What causes acne? | 6 underlying causes of cystic and hormonal acne

Acne is an inflammatory skin condition that affects millions of people around the world. Acne impacts both men and women beginning in the teens years up to age 50+. There are various types of acne, including acne vulgaris, fungal acne, acne conglobata, and acne fulminans. Underlying causes and triggers for acne are numerous and not widely talked about conventionally. This article discusses the most common underlying causes of acne based on research and clinical experience.

Conventional treatment of acne includes one or more of the following medications: topical retinoids, topical antimicrobials, azelaic acid, salicylic acid, benzoyl peroxide, oral contraceptive pills, spironolactone, oral antibiotics, and isotretinoin (Accutane).

At Naturopathic Dermatology Group, we are committed to diving deeper and identifying and treating the underlying root causes of acne. We commonly use gut, organic acids testing, hormone, and mycotoxin testing in our practice.

1. Low fiber diet

Fiber is a type of carbohydrate that our body cannot digest well, and it is essential for overall health, especially gut and skin health. Fiber is found in all plant foods, including vegetables, fruit, nuts, seeds, beans, legumes, herbs, and spices. Fiber is fuel for the beneficial bacteria in our gut that make up our microbiome. Fiber feeds our good bacteria, allowing them exist in healthy and abundant levels and to produce beneficial products, including short chain fatty acids (SCFAs). SCFAs are fuel for cells of our gut lining, suppress inflammation, and enforce tight junctions in our gut to prevent leaky gut. Fiber also helps in prevention of colon cancer and in lowering cholesterol and blood sugar.

Fiber goals: Aim to eat a total of 35g of fiber every day and 30 different plants every week for optimal diversity and abundance of the gut microbiome. We recommend using the free Cronometer app to track fiber intake.

2. Food triggers

Certain foods are known to upregulate inflammatory and growth pathways that contribute to the pathophysiology of acne. The primary pathway that contributes to acne in the body is called the mTOR pathway. When mTOR is unregulated, it promotes inflammation, sebum production, and skin cell proliferation, which all contribute to acne formation.

Dairy is probably the most well-known trigger of acne. Dairy is produced for the purpose of feeding baby mammals. It is high in growth hormones to allow baby mammals to grow very quickly in order to survive. Humans are the only species that drinks another species’s milk and who drink milk beyond infancy.

Sugar is also notorious in contributing to acne. Diets high in sugar increase insulin and insulin-like growth factor) IGF-1 production, which stimulate the secretion of androgens (testosterone and DHT) and increase sebum production.

Meat (in high quantities) contains a high amount of the amino acid leucine, which exerts the greatest effects on mTOR signaling. Stick with a maximum of one serving of meat per day and aim to consume organic, grass-fed meat whenever possible.

Wheat is also implicated in contributing to acne via increasing leucine and IGF-1.

3. Poor gut health

Gut health plays an massive role in the pathophysiology of acne, among other skin conditions. There are various aspects that contribute to optimal gut health, including the microbiome, inflammation, and integrity of the gut epithelium and mucosal lining. There are common abnormal finding we see on stool tests in patients with acne. A study looked at stool tests in a cohort of acne patients and found up to 94% had overgrowth of Candida spp, 92% had H. pylori, and 53% had protozoal overgrowth.

Other common findings among acne patients include overgrowth of non-beneficial bacteria, fungal overgrowth, overgrowth of parasites/protozoa, low levels of beneficial gut bacteria, poor digestion, eleavted inflammation markers, and low secretory IgA. The combination of low levels of beneficial bacteria (esp. Akkermansia and Faecalibacterium) and low secretory IgA indicate leaky gut, which is a breakdown of gut mucosal and epithelial integrity, which allows larger proteins, irritants, toxins, and allergens to pass through the gut lining and enter the bloodstream. This can lead to immune system activation and inflammation, which can exacerbate acne and other skin conditions. Factors that contribute to leaky gut include inflammatory diet, overgrowth of pathogenic bacteria, parasites, Candida, low levels of beneficial bacteria, low fiber diet, antibiotics, ibuprofen, and other medications.

At NDG, we run GI Map stool tests and Organic Acids Tests on all pathients to obtain a in-depth overview of gut health and toxic burden.

4. Hormonal imbalances

Excess androgens — most commonly testosterone, DHT, and DHEA — are well known causes of hormonal acne, especially in patient’s with PCOS, who after have excess blood levels of testosterone, DHT, and/or DHEA. Androgens contribute to acne by increasing sebum production. While serum levels of these hormones can be elevated, sometimes the problem with androgens occur at the follicular level, and serum hormone levels will remain normal.

Elevated insulin and insulin resistance can contribute to acne by increase insulin-like growth factor (IGF-1), which was discussed in the dairy section above. IGF-1 promotes growth in many cells and body tissues. IGF-1 increases sebum production and skin cell proliferation, leading to acne. Eleavted insulin and insulin resistance can be seen with excess sugar consumption, high glycemic index food intake, diabetes mellitus, PCOS, and other conditions.

Hypothyroidism can contribute to acne via several avenues. Thyroid hormone is important in production and balance of estrogen and progesterone. Therefore, hypothyroidism can cause imbalances in sex hormones. Hypothyroidism also contributes to slowing of gut motility and digestion, which increases the risk of microbial overgrowth and constipation. Lastly, a common symptom of hypothyroidism is dry skin, which promotes excess sebum production.

Excess cortisol production, usually due to acute and chronic stress, contributes to acne by stimulating release of inflammatory substances, such as cytokines, and increasing sebum production.

5. Medications and supplements

There are some medications and supplements that have been shown to exacerbate acne in certain people. These include flouride, vitamin B12, biotin (B7), hormonal contraception, DHEA, iodine, and hormone replacement therapy. Whey protein and pre-workout or BCAAs can also contribute to acne.

6. Improper skin hygiene

While improper skin hygiene is rarely the sole cause of acne for most patients, topical irritants, allergens, cosmetics, and poor skin hygiene can exacerbate acne. Make sure any products applied to the skin are fragrance-free and free from dyes and colorings. All skincare products and cosmetics should be certified non-comedogenic, meaning it is less likely to clog pores. Check safety ratings of all of your products on the Environmental Working Group’s free Skin Deep database.

We recommend cleansing the skin with a gentle cleanser 1-2x daily. Always cleanse the skin at the end of the day to remove sweat, dust, dirt, cosmetics, and dead skin cells. Cleansing in the morning is optional, and often we recommend rinsing the face with cold water alone.

Use a moisturizer, or ideally, a skin oil for moisture morning and night, as dry skin can increase sebum production, increasing risk of acne. Wear a sunscreen with SPF 30+ every day to prevent acne scaring and sun damage.

See our Skincare Routine Guide for detailed information on components of a great skincare routine!