What is Hormonal Acne? Shedding light on PCOS hormonal acne

Q&A with Dr. Geeta Patel

I've known the breathtakingly gorgeous Dr Geeta Patel for a few years now, and yet each time we meet, I am taken away with her jaw-dropping beauty! Her vivacious, friendly and genuine personality attracts positive vibes everywhere she goes – like a charming butterfly. She is a renowned dermatologist and an aesthetic physician trained in laser, anti-ageing treatments like Botox and fillers, and owns a one-of-a kind skin clinic – Za’hra Skin Clinic. I asked her to share some information on acne related to hormonal disruptions, particularly PCOS and what are a few basic steps we can do firstly, to recognise that it is indeed hormone-related, and what the next steps ideally should be.

1. What is acne and how does one recognise hormonal acne?

Acne develops due to inflammation of pilosebaceous units (hair follicle, hair shaft and sebaceous gland) in skin. These units secrete sebum, which is an oily substance which seals in the moisture. Acne is caused by blockage of these units. Many factors can contribute to acne and this includes genetics, oily skin, using products that may not suit your skin, medication, food and lifestyle, stress levels, sun exposure, and hormonal changes and hormonal related conditions such as PCOS.

Generally speaking acne related to hormonal changes or disruptions is when the acne erupts in lower face, predominantly by the jawline and chin. The other indications are based around the time the acne appears – before or during menses, during or after pregnancy, when starting or stopping OC pills or during perimenopause 

2. What is PCOS?

PCOS is now affecting almost 2 in every 5 adolescent girls and 1 in every 5 adult women in India. Moreover, Indian women seem to develop PCOS at an earlier age than other countries. PCOS is a heterogeneous, reproductive-metabolic pathological disorder affecting women of reproductive age group - the primary cause of which is ovarian androgen overproduction. The major symptoms are menstrual irregularities, infertility, hirsutism, persistent and severe acne and metabolic syndrome (obesity and insulin resistance).

PCOS is now affecting almost 2 in every 5 adolescent girls and 1 in every 5 adult women in India. Moreover, Indian women seem to develop PCOS at an earlier age than other countries.

3. Why do I have PCOS?

A number of factors contribute towards PCOS, which include lifestyle-related factors that include unhealthy diet which has higher carbohydrates, refined and processed foods, alcohol and low dietary fibers. Lack of physical activity of a very sedentary lifestyle plays a role, along with chronic stress. Chronic stress activates hypothalamic-pituitary-adrenocortical and sympatho-adrenal which precipitates insulin resistance in the long-term. Genetic predisposition, body fat patterning, early-life adversities such as malnutrition, insulin resistance.

4. What is the right way to diagnose PCOS?

It is essential that you first meet with a qualified dermatologist, who will prescribe a series of tests to do.

Usually, the diagnosis of PCOS is made using the Rotterdam criteria, meeting two of the following three conditions: Androgen excess, Ovulatory dysfunction, polycystic ovaries. The Rotterdam criteria define PCOS by the presence of two of the following after exclusion of other androgen excess or related disorders:

• irregular menses
• hyperandrogenism (either clinical or biochemical)
• polycystic ovary morphology, after excluding other endocrine causes such as hyperprolactinemia

Laboratory tests that you can get done are:

• Serum testosterone
• Serum 17-hydroxypogestrone (OHP)
• Serum thyroid stimulating hormone (TSH)
• Serum prolactin
• Serum or urine human chorionic gonadotropin (HCG)
• DHEA-S
• Serum free igf-1
• LH and FSH levels
• 24-hour urinary free cortisol
• Complete lipid profile that includes cholesterol, LDL, HDL, triglycerides
• Oral glucose tolerance test
• Blood pressure

It is vital to get early detection of PCOS as there are multiple long-term health risks that include depression, cardio-vascular risks, type 2 diabetes, pregnancy and fertility complications, obstructive sleep apnea.

5. What is a recommended treatment for hormonal acne and general acne?

For Basic self-care, it is recommended:

• Washing the face twice in a day with a gentle, pH balanced cleanser
• Washing the face after sweating (after exercise, removing masks, helmets etc.)
• Switching to gentle, non comedogenic skin care products that do not contain alcohol or abrasive material that scrub the skin.
• Using clean towels and face cloths and washing items that touch the face often
• Avoid touching the face to pick or squeeze acne.
• After washing the face, a person may wish to try topical anti acne treatments. Some ingredients to look for include:

Salicylic acid, reduces inflammation and unclogs pores

Topical Retinoids, which unclog pores and reduce oiliness

Topical Benzoyl peroxide and clindamycin, which kills bacteria that cause acne. 

A person can buy skin care products that contain these ingredients over the counter. Alternatively, a dermatologist can make recommendations or prescribe medical strength versions. Many acne treatments increase the skin’s sensitivity to sunlight, so it is important to also use a sunscreen to protect the skin from UV damage during the day.

Keeping a diary and trying things one at a time may help people determine whether or not dietary changes and other strategies are helping their acne.

Medication:

• Only under dermatologist’s guidance, sometimes people require certain oral medications such as:
• Antibiotics, such as azithromycin, tetracycline group etc. which can help with painful inflammatory acne
• Spironolactone, which is a hormonal treatment that can block the effect of androgens on the skin
• Oral retinoid, such as Accutane
• Netfor Min and Myoinositol – especially in insulin resistance
• Birth control pills etc.

PCOS management is a multidisciplinary approach requiring combined efforts of a dermatologist, endocrinologist and or a gynaecologist.

6. Does diet and lifestyle play an important role in PCOS?

Yes it does! A healthy and active lifestyle is key and essential to manage and alleviate symptoms. While there is no one particular diet that is key to follow, there are plenty of recommendations, and as each body is different, you will have to pick one that suits you.

Yoga works on the sympathetic nervous system and calms anxiety and practising yoga regularly reduces the anti-Müllerian hormone (AMH), luteinizing hormone, testosterone in the body.

Practising yoga on a daily basis helps in decreasing the testosterone levels, and also helps in controlling depression and anxiety associated with PCOS. Any woman with PCOS should practice yoga for about 30 mins for 5 days in a week and that would help in reducing the testosterone levels to about 30%.

Overall, here are a few generalised diet recommendations to include into your regime:

Low GI Foods

Non starchy vegetables, Whole grains and cereals, Beans and legumes, Nuts and seeds, Fruits such as apples, berries and plums. Incorporating foods such as olive oil, eggs, chicken and fish into diet can help keep blood sugar levels stable and provide important nutrients for skin health.

Fatty Acids

it is recommended to pick foods that are high in fatty acids such as Omega 3, 6 and 9 as they have good anti-inflammatory properties – this includes oily fish, such as wild salmon , sardines and mackerel, fish oil supplements, nuts and seeds such as flax seeds and walnuts, soybeans and soy products such as tofu, spinach.

Antioxidants

Some research indicates that people with acne are more likely to be low in certain antioxidants such as selenium. It is unclear if this directly causes acne. However, because antioxidants have other important health benefits, it is a good idea to eat foods that contain them. These foods include: Brazil nuts, fish, seafood, beef, turkey and organ meats which contain selenium. Red grapes, mulberries and peanuts which contain resveratrol. Blueberries, leafy greens, red cabbage and green tea are other examples of food containing antioxidants

Fitness

Work on being active through the day, taking the stairs instead of the elevator, brisk walking or pilates – whatever activity that can fit into your schedule and be achieved easily. Fitness is fundamental in getting results – observational studies show that moderate weight loss (5-10%) in women with PCOS can improve insulin resistance as well as androgenic and reproductive outcomes.

Mental Health

Having a clear skin also comes from a clear mind. Find peace and joy in your daily life, figure out how to manage stress levels, make mini rituals that you look forward to, and download apps that help maintain your mental balance such as through meditation, yoga asanas or chanting.

7. What are the effects on mental health have you seen with PCOS sufferers?

Hyper androgenic symptoms are often underreported and have a negative impact on quality of life and psychological wellbeing. Depression and anxiety are common amongst women with acne. Women with Acne and hirsutism also experience high levels of psychological distress! Clinically important depression and anxiety have been reported in 18% and 44% of acne patients, respectively. Psychosocial impact may not always correlate with disease severity but it may influence treatment decisions, for example, the need to refer to a dermatologist.

Patients who implement healthy habits with regard to diet and exercise, enhance their hormonal function considerably and help their bodies in the long run. “In PCOS, sattvic food plays an important role. Fresh home cooked meals, supplanted by plenty of drinking water, and reducing salt intake three days before the menstrual cycle, will make a difference. Obesity due to the illness should be treated naturally by changing one’s lifestyle. Green leafy vegetables should be consumed regularly, especially for breakfast and lunch.

Stress has a negative impact on PCOS symptoms too. It is of utmost importance to relax the mind so as to keep the cortisol levels under control. Cortisol levels (testosterone) are responsible for weight gain. Hence, conscious relaxation techniques should be incorporated in daily life to calm the entire body and mind and alleviate stress. 

Dr Geeta Patel is a leading consulting skin specialist, cosmetic dermatologist and laser physician

She is the founder of Zah’ra Skin & Laser Clinic

Follow her at: @zahraskinlaser