Acne will affect most of us at some point in our life. And it’s a bit shit if you get it really bad- you’ll be doing everything the same and then one day puberty hits, bam! Acne eruption. You’re not doing anything different to your best friend with crystal clear skin. A lot of it is out of your control. But by understanding how acne works, we can combat it.
So what causes acne?
Acne affects sebaceous glands of the skin- these are located all over your body (except palms and feet). Some people’s genetics decide to give them bigger sebaceous glands, or glands that secrete more sebum. These glands are also reactive to hormones, and pump out more sebum when there’s testosterone around. This is why teenage guys get worse acne than girls.
There are four main factors in the development of acne
- Excess sebum production from testosterone stimulation
- Blockage of the gland from hyperkeratinisation (too much growth of the skin, meaning that when skin is shed it gets stuck in the glands). Leads to a comedome.
- Excess growth of the nasty bacteria Proprionibacterium acnes
Acne and Hormones
- Androgens (testosterone and other manly hormones) are important for the proper function of many things in your body, but in acne, they are just meddlesome.
- When you’re on your period, your estrogen drops. This means testosterone rises (because estrogen usually blocks testosterone production) which is why you get worse acne on your period
- During puberty, an increase in testosterone (normal in both girls and boys) gives you more acne in your teens
- Some women may have “hyper-androgenic states” like polycystic ovarian syndrome, or some types of hormone-secreting tumours. This gives them more acne. Hirsutism (having excess hair) and irregular periods are signs of this. If you’re worried that you could have this, you can get your testosterone levels checked at the doctors with a simple blood test.
Acne and Food
- Food can affect how much acne you get. Western food is terrible. In China, under 50% of 19 year old had acne. In Australia, over 90% of 16-18 year olds had acne. Could be partially genetic, but food has something to do with it and here’s why:
- All the carbs we eat causes an increase in insulin, which causes secretion of insulin-like growth factor 1 (IGF-1). This causes our adrenal glands to pump out more testosterone, meaning more stimulation of our sebaceous glands to give us acne. It also causes the skin cells to overgrow, causing the dead skin to block the sebaceous glands. Reducing insulin levels in people with insulin resistance could improve their acne.
- One trial found that a low GI diet reduced circulating testosterone levels, and also the amount of acne.
- Milk can exacerbate acne. It’s not to do with the fat content because a study found that skim milk was just as bad. There are a number of hormones found in milk which can be converted to testosterone in the body. This means that milk from other sources may be better than cow’s milk so consider almond, or soy milk (the hormones in soy might actually block the testosterone).
- There isn’t a consensus on chocolate yet, but considering its made of milk and sugar, the milk’s hormones and the sugar’s effect of increasing insulin could be a reason why zits are worse after a chocolate binge.
- Protein shakes can increase acne- casein and whey are from milk and may also contain hormones that turn into testosterone in the body.
Acne and Cosmetics
- When the sebaceous gland is blocked it becomes a comedome, which are whiteheads and blackheads. When these get infected, they get red and nasty and become an inflammatory lesion. Use non-comedogenic make up.
- If your skin is oily don’t over-moisturise as it can create a nice environment for the bacteria to proliferate
Acne and Stress
- Stress increases acne
- Stress releases corticosteroids, which does things to the hormones in your body, which can cause an acne breakout. This is why we all get zits in exam time!!
How to Treat Acne?
Now that we know what acne is caused by, we can target our treatment. You can follow all the above information and avoid milk, avoid chocolate, avoid high GI foods, stop stressing and use non-comedogenic makeup, but for some people there still won’t be any improvements.
Topical treatments are targeted at removing the sebum, killing the bacteria, and getting rid of keratin that blocks pores. This includes benzyl peroxides, topical retinoids, and topical antibiotics. Minimal side effects, although your skin may become irritated.
These will work for mild acne, however they have no effect on sebum production.
The oral contraceptive pill is great for women with hormonal acne- if you have acne that concentrates on your chin and jawline it’s likely that your acne is hormonal.
The estrogen in the pill antagonises the testosterone in your body that causes the sebum secretion. The pill has minimal side effects (differs from person to person), however there are some contraindications. If you are a heavy smoker, have a history of blood clots, or have migraine with aura are just to name a few. You have to talk to your doctor to see if the pill is right for you.
If you have an underlying insulin resistance, your acne may benefit from treating that condition.
If you’re male then the pill is not an appropriate treatment for you.
These work by reducing the amount of P. acnes hanging around inside your skin, as well as reducing some of the inflammatory effects. There are a number of different antibiotics you can use. The one I know is Doxycycline, as it is a cheap and commonly used drug and has been effective in some of my friends. There are possible adverse effects that some people might get such as photosensitivity, abdominal discomfort, dizziness. The severity of these effects will differ from person to person.
Roacutane is a powerful drug that is used to treat severe, cystic acne resistant to other treatments.
Roacutane attacks all four causes of acne by reducing production of sebum, reducing keratin build up, lowering inflammation and getting rid of those nasty bacteria. It is very effective. 60% of patients stay acne-free after one course (at least 5 months) and often acne continues to improve even after treatment has ceased.
Roacutane gets a lot of bad press because yes, it is a potentially dangerous drug. In Australia, only a dermatologist can prescribe it and you must be carefully monitored. It is metabolised by the liver and so if you have liver failure, you may not be able to take this drug as it will stay in your body too long. It works by reducing sebum production which is great for the acne problem areas, but unfortunately it works all over the body so your skin will be dry all over.
There is a lot of press about roacutane and depression. In my opinion, a lot of the scare has been hyped up by the media. There has been a large and well-reported retrospective cohort study (this is ok level evidence, a randomised control trial is the best evidence) that explored the link. They found that people taking roaccutane had increased risk of suicide 1 year before starting treatment, risk of suicide was highest 6 months into treatment, and fell back to expected levels 3 years after treatment.
This says that the risk of suicide increased before starting treatment of roaccutane, so that the peak at 6 months into treatment can’t be from roaccutane by itself.
There are a few case reports that suggest that conditions like anxiety, depression and psychosis may worsen soon after starting roaccutane treatment. I would like to point out that the fact that these are case reports meant that this stuff happens quite rarely.
There is not enough research into this field. It is proven however that people suffering severe acne may suffer extreme self-esteem issues, social isolation, and depression.
If you are thinking of starting the treatment, it is a pros and cons toss up. If your acne is causing you to feel terrible, then you should treat it- acne is a treatable medical condition. Watch out for the common side effects like dry skin and dizziness, and if you can’t cope, don’t continue the treatment. While those cases of increased depression and anxiety are just that, cases, it is recommended that you are monitored and counselled by your GP to screen for any signs of depression.
On a closing note is that one thing for absolute certain regarding roacutane (and the reason why it is under strict prescription guidelines) is that you must not be pregnant, and must not fall pregnant during your treatment. In Australia, they go as far as having you sign that you will be on at least two methods of contraception, and to terminate your child if you do fall pregnant on the treatment. This is because the link between roacutane and severe birth defects is very well established– it causes cardiovascular abnormalities, mental retardation, limb deformities. This is not something you want for your child. If you are thinking about pregnancy in the near future stay well away from this treatment.
Clinical and Experimental Dermatology – What’s new in acne? An analysis of systematic reviews and clinically significant trials published in 2010–11 (paper by R. C. Simpson, D. J. Grindlay and H. C. Williams)
Australian Doctor – How to Treat Acne (article by Dr Benjamin Daniel and Professor Dedee Murrell)