The Role of Hormones in Acne
When It Comes to Acne, Androgens - which Are Male Hormones Present in Both Males and Females - Are at Fault
The Essential Information
You may have heard of "hormonal acne" before, and it is true that when hormones get out of balance, acne can result. But the term "hormonal acne" is something of a misnomer. In fact, all acne is hormonal. Hormones are necessary for acne to start, which is why we see acne afflicting young people as they hit puberty and the body starts to produce hormones. Specifically, it is androgens, which are male hormones found in both males and females, that are crucial to the development of acne. These hormones increase the amount of skin oil, called sebum, that the body produces. Sebum is a necessary factor in the development of acne. When a pore is clogged, it is sebum that gets trapped inside the pore, leading to an acne lesion.
Generally speaking, the more androgens the body produces, the more sebum is created, and the more acne is seen. There are three main types of androgens involved in acne, which are DHT, testosterone, and DHEA-S, and all three stimulate the production of sebum. Many factors can result in increased androgen levels, but puberty is the universal culprit in most cases.
Androgens are male hormones found in both males and females, although they exist in a smaller amount in females. Androgens are responsible for developing the sexual characteristics of males. The pituitary gland, found at the base of the brain, regulates the production of androgens. This gland stimulates the adrenal glands - which are found near the kidneys - the sex organs, and the skin itself to produce androgens in both genders.1 In acne, androgens are responsible for stimulating the production of sebum (skin oil), which can lead to breakouts.2
Androgens and the Development of Acne
Excessive sebum production, called seborrhea, is a major component in the development of acne. Sebum is produced in glands calledsebaceous glands, which are attached to the side of skin pores. Androgens work to increase sebum production by moving from the bloodstream directly into special cells called sebocytes. Sebocytes are the sebum-producing cells of the sebaceous glands, and androgens stimulate those cells to produce more sebum once they enter the sebocytes. Research has clearly shown that more androgens leads to increased sebum, which is a contributing factor to acne. In fact, acne first develops during puberty because puberty is the stage at which the body begins synthesizing androgens. In some acne patients, normal levels of androgens can still bring about increased sebum production. To explain this concept, scientists believe that the sebocytes in some acne patients are more sensitive to androgens than others. In other words, the same amount of androgens can cause the sebocytes of some acne patients to produce more sebum than other acne patients. In these patients, the sensitivity to androgens results in increased sebum production, even when there is not an excess of androgens. Sebum production can also be regulated by the size of the sebaceous gland: the larger the sebaceous gland, the more sebum is produced. The largest sebaceous glands are found on the back, neck, chest, and face, which explains why acne develops more often in these areas of the body.1-3
How an Acne Lesion Forms
An acne lesion develops when skin cells block the opening of a pore. Normally, sebum produced inside the pore is expelled onto the surface of the skin. However, it cannot escape if the pore opening becomes blocked, and this results in a buildup of sebum inside the pore--serving as a "breeding ground" for acne bacteria. Since androgens increase the production of sebum, more sebum ends up being trapped in the pore, on which a bacterial strain called C. acnes feeds. Greater sebum levels allows for a larger amount of C. acnes, which increases irritation and inflammation. Soon, a comedone (clogged pore) is formed.2,3
Types of Androgens
There are many types of androgens, but only three relate to acne.
- Dihydrotestosterone (DHT) is the most powerful androgen, and it can cause an increase in sebum production
- Testosterone is another powerful androgen that can cause an increase in sebum production. Sometimes, if the body needs more DHT, it can convert testosterone into DHT through a special protein called 5α-reductase (5-alpha reductase). This increased production of DHT will also lead to more sebum production. In the past, scientists believed that testosterone only increased sebum production after the body converted it into DHT. Following that idea, they used drugs that prevented the 5α-reductase conversion of testosterone into DHT to prevent sebum production and treat acne with some success. However, some research has shown that testosterone can increase sebum production by itself, so drugs that only inhibit the conversion of testosterone into DHT may not always be effective in this regard to treat acne.3,4
- Dehydroepiandrosterone sulfate (DHEA-S) is a weak androgen that the body can convert into DHT or testosterone if it is in need of a more powerful androgen. Researchers have found that although weaker than either hormone, DHEA-S is more abundant in sebum-producing cells than DHT or testosterone. This suggests that controlling it may be just as important as controlling other androgens that regulate sebum production. In fact, researchers have found that in acne patients, higher DHEA-S levels are most strongly associated with higher sebum output.2
What Causes an Increase in Androgens?
As higher levels of androgens leads to higher sebum production - and acne, in some cases - it is important to understand the factors that can cause higher levels of them. There are four main factors in the case of increased androgen levels.
- Age: The age of a person drastically affects his hormone levels. When we are born, there is a small surge of androgens, which sometimes results in the development of baby acne, called acne neonatorum. During childhood, the production of androgens decreases, which explains why children almost never develop acne. During puberty, however, the production of androgens peaks, which results in the emergence of acne during the teenage years. If a person does not go through puberty, as in the case of castrated men, then she will not develop acne because she lacks androgens.3 - 5
- Diseases: Certain diseases can cause an increase in androgens. These diseases often affect the glands and organs responsible for producing them, such as the adrenal glands (glands above the kidneys), ovaries (female reproductive organs), and the pituitary gland (gland at the bottom of the brain). Examples of such diseases include adrenal gland tumors, adrenal hyperplasia (increased adrenal tissue), ovarian tumors, and polycystic ovaries, among others.3
- Genetics: A person with an extra Y chromosome will produce more androgens. A normal male possesses two sex chromosomes: an X and a Y (XY). If a male has an X and two Ys (XYY), then he will produce more androgens.
- Taking androgens: An increase in androgens can be caused by taking more of them. One means by which people artificially increase androgen levels is to use testosterone injections or take testosterone pills, which are used for muscle growth in bodybuilding. However, certain medical conditions require the administration of testosterone, so these can also cause an increase in androgens.3
- Androgen, Wikipedia. https://en.wikipedia.org/wiki/Androgen
- Toyoda, M. & Morohashi, M. Pathogenesis of acne. Med Electron Microsc 34, 29 - 40 (2001). https://www.ncbi.nlm.nih.gov/pubmed/11479771
- Degitz, K., Placzek, M., Borelli, C. & Plewig, G. Pathophysiology of acne. JDDG 5, 316 - 323 (2007). https://www.ncbi.nlm.nih.gov/pubmed/17376098
- Leyden, J. et al. A systemic type i 5 α-reductase inhibitor is ineffective in the treatment of acne vulgaris. J Am Acad Dermatol 50, 443 - 447 (2004). https://www.ncbi.nlm.nih.gov/pubmed/14988688
- Cunliffe, W. et al. Comedone formation: Etiology, clinical presentation, and treatment. Clin Dermatol 22, 367 - 374 (2004). https://www.ncbi.nlm.nih.gov/pubmed/15556720