Are You Treating the Root Cause of PCOS Acne?
Feel like you are too old to be suffering from ‘teenage’ hormonal acne.
You’re not alone. Acne affects up to 1 in 3 women with PCOS and was actually what drove me to going to my GP for hormone tests. Fortunately, I never suffered from the painful nodular or cystic acne that I see in some of my patients. However, I was 24 and had decided that I was well past the age for teenage acne.
I’d been to the GP many times before for my acne, only to be prescribed the birth control pill and a low grade antibiotic. No further investigation was done. It was only when I read that hormones could be causing my acne that I specifically asked for some hormones tests. Low and behold, my testosterone and insulin levels were found to be off the charts. I was diagnosed with PCOS.
PCOS Acne: Prescription Drugs
Unfortunately, even with this newly-diagnosed PCOS, the prescription didn’t change. I was still given the birth control pill, an antibiotic and a topical cream. It was also suggested that if I saw no improvements then I could try spironolactone (a powerful anti-androgen) or isotretinoin (marketed as Accutane). The problem with both of these treatments is that they produce a lot of nasty effects in the body. They also don’t really solve the root cause of the acne.
Although I see PCOS acne improvements from the pill, antibiotics, and spironolactone, a compensatory rebound effect often happens when the drugs are stopped. As I explained in my article about why the pill is not an effective treatment for PCOS, drugs like the pill don’t decrease testosterone levels, they just mask its effects. When you stop taking the drugs then your testosterone levels will be just as high as they were before.
Accutance for PCOS Acne
Conversely, Accutane works by altering gene expression and the side effects are incredibly scary. They include:
– Severe foetal abnormalities in women taking Accutane during pregnancy.
– Inflammatory bowel diseases, like ulcerative colitis and Crohn’s disease.
– Increase in suicidal feelings.
After being sued for $20M, the drug maker, Roche, issued a recall of Accutane and stopped production. Unfortunately, other drug manufacturers have plugged this gap in the market. I imagine that they probably have a bit more legal protection than Roche.
So, instead of opting for drugs that, at best, merely act as a bandaid and at worst, can cause real damage, we need to treat acne by fixing the root cause. Most commonly this is high androgen levels and insulin resistance.
The Root Cause of PCOS Acne
To understand the relationship between acne and PCOS and role of androgens (testosterone) and insulin resistance in the development of it, we first need to look at the formation of PCOS acne:
1. Testosterone, DHEA-S (androgens) and insulin, stimulate the sebaceous glands in the skin to overproduce oil.
2. Pores get clogged and oil is trapped inside them. Bacteria then grows in these pores, causing inflammation to form around them. Antibiotics are often prescribed for acne because they kill this bacteria.
3. The immune system detects a foreign object (bacteria) and activates the inflammatory system to fight the bacteria. This causes swelling, redness, and pustule formation as the immune system tries to force the bacteria to the surface.
Androgens are the root cause of PCOS acne problem. You need tackle the root cause of PCOS acne to treat it effectively. You need to stop the overproduction of androgens (testosterone and DHEA-S). In my article, What’s Causing Your PCOS, I outline the main causes of high androgens. In this article I’ll explain the main ones, insulin resistance and inflammation.
Insulin is your glucose storage hormone. If your cells become resistant to insulin then your body will respond by producing more and more insulin. This is the early stages of Type 2 diabetes. High levels of insulin stimulate the ovaries to overproduce testosterone. As detailed above, this causes PCOS acne havoc as it simulates more oil production in the sebaceous glands.
In my article about facial hair growth (hirsutism), I explained how studies have shown that high levels of insulin not only act on the ovaries, but also on the hair follicles to cause an increased growth of terminal hairs. Similarly in PCOS acne cases, insulin has a nasty double whammy effect. Insulin produces insulin-like growth factor, which stimulates even more oil production. A 2015 randomised controlled trial found that acne patients were significantly more likely to have insulin resistance than those without.
70-80% of women with PCOS have insulin resistance, but this mostly goes undiagnosed. This is because the normal tests, fasting blood glucose and HbA1c, aren’t sensitive enough to pick up early stage insulin resistance. If you’ve only had these tests, then please read my article about insulin resistance and PCOS and get the correct testing.
Inflammation and Poor Gut Health
I’ve written extensively about the research showing that PCOS, like most modern diseases, is caused by chronic inflammation. Unsurprisingly, acne is also caused by high levels of inflammation.
Inflammation is a normal feature of our immune system. However, our bodies are not designed for it to be turned on all the time. Inflammation not only causes insulin resistance (causing increased androgens), but also causes acne in it’s own right. One of the main factors that cause inflammation is poor gut health.
Scientists have understood that our skin is influenced by our gut health since the 1930s. Early researchers in this area connected an imbalanced gut bacteria with skin issues like acne. Their theory was that too much bad bacteria in the gut causes systemic inflammation and skin issues. Modern studies have confirmed this. The studies have shown that increased levels of bad bacteria, especially in the small intestine, lead to increased levels of inflammatory markers. Studies have also shown that inflammatory pathways are activated in acne patients.
Although I can’t compare my observations to a randomised controlled trial (the gold standard in research settings), I’ve see this constantly played out in practice. In fact, I’ve never met a patient with PCOS that didn’t also have disrupted gut flora.
Treating the Root Cause of PCOS Acne: Inflammation and Insulin Resistance
I’ve explained the root causes of PCOS acne: excess androgens caused by inflammation and insulin resistance. But to help fix your PCOS acne, you need to treat inflammation and insulin resistance. Here’s how.
Removing sugar is one of the best things that you can do to reverse insulin resistance and inflammation, and therefore fix acne. Sugar causes insulin spikes and makes pre-existing insulin resistance even worse. Bad bacteria also feed off sugar, which increases inflammation.
A 2007 study proved this when they took participants aged between 15 and 25 and separated them into two groups: a control group and a low sugar group. The control group continued eating their standard high sugar diet. The low sugar group ate more high protein foods, or a low GI carbohydrate diet. The low sugar group significantly decreased their androgen levels and total acne lesion count compared with the control group.
Milk consumption results in significant increases in insulin and insulin-like growth factor, IGF-1. Correlational studies that have looked at populations that don’t consume dairy have suggested that dairy may play a part in acne development. I’ve certainly seen improvements in PCOS acne in many of my patients when they’ve removed dairy from their diets. Removing dairy reduced their acne significantly.
Some of the best supplements for PCOS acne include:
Zinc is like a miracle nutrient for PCOS acne. It reduces androgen levels, is an anti-microbial, therefore killing bacteria, and reduces inflammation. Zinc acts on all three steps of the acne pathway.
Chinese medicine has used the berberine herb for insulin resistance for generations. Berberine has repeatedly been shown to improve insulin resistance as much, if not more, than the drug metformin. The bonus is that it does not leach vitamin B12 and folate from the body like metformin does.
Inositol is a B vitamin that is crucial in the glucose metabolism pathway. Studies have shown that women with PCOS may have a defect in the way inositol acts in the body. One study showed that supplementing with inositol decreased insulin and androgens, as well as triglycerides (a measure of insulin resistance), in women with PCOS.
Heal Your Gut
The aim of rebalancing your gut bacteria (microbiome) is to increase the number of good bacteria and reduce the number of bad. Probiotics can reintroduce good bacteria into the digestive tract. A large study of PCOS women showed that probiotics also lowered blood sugar levels and reduced insulin resistance.
You can get probiotics by taking a good quality supplement and eating fermented food. I would encourage you to introduce fermented foods into every meal. They significantly reduce the breakdown of carbohydrates, which reduces blood sugar.