Just thinking about “acne” makes my stomach churn, since it is one of the most hated of all the PCOS symptoms. Acne affects a large percentage of women with PCOS and is something you simply cannot ignore. It stares at you with every glance at your reflection. I am fully aware of the pain experienced by those with acne; I suffered for much of my adult life with it. I want to up-front tell you that I cannot give you a magic pill to clear your acne, but I will share my most effective approaches, and let you know of some exciting up-coming research.
The sad thing is that there are many dermatologists who believe they have the magic pill in the form of Isotretinoin (Accutane), a drug originally formulated as a chemotherapeutic agent. I must issue a serious warning concerning this medication for PCOS women. The success rate in this group is much lower than for others; only about one in three has long term benefit. Some see short-term improvement, followed by the acne’s return with a vengeance a short time later. Isotretinoin also has many side-effects such as headaches, dry eyes, cracked lips, bleeding gums, and fatigue. Among the more serious ones are birth defects, increased suicidal feelings and suicides, liver injury, elevation of blood lipids (fats), and permanent irritable bowel syndrome.
The other issue I want to address immediately is the use of oral contraceptives for PCOS acne. Oral contraceptives do sometimes help reduce acne in PCOS women, though often it does not. Oral contraceptives are chemical hormone mimics and are not good for the gut health. They deplete the body of B vitamins as well. They increase blood clot formation, which can be life-threatening. Long term use can increase breast cancer risk. They also can increase headaches and depression. These effects make me hesitant to prescribe them, though I will at times.
Spironolactone is another conventional drug often prescribed for acne, with mixed results. Although technically approved as a diuretic, it seems to work by blocking the action of testosterone in the skin. My patients have had less than stellar results with this treatment, but it can be tried.
I’d like you to understand why you have such stubborn acne. Your acne is the outward manifestation of inner inflammation combined with an elevated level of androgens (male type hormones)! Those of you who have read my previous article on PCOS and inflammation understand that a cardinal issue with PCOS is systemic (generalized) inflammation. This inflammation is also occurring in your skin, and so you must tackle this problem for what it truly is – a terrible SYMPTOM of an underlying inflammatory situation. The high levels of inflammation trigger still higher systemic levels of testosterone and DHEA (adrenal androgen), further aggravating the acne in an emotionally aggravating feed-forward scenario.
In PCOS women, the bacteria on the skin have been demonstrated to be different from that of “normal” women. Additionally, the sebum, or oily material which protects our skin, is also unique in PCOS women; its constituent fatty acid components are not the same and have reduced capability to fight off infection, hence the development of cystic, recalcitrant acne.
So what shall we do? We must douse those fires! We first must measure your inflammatory status and then must lower it. Your acne will dramatically improve once the flames are out. Start by getting your inflammatory lab tests performed. Contact me if you need help on this. Over the past few months, I’ve worked out a system to help all get these important tests performed at a network of draw sites. Next, we must get that inflammation down. As this is a short article on a very complex problem, I can only provide an overview of my program. If desired, I am happy to help you individually, simply contact me.
The treatment of PCOS related acne starts with your food choices. You must eat an anti-inflammatory diet. Avoid all dairy, in all forms! Dairy increases levels of IGF-1, which increases testosterone, increasing acne! Also, avoid all wheat and gluten, all sugars and sweeteners, alcohol, white rice and corn, and all chemical and processed foods.
There is no diet which is perfect for all PCOS women, so please feel free to do some experimentation to discover what works best for you. We are all unique in our immune systems, our toxic load, and genetics. The unifying theme must, however, be a diet to reduce inflammation! For those who enjoy it and can handle it, I suggest trying initially, for three to six months only, an organic vegan diet consisting of 10 servings (1/2 cup each) of vegetables, including at least 4 servings of a variety of root vegetables such as beet roots, turnips, rutabagas, parsnips, and carrots. Add in 2 fruits, particularly tart apples and berries. The other vegetables should consist of many different varieties of vegetables – all the colors of the rainbow! The phytonutrients and anti-oxidants in these foods fight inflammation and the resistant starch fibers in the vegetables, particularly in the root vegetables, provide nourishment to those critically important bacteria living in your intestinal tract. Add in organic beans, lentils, a handful of organic raw seeds and nuts, small amounts of whole grains such as millet, buckwheat, quinoa, and brown rice, along with lots of green and spearmint tea. This diet is high in nutrients, anti-oxidants, and gut-nourishing fiber. A healthy gut lowers generalized inflammation, which in turn lowers circulating testosterone and DHEA levels, which then reduces inflammation in the skin and improves acne! But if not eating animal products is more than you can handle, go ahead and add in some organic eggs, chicken, red meat, and fish.
Another option exists for women without disordered eating. Published data has revealed that testosterone and inflammation can be reduced by eating most of the day’s calories at breakfast, a third at lunch and fewer than a hundred calories at dinner. In one study, testosterone and insulin levels were reduced quickly by 50%! Although this was an incredible achievement, please recognize that this regimen was only tested in one study, and this way of eating is definitely neither suitable nor feasible for everyone!
You also must control stress! High stress causes increased output of cortisol, and that causes more acne! I hope to write an article on stress and PCOS in the upcoming months, but for now I would recommend buying guided imagery CDs for stress, take a course in meditation, learn progressive relaxation or tapping, get massages, or all of the above! There are studies showing that hypnosis can actually improve acne. The mind controls your stress level and your immune system’s responses, and YOU can control your mind with practice!
Sleep is a critical element related to inflammation. Just one night of sleep deprivation results in elevated markers of inflammation. Maintaining your Circadian Rhythm is a key element of health and the management of your acne. Wake and sleep consistently and get 7-8 hours of sleep nightly.
There are a few key supplements I recommend to reduce acne. They work by improving detoxification functions in the liver and by improving the metabolic functions of the body. In turn, generalized inflammation is reduced. Myo-Inositol, resveratrol, N-Acetyl Cysteine, and berberine are all very helpful. Taking a high potency B complex, containing methylated B vitamins is important. There are also published studies showing benefit from taking Vitamin B5, at a dose of 2 grams, 3 times daily, along with CoQ10, and L-Carnitine at a dose of 1 gram twice daily. Spearmint tea has been shown to lower testosterone levels and reduce acne.
Healing acne is slow going, so expect it to take 6 months to see very significant improvement.
In terms of topicals, several are helpful. Organic essential oils can help to control the skin bacteria. Blends with Thyme and Tea Tree are great. We use an excellent blend called Clear Skin by Simplers Botanicals. I recommend an organic acne line from Sophyto. In a study pitting ProActiv against Sophyto, Sophyto won! It incorporates antioxidants from organic fruits and vegetables grown on a farm on the British Isles. There are also several prescription topicals I have made up at my local compound pharmacy which I utilize. I have also found that acne peels can be very beneficial by exfoliating the skin. I have had success with a peel called ViPeel, designed specifically for acne skin.
I also want to emphasize that I am vehemently against the use of antibiotics for the treatment of acne. Actually, they rarely work for PCOS patients anyway, and from a long-term view, they are incredibly harmful to the GUT microbiome. Remember, there are supposed to be bacteria all over our bodies and within our bodies. The “right” bacteria in our guts reduce inflammation, and hence, reduce acne. Bacteria also typically grow resistant in time to the antibiotics and cease working at all, and so the antibiotics can create more harm by killing off our GOOD bacteria, those which are actually protective!
In terms of future hope, I am currently working to begin a study of the effects of a five-day diet which mimics the effects of fasting on the state of acne in PCOS women. It has been shown that this program reduces markers of inflammation, IGF-1, and insulin levels, all of which are associated with acne. The hope is that this dietary program will substantially reduce acne.
In summary, as you have seen, there clearly is no magic bullet for the treatment of PCOS acne, whether cystic or not. As my imperative is always to do no harm, I avoid Accutane and antibiotics, and prescribe oral contraceptives judiciously. My ultimate hope is to reduce the underlying generalized inflammation and lower androgen levels (testosterone and DHEA levels), while also healing the gut of PCOS women. Then the fire in the skin will be calmed, and the acne will finally fade away.