Persistent acne can be the result of abnormal hormonal fluctuations in the body. An increase in androgens, a type of hormone, can lead to acne that is resistant to many topical treatments.

Sebaceous Glands

To understand why hormones play a large role in the pathogenesis of acne, it is important to understand the function of sebaceous glands in the skin.

Sebaceous glands are a type of structure present on the skin. It is usually attached to a hair follicle and secretes an oil-like substance. This substance contains fatty acids and other substances that help to maintain the skin barrier and protect the skin from external antigens (1).

The production of sebum is important as it is antibacterial, protects the skin against UV rays and moisturizes the skin. 

Unfortunately, when excess sebum is present on the surface of the skin, it can create a blockage. It clogs the pore and leads to an inflammatory reaction that results in an acne lesion. Not only is an excess amount of sebum a contributing factor of acne, but any changes in the composition of sebum (such as a change in the fatty acid content) can also contribute to acne.

Androgens

Androgens are a type of hormone present in both males and females. It plays a role in the growth of the human body, as well as reproduction (1).

One function of androgens is to bind to androgen receptors on the surface of the skin. This upregulates the production of sebum in the skin (1). While there are many benefits to sebum production, it is important to regulate the amount of sebum produced by the skin.

Androgens and Acne

Numerous studies have been done which show the correlation between androgen levels in the body and the appearance of acne. One study showed that levels of testosterone, a type of androgen hormone, were elevated in patients with acne (2).

Another study looked at men who had a condition known as androgen insensitivity syndrome. This is a condition that causes the body to be unable to use androgen hormones. In these men, acne was completely absent (2). This may suggest that the lack of androgenic activity reduced and possibly eliminated the possibility of acne formation. 

In addition, it has been found that androgen receptors were more common in the T-zone than the rest of the face (2). This area includes the forehead, nose, and chin. Typically, these areas secrete more sebum than others, and often have more acne than other parts of the face. 

Children with adrenal issues, the glands that produce androgens, have been shown to suffer from acne issues (2). This suggests a link between androgen production and acne formation.

In other people with acne, dysregulation of androgen receptors were also present. This could cause an excess amount of androgens to be produced. 

Causes of Hyperandrogenism

Due to genetics, inflammation in the body, and/or issues with insulin signalling, women may develop polycystic ovary syndrome (PCOS). One characteristic of PCOS involves an increase in androgen production. Untreated PCOS can cause increased activation of androgen receptors and cause a subsequent increase in sebum production (3).

Endocrine disrupting chemicals present in plastics and water can cause issues with androgen secretion (2). Bisphenol A (BPA) is a type of chemical common in plastics. Once in the body, it can accumulate and disrupt the function of the adrenal gland. This produces an excess of androgens.

Lastly, diet may be another factor that effects the secretion of androgens (2). Diets that include high-glycemic foods (sugary foods, as well as some high-carb dishes) can spike levels of insulin-like growth factor. This stimulates the adrenal glands to produce an excess amount of androgens.

Diagnosis and Treatments

Blood tests that test serum levels of androgens can help determine whether or not your hormonal levels fall within the normal range or if it is in excess (4).

The treatment for hyperandrogenism involves oral medications that interfere with the abnormal hormone production in the body. Often, topical treatments may not affect the skin significantly and therefore, many do not find improvement with topical treatments alone.

One type of treatment includes spironolactone. This is a medication that can be used for hyperandrogenism, as well as a few other conditions including heart failure and kidney disease (4). It is an androgen blocker. It competes with androgens and prevents androgens from binding to androgen receptors on the surface of the skin. This way, it prevents the skin from upregulating sebum production and therefore, reduces the chances of acne formation.

For women, oral contraceptives can be used to regulate hormones. These can reduce androgens like testosterone, and increase opposing hormones like estrogen. 

There are also enzymes that can be taken orally that reduce the amount of androgens in the body (4).

References

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6408631/
2. https://www.mdpi.com/2073-4409/10/6/1439/htm
3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3846536/
4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2923944/