Acne is a common skin condition that affects nearly 85% of people at some point between the ages of 12 and 24. It occurs when hair follicles become clogged with dead skin cells and oil, allowing bacteria to grow and cause inflammation. Acne can range from mild to severe, with one of the more painful and difficult to treat forms being cystic acne.
What is Cystic Acne?
Cystic acne consists of large, red, and painful breakouts deep within the skin. These cysts form when acne blockages burst underneath the skin, causing inflammation and fluid buildup. The result is firm, tender nodules that can take weeks or months to fully go away. Cystic acne is considered more severe than smaller whiteheads or blackheads on the surface of the skin.
While anyone can get cystic acne, it more commonly affects women. This suggests hormones often play a role in its development. The main hormonal drivers behind cystic acne include:
- Androgens like testosterone
When these hormones are out of balance, it can stimulate the oil glands and hair follicles in ways that lead to cystic blemishes.
Androgens and Cystic Acne
Androgens are hormones that cause increased activity and growth in oil glands, as well as increased production of skin cells that can clog pores. The most well-known androgen is testosterone. While both men and women naturally produce testosterone, women produce it at lower levels. However, women with polycystic ovary syndrome (PCOS) make higher than normal testosterone.
Elevated androgen levels cause the sebaceous glands in the skin to get larger and make more oil (sebum). This excess oil provides the perfect environment for acne-causing bacteria to multiply and congest pores.
In addition, androgens stimulate keratin production. Keratin is a protein that helps form the inner skin lining. Overproduction causes skin cells to build up and stick together, creating blockages.
These combined effects make women with high testosterone levels prone to severe, cystic acne. The chin and jawline are especially vulnerable due to having a high concentration of oil glands.
Main Causes of Excess Androgens in Women
- Polycystic ovary syndrome (PCOS)
- Congenital adrenal hyperplasia
- Cushing’s disease
- Tumors on the ovaries, adrenal glands, or pituitary gland
- Hyperthecosis of the ovaries
PCOS is the most common cause of elevated androgen levels in women. Up to 10% of women of childbearing age have PCOS, which interferes with ovulation and causes cysts on the ovaries. The exact reason PCOS leads to high testosterone is unclear but likely involves excess insulin stimulating androgen production in the ovaries.
Insulin Resistance and Cystic Acne
There is a clear link between insulin resistance and cystic acne. Insulin is the hormone needed to allow blood sugar into cells for energy. When cells stop responding to insulin as they should, it results in higher than normal blood sugar and insulin levels. This is known as insulin resistance.
Those with insulin resistance often struggle with acne, especially inflammatory cystic acne on the lower face, neck, and body. There are several reasons why insulin resistance may promote cystic blemishes:
- Increases testosterone and other androgen levels
- Leads to higher IGF-1, another hormone implicated in acne
- Triggers inflammation
- Increases skin cell growth and sebum production
These effects create the perfect cascade of excess oil, clogged pores, bacteria, and inflammation characteristic of cystic acne. Those with obesity, diabetes, and metabolic syndrome involving insulin resistance need to be alert for developing severe acne.
Cortisol and Cystic Acne
Cortisol is the primary stress hormone in the body. It has effects similar to androgens and insulin, making higher than normal levels a potential acne trigger. Reasons why cortisol may contribute to cystic acne outbreaks include:
- Increasing oil gland secretion
- Altering immune function in ways that increase inflammation
- Boosting sebum production
- Decreasing insulin sensitivity
Stress is not an absolute cause of acne. But chronic stress leading to high cortisol can worsen cystic acne in those already prone to it. This is sometimes called “stress acne” since flares often correspond with stressful periods.
Other Hormonal Factors in Cystic Acne
While androgens, insulin, and cortisol play the biggest roles, other hormonal factors may contribute to cystic acne as well. These include:
- Estrogen – Can increase oil gland activity. Low estrogen levels in relation to androgens is associated with excessive acne.
- Prolactin – This hormone stimulates breast milk production but may also activate oil gland growth.
- Growth hormone – Works synergistically with insulin-like growth factor (IGF-1) to trigger increased sebum production.
- Thyroid hormones – Both increased and decreased thyroid function can worsen acne severity.
In most cases, there is no single hormone to blame for cystic acne. Imbalances in androgen, insulin, and inflammation pathways appear the most influential. However, the hormonal interplay is complex and varies between individuals.
The Menstrual Cycle and Cystic Acne
Fluctuating hormones during the menstrual cycle are why some women experience monthly breakouts. Acne arising around the time of menses is termed premenstrual acne. It often persists through the period into the following ovulation phase. Key points about premenstrual acne include:
- Most common in women ages 20 to 35 years
- Often cystic and concentrated on lower face, jawline, neck, and upper back/chest
- Believed caused by dips in estrogen increasing testosterone impact
- Exacerbated by prostaglandin release inducing inflammation
- May signal conditions like PCOS or hormone imbalances
While many women experience some degree of premenstrual acne, those with moderate to severe flares should be evaluated for underlying hormonal causes. This is especially true for cystic acne cases.
Hormonal Causes of Cystic Acne in Men
Since androgens drive excess oil production and skin cell growth, what causes cystic acne in men? The main factors include:
- Puberty – Rising testosterone levels during adolescence spark acne in teenage boys. Cystic acne most common at ages 14-19.
- Anabolic steroid abuse – Artificially increasing testosterone and growth hormones worsens acne.
- Insulin resistance – Particularly with obesity, leads to higher insulin and androgen levels.
- Stress – Chronic stress impacts cortisol and other hormones, including testosterone.
- Congenital adrenal hyperplasia – Rare disorder causing testosterone overproduction.
Adult males can also develop cystic acne flares related to hormone fluctuations, insulin resistance, and life stress.
Diagnosing Hormonal Acne
Suspect an underlying hormone imbalance may be contributing to recurring cystic acne if you have:
- Acne concentrated in “hormonal areas” like the lower face, jaw, neck and upper back/chest
- Moderate to severe “cyclical” acne before periods that improves after menstruation
- Chronically elevated androgens like testosterone or DHEA sulfate
- Conditions like PCOS or congenital adrenal hyperplasia
- Signs of insulin resistance including obesity, skin tags, high blood pressure, etc.
- Always get cystic acne during stressful periods
Your doctor can run blood tests to check for hormonal abnormalities like high androgen or insulin levels. Pelvic exams and ultrasounds may also be warranted to look for ovarian cysts. Once any hormone-related conditions are diagnosed, proper treatment can help clear acne.
Medical Treatments for Hormonal Acne
Dermatologists have several options for managing cystic acne related to hormone disorders:
- Oral Contraceptives (OCPs) – Birth control pills containing estrogen and progestin can lower androgen levels and reduce ovarian cysts. Often very effective for hormonal acne.
- Spironolactone – Aldosterone blocker with anti-androgen effects. Used off-label to treat acne in women.
- Isotretinoin – Highly effective oral retinoid treatment for severe, resistant cystic acne.
- Antibiotics – Help combat acne bacteria. Mainly useful in the initial inflammatory phase.
- Retinoids – Prescription topical vitamin A preparations like tretinoin help unplug blocked pores.
- Dapsone – Antibacterial gel that reduces acne inflammation and lesions.
Lifestyle adjustments like stress reduction and insulin stabilization may further aid hormonal acne treatment. Most women with acne related to hormonal imbalances respond excellently to OCPs or spironolactone.
Natural Remedies for Hormonal Cystic Acne
Natural supplements and herbs may help rebalance acne-provoking hormones alongside medical treatment. Those with the most scientific backing include:
|Saw Palmetto||Blocks the activity of testosterone and DHT|
|Spearmint Tea/Extracts||Reduces free/total testosterone ratio in females|
|Omega-3 Fatty Acids||Decrease androgen levels and sebum production|
|Green Tea||May inhibit 5-alpha reductase to lower DHT and sebum|
|Vitex Agnus Castus||Regulates pituitary gland function and prolactin|
|Zinc||Necessary for hormone synthesis and metabolism|
|Probiotics||Help optimize estrogen metabolism|
Always consult your dermatologist before taking supplements, especially if using prescription acne medication. Herbal remedies may help normalize hormone balance, but more clinical research is needed.
Lifestyle Tips for Hormonal Cystic Acne
Certain lifestyle measures can assist in controlling cystic acne by optimizing hormone levels:
- Take care of insulin resistance – Follow a low glycemic diet, exercise regularly, and ask your doctor about metformin.
- Reduce stress – Make time for relaxing activities like yoga, meditation, massage, etc. to lower cortisol.
- Avoid hormonal triggers – Limit dairy, high-glycemic carbs, caffeine, and soy which may impact hormone levels.
- Balance blood sugar – Prevent surges and crashes by eating fiber-rich complex carbs and lean protein.
- Exercise moderately – While too much intense exercise raises cortisol, regular moderate workouts help.
- Get enough sleep – Aim for 7-9 hours per night to allow hormone reset.
Implementing healthy stress, diet, and lifestyle habits goes hand-in-hand with medical therapy for resolving cystic acne.
Hormonal imbalances involving androgens, insulin, cortisol, and other hormones often drive cystic acne formation. Common triggers include PCOS, metabolic issues like diabetes, adrenal disorders, and monthly menstruation. Testing can help pinpoint specific hormone abnormalities that may be corrected with OCPs, spironolactone, or other medications. Lifestyle and natural approaches further support normalizing hormone levels to prevent recurrent cystic breakouts.