Hormonal Acne: A Primer and Playbook

I managed to get through the first 27 years of my life without acne. I was blissfully ignorant of even the basics of skincare, I never gave foundation or concealer a second thought, animated forest animals helped me get dressed in the morning. It was great. Two thumbs up to not having acne.

Aaaaaand then I got a hormonal IUD, and everything went to shit. I started getting several enormous, painful cysts every week all over my chin and nose. Each cyst took 2-3 weeks to heal, and even then would leave red marks that lasted for months. Despite my best efforts to not care, I was humiliated. I have almost no pictures from that time, and in the few photos that remain, I’m doing the woman-carrying-a-laundry-basket-to-hide-her-pregnant-belly TV trick by holding something (often my dog) in front of the lower half of my face.

Thanks to a few gamechangers, it has been three months since my last cyst. Hormonal acne is a really common issue and one I don’t see addressed often, so I want to share my journey and what’s worked for me. As a blanket disclaimer, I am not a doctor, I’m not an expert, I’m just sharing my research and personal experiences. Your best route is always to go to a dermatologist.

Also, this is a post for the ladies, or people with natural female hormones. If you’re male and/or taking female hormone supplements, your acne may absolutely be hormonal, but you might need different solutions than the ones I address here.

How can I tell if my acne is hormonal?

There are two major ways: placement and timing.

Placement: where do you break out? Hormonal acne tends to be in the lower half of your face, clustered around your chin, nose, and lower cheeks.

Timing: do you break out at around the same time every month? A lot of hormonal acne is correlated to the later stages of your menstrual cycle, so you might see a flurry of zits in the week before your period or during your period itself. Or, as was my case, your acne appeared after you started using a new form of hormonal birth control.

What causes hormonal acne?

Our skin is especially susceptible to hormones because sebaceous glands (the glands that produce our skin’s oil, or sebum) can actually function as independent endocrine organs. That is, our sebaceous glands interact directly with the hormones floating around in our body.

And there are a lot of hormones floating around in our body. In terms of hormonal acne, there are three major hormones we care about: estrogen, progesterone, and androgens (the male hormones – mainly testosterone and dihydrotestosterone, or DHT).

Androgens are little troublemakers. They stimulate growth of the sebaceous glands, increasing sebum levels (making your skin more oily and likely to get clogged). Androgens can also cause hyperkeratinization, where dead skin cells don’t slough off naturally and instead get caught in your pores, clogging them and causing breakouts.

(Interesting sidenote: a symptom of Polycystic Ovarian Syndrome is excess androgen production, so hormonal acne is strongly correlated with PCOS. Another interesting sidenote: there’s a disorder called Complete Androgen Insensitivity Syndrome, where a person is lacking androgen receptors entirely – people with CAIS have very, very low rates of acne. Hormones are so goddamn interesting, you guys.)

Estrogen is our best friend. It actually decreases sebum production and reduces androgen production. Plus, it helps create more sex hormone-binding globulin (SHBG), which binds to and neutralizes androgens. In terms of skin, estrogen is a dang superhero.

Progesterone is the date your friend brings to your party, and you assume he’ll be cool because your friend Estrogen has great taste, but then he gets way drunker than everyone and won’t shut up about that time in 2004 he made out with twins. Progesterone binds to androgen receptors and therefore stimulates a lot of the same effects on your skin than androgens do. Namely, oily skin and/or killer breakouts.

All three hormones are naturally present at all times in our bodies, but fluctuate in specific ways as we move through our menstrual cycle. Here’s a graph of the levels of those three hormones throughout a typical 28-day cycle (day 1 is the first day of your period):

Source: www.venusweek.com

As you can see, estrogen starts rising after your period and peaks around day 13, which is when you ovulate. Progesterone starts rising shortly after that, and peaks a few days before your period. Testosterone fluctuates a bit but is generally pretty low.

Ever noticed that your skin is really nice a week or two after your period? Or that your breakouts start to kick in a week before your period? That’s because of estrogen and progesterone, respectively.

So that’s why your skin is rioting. Cool, but not super actionable. What can you do about it?

How to treat your existing hormonal acne

Fortunately, your skin is an extremely effective barrier against the outside world and the dirt, pathogens, and other drama that might wreak havoc on your insides. Unfortunately, that means stuff you put on your skin pretty much stays on the outside; even ingredients that penetrate the epidermis rarely make it past the dermis. So, there’s not much you can put on your outside that will fix the underlying hormone problem, since hormones are firmly on your inside.

That said, there are a lot of great products that can help your cysts heal quickly. Here are a few that have worked for me.

Mario Badescu Buffering Lotion ($19): this stuff is the touch of God. But not a gentle, forgiving, New Testament God, I’m talking a vengeful, jealous, “WHAT THE FUCK DID YOU SAY ABOUT ME” Old Testament God. This stuff demolishes cysts, and it’s the only thing I’ve found to make a difference on cysts before they even surface, but it’s also mostly ethanol and will dry the shit out of your skin in the process. It’s worth it to me, but choose at your own risk. As soon as I feel the sharp ache of a cyst in progress, I dab some on every night before bed until it’s gone.

Queen Helene Mint Julep Masque ($5): this is a great and amazingly cheap clay mask. I use it as a spot treatment on cysts that have surfaced, and it really dries them out.

Hydrocolloid bandages (I use Nexcare Acne Absorbing Covers, $8 for 36): Once a cyst has surfaced, I’ll slap one of these on before bed and wake up to an absolutely disgusting bandage that’s sucked out a ton of pus. A lot of people lance their zits beforehand with a clean needle; I never found it made a difference it how well the bandage worked, but lancing it always led to worse scarring, so I leave it alone.

Keep your moisture barrier strong: This could use its own blog post – oh wait, it already did, by the brilliant Skin And Tonics. By keeping your moisture barrier healthy, your skin is more resilient and protective, and your breakouts might not be as bad.

Don’t Pick Your Goddamn Skin, Dummy™: After many, many months, I finally figured this one out. Whenever I gave in and decided to forcefully squeeze out gunk from one of my pores, two days later, a cyst would pop up in that same spot. So, you know, stop it.

How to prevent hormonal acne

As I mentioned, the only way to really prevent hormonal acne breakouts is to address the internal hormonal imbalance that’s causing the breakouts in the first place. For the most part, that means taking pills. There are two common prescription treatments for hormonal acne: combination oral contraceptive (birth control) and spironolactone.

Birth control pills that contain both estrogen and progestin will up your estrogen levels and do all those beautiful things that estrogen does. There’s really nothing more YMMV than birth control pills, though, so it may take a bit of experimenting to find one that works for you. Be aware: progesterone-only forms of birth control, like the Mirena IUD, can make your acne worse. To address hormonal acne, your birth control must contain estrogen.

Spironolactone is a prescription medication that functions as an androgen receptor blocker. It both blocks the binding of androgens to androgen receptors, as well as reduces the production of androgens in the first place. This is a great alternative to birth control.

Both of those are pretty serious medications that can have a lot of unpredictable and potentially undesirable side effects. I never used either. What cured my hormonal acne was [CUE SOUND OF ANGELS DESCENDING AND BRINGING LIGHT AND JOY TO ALL THE EARTH’S CREATURES]…

Evening Primrose Oil supplements.

These are, without a doubt, the most effective product I’ve ever used for my skin and the most important part of my skincare routine. My hormonal acne dropped off by about 90% within three days once I started taking these.

Now, the disclaimer: there is absolutely no scientific research to back this up. As far as I can tell, there was only one study done on evening primrose oil’s effect on estrogen levels, and it showed no correlation. I’ve read they’re a source of phytoestrogens, a compound that acts like estrogen in the body. (Scientifically speaking, I can say that EPO is very high in gamma-linolenic acid, an omega-6 essential fatty acid that the body can’t produce itself and needs to get from your diet, so it’s still a good thing.)

Evening primrose oil supplements changed my face completely. I take one 1300mg pill in the morning and another at night. I have no scientific ground to stand on when I say this, but it’s absolutely the truth: evening primrose oil is 100% the reason I no longer struggle with hormonal acne.

But, as with anything and everything skincare-related, your mileage can and will vary. One person’s HG is another person’s WNR. I hope some of the stuff that worked for me works for you, though. I hope that a lot.

Sources: 1, 2, 3, 4

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