens, phthalates and triclosan, as these are endocrine disruptors.

In theory, acne tends to disappear once you reach 40.

Menopause can trigger an increase in acne as your internal “climate” during this period is androgenic given the low levels of oestrogen. If this is the case, hormone replacement treatments are recommended for hormonal acne, as they provide extra oestrogen. At this age, however, it is important not to confuse acne with rosacea, which isn’t hormonal and requires attention from a dermatologist.