Hi, This is Francesca from The PCOS Newsletter where we provide answers to complex PCOS questions in a concise and easy-to-understand format. This week we are looking at the link between Acne and PCOS.
This week’s question:
Is there a link between Acne and PCOS?
Acne is always a very sensitive topic because it affects our self-esteem. Our appearance is how the world perceives us and it's hard to show up when we don't feel our best. The skin can also be a window for health care professionals and ourselves to understand what is happening inside our body.
In adolescent years, it is very common to experience acne due to an immature endocrine system. Imbalances in hormones often lead to pimples, blackheads etc. It is thought that up to 85% of adolescents get varying levels of acne.
Acne in itself is not a serious condition, however, it has huge implications for our self-esteem and our psychological well-being. Given this starts in our adolescent years and continues in our 20s, when most of our romantic connections happen, it can be hard on our confidence. I got my worse case of acne when I was in my final year at university and without too much detail: it was NOT fun.
In the case of PCOS, excess androgens express themselves as more than just irregular periods. They affect our skin and as a result, create acne. They can also affects our hair follicles and grow hair in unwanted places (you can read more about this, here) and the list continues.
The simple answer is: Yes, there is a link between acne and PCOS.
It is extremely important to trace back why is acne happening so that we can go to the cause rather than treating the symptoms. I see a lot of topical solutions for acne which will only fix the problem temporarily as the driver is not superficial.
What is the deal with androgens?
Androgens are our male hormones and they play a major role in our menstrual cycle, bone mass, libido and muscle mass. The most common androgen you will hear about is testosterone but there are a few others (DHEA, Androstenedione, DHT, DHT-S).
The interesting thing is that androgens are primarily created by the ovaries and adrenal glands, but the skin also contains receptors and enzymes that can metabolise them.
Let’s deep dive in what this means for the skin.
Excess androgens act on the skin by enlarging sebaceous glands and increasing sebum production. This excess sebum production clogs the pores of your skin, so they can't shed dead skin cells and replace them with new ones. The combination of excess sebum and clogged pores creates the ideal environment for Propionibacterium acne. This bacteria leads to inflammation and the creation of papules, pustules, nodules, cysts and scars.
What about other hormones?
Insulin and insulin growth factor also play a role in acne. These hormones are thought to exacerbate the production of androgens and worsen the whole situation. This is the reason why insulin resistance is one of the drivers of PCOS (more on this in follow-on newsletter issues). There are studies which found a correlation between the facial sebum excretion rate and serum IGF-1 levels in acne patients. This is where lifestyle change that promotes the regulation of insulin levels can have a big impact on acne.
What are the treatment options?
For mild and severe acne there seem to be a few treatments that get recommended:
Retinoids and Other Topical Products - retinoids are a derivate from Vitamin A that causes the skin to re-grow quicker and a result leaves the sebum little time to build up
Antibiotics - antibiotics are used to keep the inflammation caused by bacteria under control
Roaccutan (Isotretinoin) - this compound decreases the size of sebaceous glands in the skin
Contraceptive pill - synthetic hormones in the pill bring the reproductive hormones in balance temporarily regulating androgen levels
Metformin - this helps with the regulation of glucose metabolism and a result the decrease in insulin resistance which in turn has an effect on levels of circulating androgens
There could be other treatment options I have missed. Your GP, endocrinologist or dermatologist might have other options.
My take is that all of the above medications help with the symptoms but don’t solve the problem. They certainly help and I found a big relief when I was given the pill and my acne cleared out. However, the moment you stop taking them, if there is a driver such as PCOS underlying it, it’s very likely the symptoms will be back.
My training is focused on nutritional therapy so I truly believe the best way to tackle acne is through a system-based approach. It is important to look at all systems of the body (including your gut and immune system) and create a balanced lifestyle that can bring your body back in balance.
What are the treatment options I see?
These are some areas I would look at but it highly depends on individual cases.
Quality of nutrients - our body, including our skin uses vitamins and minerals such as Zinc, Selenium and Vitamin C to carry out their day-to-day job. It is important to assess if we are getting enough of these different nutrients in our diets.
The gut microbiome - this is a new area of research concerning the link between the gut and the skin. However, the most important connection is how our gut influences our immune system and the clearance of hormones.
Blood sugar regulation - levels of circulating insulin are incredibly important for the management of PCOS and keeping these under control will help lower levels of androgens.
Reproductive hormones - it is important to try our best to bring back the normal functioning of our reproductive hormones so we can bring down the levels of androgens and their manifestations (acne, weight gain, irregular periods etc)
Acne is one of the symptoms of an underlying condition such as PCOS. Trying to solve the symptom can help alleviate the pain temporarily (which sometimes is needed). However the best approach is to take the time to understand what is driving the issue. The reality is that we need to work on our diet, habits and get to know how our body operates to find a long-term solution for chronic problems.
I hope this helped bring some light to acne as a symptom of PCOS. Please don't hesitate to reply to this email with any follow-on questions you might have.
See you next Sunday,
Franik, G., Bizoń, A., Włoch, S., Kowalczyk, K., Biernacka-Bartnik, A., & Madej, P. (2018). Hormonal and metabolic aspects of acne vulgaris in women with polycystic ovary syndrome. European Review for Medical and Pharmacological Sciences, 22(14), 4411–4418. https://doi.org/10.26355/eurrev_201807_15491
Lee, Y. B., Byun, E. J., & Kim, H. S. (2019). Potential role of the microbiome in acne: A comprehensive review. Journal of Clinical Medicine, 8(7), 987. https://doi.org/10.3390/jcm8070987
Melnik, B. C., & Schmitz, G. (2009). Role of insulin, insulin-like growth factor-1, hyperglycaemic food and milk consumption in the pathogenesis of acne vulgaris. Experimental Dermatology, 18(10), 833–841. https://doi.org/10.1111/j.1600-0625.2009.00924.x
Ramezani Tehrani, F., Behboudi-Gandevani, S., Bidhendi Yarandi, R., Saei Ghare Naz, M., & Carmina, E. (2021). Prevalence of acne vulgaris among women with polycystic ovary syndrome: a systemic review and meta-analysis. Gynecological Endocrinology: The Official Journal of the International Society of Gynecological Endocrinology, 37(5), 392–405. https://doi.org/10.1080/09513590.2020.1859474
Yen, H., Chang, Y.-T., Yee, F.-J., & Huang, Y.-C. (2021). Metformin therapy for acne in patients with polycystic ovary syndrome: A systematic review and meta-analysis. American Journal of Clinical Dermatology, 22(1), 11–23. https://doi.org/10.1007/s40257-020-00565-5