Understanding Hormonal Acne

Androgen, enzymes and the sebaceous gland. What role do they play in the condition of DHT Mediated Acne (Adult Female Hormonal Acne)?

In the article about the endocrine system we looked at the influence hormones had on our skin and related systems. This article will take a closer look at the sebaceous gland, the enzymes, hormones and the role they can play in some forms of acne.

We know hormones play an important role in skin physiology; the androgen hormones are of particular relevance re hair growth and sebum production. Testosterone arising from the circulation is converted to its more potent, reduced form dihydrotestosterone (DHT), by the enzyme 5a-reductase.
Dihydrotestosterone is primarily responsible for androgen receptor binding and creating an end result. Testosterone and DHT can both bind to the androgen receptor: however, DHT binds with greater affinity. Although DHT and testosterone act through the same receptor, in certain instances they mediate different physiological responses.

There are two distinct forms of 5a-reductase, Type 1 and Type 2, which differ in their tissue distributions. The Type 1 isoenzyme is widely distributed. The Type 2 isoenzyme is restricted to certain sites, including the hair follicle, prostate, and other tissues involved in sexual differentiation. Isoenzyme Type 1 predominates in sebaceous glands, influencing sebum production in the condition of acne, it is Type 1 that is of relevance to the skin treatment therapist when understanding and establishing cause of adult female hormonal acne.

Acne

is an inflammatory disease of the pilosebaceous unit with the several phases involved in its formation. Abnormal desquamation of the corneocyte (excess keratin causing closed/open/micro comedones) Proliferation of Propionibacterium acnes. (P acnes bacteria within the pilosebaceous duct causing increased free fatty acids from the triglyceride content of the sebaceous gland ) Androgen induced excessive sebum production (sometimes) Inflammatory response. (from the free fatty acid increase)
The effects of androgens on acne are most evident in adult women (in contrast to adolescent acne in boys and girls). Circulating androgens are typically in the normal range, but levels have been shown to be significantly higher in women with acne than in women without acne.

More efficient conversion of testosterone to DHT in the sebaceous gland as a result of locally enhanced Type 1 5a-reductase activity is the more likely to be the cause. DHT is the major nuclear androgen ultimately responsible for the increased sebum production by the sebaceous gland in hormonal mediated acne.

The female adult variety of hormonal acne is often found around the lower face, particularly along the chin, jaw-line and neck. The lesions are predominantly of a papule-nodular type and are very tender. Macules are also found to be predominant with the acne that has been stimulated by high “androgen climate” contraceptives.

Impaired Acid Mantle

occurs with daily stripping of the acid mantle, harsh cleansers and toners are not recommended for acne skin. It is preferable to approach the acne skin as sensitive, to ensure no long term damage is done to the epidermis and dermis. The acid mantle is the eco environment for the flora (antigens) that protects the skin from the outside world. (First line of skin barrier defence) Removal of this defence results in dryness, slow TEWL, secondary infection, slowness to heal and scarring.

Excess keratinisation

occurs by the build up of dead skin cells on the skin surface and within the pilosebaceous duct, this abnormal build up leads to comedones (blackheads). Instead of undergoing normal shedding and discharge through follicle, abnormal desquamated cells become unusually cohesive, form a microscopic plug. The progressive accumulation of these micro-comedones leads to visible comedones, the non-inflammatory lesions of acne.

The trapped sebum in the follicle favours the proliferation of the P acnes bacteria (Propionibacterium acnes), an anaerobic diphtheroid organism, which is normally present in the uppermost part of the pilosebaceous duct and skin surface.

Sebaceous Gland Secretions:  The secretory product of the sebaceous gland leaves the cell by the holocrine method. In the holocrine method of secretion the release of the secretory product of the cell (primarily triglycerides) involves the breakdown and loss of the whole cell. Prior to the release of the secretory product, the cell maximises the production of the secretion by breaking down its own organelles to provide the raw materials. As much of the cell as possible is converted into the secretory product prior to breakdown of the cell and the release of the secretion.
Androgens play a role in stimulating the sebaceous follicles to produce more sebum, which causes the enlargement of the sebaceous follicles. However, there are hyper-androgenic individuals who have little or no acne.

Propionibacterium acnes (P acnes)

Sebum provides triglycerides, (lipids) which can be hydrolysed to glycerol by P. acnes bacteria. Glycerol is a nutritional requirement for the proliferation of the bacteria. The by-product of this biochemical reaction is free fatty acids, which have pro-inflammatory and comedogenic properties. This is the direct inflammation caused by the proliferation of P. acnes.

In addition to triglyceride hydrolysis, P. acnes also release chemotactic factors that attract neutrophils. The release of hydrolytic enzymes by the neutrophils causes the rupture of follicular wall, and thus, furthers inflammation.

P. Acnes bacteria also cause complement activation and release of proteases. The penetration of these hydrolytic enzymes into surrounding dermis causes the inflammatory lesions of acne vulgaris. These lesions include papules, pustules, and macules.

What works on Hormonal Acne (DHT-mediated acne)?

A specific anti-androgen that can inhibit 5a-reductase without blocking the androgen receptor is the ideal approach to treating DHT-mediated acne.

It has been found that neither topical acne preparations nor oral antibiotics influence sebum production that has been stimulated by Type 1 5a-reductase. A specific anti-androgen that can inhibit 5a-reductase without blocking the androgen receptor is the ideal approach to treating

DHT-mediated acne. Therapists often recommend that Diane 35, Aldactone or Androcur to offer some relief to adult female sufferers of hormonal acne.

Topical therapies that can inhibit 5a reductase.

• Azelaic Acid, Vitamin B6 and Zinc

Azelaic acid is a naturally occurring dicarboxylic acid found in whole grain cereals, rye, and barley and animal products. Azelaic Acid has antibacterial plus anti keratinising actions. It is FDA approved as a topical preparation for treatment of acne and is effective against a number of skin conditions when applied topically. There is strong scientific evidence that Azelaic Acid is a potent inhibitor of 5-Alpha Reductase. Vitamin B6 and Zinc Sulfate have also shown to inhibit 5-Alpha Reductase individually. When Azelaic acid, Vitamin B6 and Zinc Sulfate where added together at very low concentrations, 90% inhibition of 5 Alpha-Reductase activity was obtained (Published Study).

• GLA and ALA

Gamma Linolenic Acid (GLA) and Alpha Linolenic Acid (ALA) are essential fatty acids found naturally in high concentrations in plant oils. GLA and ALA have been individually shown to inhibit 5-Alpha Reductase (Published Studies).
Used in conjunction with topical applications of skin care that address the excess keratin condition (Like Salicylic acid, to unblock the pilosebaceous duct) on a daily basis and by following with products containing “an antiseptic active” (tea tree oil) to reduce the inflammatory action, a beneficial result will occur.

• Sensible daily care:

Of all of the literatures that I have researched, none offer sensible advice for the hormonal acne sufferer. Sensible daily care can go a long way to alleviate scarring, pitting and causing an impaired acid mantle. In addition, avoiding comedogenic cosmetics will help prevent future blockages of the pilosebaceous duct. (Comedogenic ingredients to avoid)

Do not recommend cosmetics or skin care for an active, oily, acne skin. These will exacerbate the erythema and dry out the unaffected skin, which is usually the majority. Instead concentrate on caring for the erythema and aid the healing processes.

Daily care:

• Cleansing with mild cleansers that will not strip the acid mantle, cause redness or tight stinging sensations. Avoid cleansers for an oily skin and look to those designed for a sensitive skin. Avoid cleansers that contain sensitising surfactants. (surfactant list)
• Pre cleansers: Have recently being reinvented into user friendly and very effective preparations. Designed to soften comedones and loosen dead skin cells thus aiding desquamation and unblocking the pilosebaceous duct. Used before the usual cleanser that remove makeup and daily grime these pre cleansers are non-aggressive and replace granule exfoliators that scratch and damage the skin surface.
• Post cleansing or toning. These have changed in formulation and are very different from the old alcohol based toners of the past. Designed for acne, active or oily skins modern toners do not contain degreasing agents that strip or dry the epidermis. Instead they complete the cleansing process and aid desquamation with ingredients like lactic, glycolic or salicylic acid including antibacterial plant extracts and softening hydrating actives.
• Exfoliates: are not recommended for hormonal acne, nor the active oily acne skin. Do not recommend them for home use. Offer a regular salon treatment to address excess keratinisation and extraction of comedones.

Daily protection:

Daily protection should begin with the application of a healing agent to each individual blemish or affected area. These healing agents should contain anti-inflammatory, bacterial agents like Tea tree oil, or colostrum and/or 5a reductase inhibitors like Azelaic Acid, Vitamin B6 and Zinc along with Vit C & A to help regenerate new tissue.
Typical of any sufferer of acne, camouflage has priority. Unfortunately many foundations are comedogenic, occlusive, dehydrating with high fragrance and colouring. All of which aggravate an acne skin.

Choosing a foundation means being vigilant of comedogenic ingredients and taking care to read the composition of the foundation. (Back of packaging) Avoid foundations that need to be applied with a sponge, look for pump dispensers and dont buy oil free. “Oil free foundations” are not suitable for any skin condition, they have been found to aggravate surface dehydration creating fine lines and dryness. (Not a good look)!

Do not buy cheap foundations, it is always worth spending a little more to get the right product. Spend time researching and reading as many books as you can re cosmetic formulations. Be wary of foundations that are labelled “anti ageing” always check the formulation for comedogenic ingredients.

Sun protection is part of daily protection. We are now very aware of the damage incurred by UVR, in particular UVA. UVA is well known to damage a great deal of the dermis, causing premature ageing and compounding scar tissue. Under no circumstances should any type of acne be exposed to UVR. In addition an antioxidant preparation should be part of the sun protection routine. Vitamins A, C & E, offer multilevel protection, not only from free radicals but also contribute to the formation of healthy cells at dermal & epidermal level.

Interested in a course about Acne? Take a look at Understanding Acne from Pastiche Training. Accredited for 6 CPD points.