FEMALE ACNE 16
Effectsof Hormonal Acne on Women
Thepurpose of this paper was to evaluate the effects of hormonal acne onwomen. Acne is the most common disease of the skin. It is mainlycaused by hormonal surges and imbalance between testosterone andestrogen hormones. During puberty and pre-menopause, women undergohormonal surges that are caused by pregnancy or menstruation. Acneamong women who have reached menopause is mainly caused by imbalancebetween testosterone and estrogen. Hormonal imbalances unmasktestosterone, which in turn stimulates sebaceous glands to secretesebum in excess. The excess sebum acts as a source of food for P.acnebacteria, which is easily sensed by the immune system. Acne causesboth physical effects (such as scars) and psychological effects (suchas depression) on patients. Acne can be treated using a combinationof therapeutic approaches, including hormonal therapy, topicaltreatment, antibiotic tablets, and non-pharmaceutical techniques.
Keywords: Acne vulgaris, hormonal imbalance, hormonal surges,therapeutic approaches, secretion.
Asmooth skin is one of the key elements of beauty that women value inlife. Unfortunately, bacterial infection known as acne vulgariscauses skin lesions, pimples or plugged pores that reduce theperceived beauty of women. These lesions can occur in many parts ofthe body, including chest, back, shoulder, and face. 1(1)Acne is the most common disease of the skin that can lead topermanent scarring or disfiguring of the skin. Although both men andwomen get at least a few lesions in the course of life, acne that islinked to hormonal changes (such as menstrual cycle) in women may bepersistent. Acne may occur in women in different forms, includingcomedone (plugged pore), pustules (pus containing pimples), nodules(lodge deeper into the skin), and cysts (deep within the skin andfilled with pus). 1(1)This paper will address different aspects of acne in women, includingits causes, hormonal activity in various stages of life, diseasemechanism, effect on patients, and treatment among other factors.
Althoughacne can be caused by many factors (including certain medication,diet, and genetic predisposition) hormonal changes during differentstages of life are the major causes of this disease in women. In mostcases, the outbreak of acne occurs during puberty, when the younggirls start experiencing hormone swings. This swing in hormones ischaracterized by an increase in production of hormones that determinesexual characteristics of the affected girls. Production of highlevels of hormones stimulates sebaceous glands, which in turnproduces excess sebum. 2(1) Accumulationof sebum bloc the skin pores and acts as a medium for proliferationof acne causing bacteria. In additional, hormonal imbalance (estrogenversus testosterone) may also cause acne in women.
Hormonalactivity in different stages of life
Hormonalactivity during puberty
Currently,there is one type of hormone that has been identified as a directcause of acne in girls during puberty. Testosterone is the mostimportant type of androgen or male hormone that is present in bothwomen and men. Its production increases during puberty where itover-stimulates oil glands to produce more sebum than the skin needs.This alters the process of the development of cells lining the hairfollicles. 2(1) Thisleads to the formation of pimples on the skin. The hormone isproduced to maintain the bone as well as muscle strength in women.Although the two major female hormones (including estrogen andprogesterone) are not directly associated with the breakout of acnein female during puberty, imbalance between these hormones andtestosterone may cause acne. A fall in level of Estrogen below thehealthy level results in the occurrence of acne. 3This mainly occurs during pregnancy and menstrual cycles in case theyoung girls get pregnant during puberty that ends at the age of about15 years.
Theoccurrence of acne during pre-menopause
Althoughmany people associate acne with puberty, women who have reached thepre-menopause period suffer from this skin condition. Pre-menopauserefers to the period between the time when women enter thereproductive stage and the onset of the symptoms of menopause. 4Similar to puberty, this period is characterized by regular surge inproduction of hormones, which in turn affects the process of sebumsecretion. These fluctuations occur during pregnancy or menstruationwhen the skin produces some pimples a few days before menstruationand within the first three months of pregnancy.1 (1)During this period, the level of estrogen is lower than healthlevels, thus unmasking testosterone that stimulates overproduction ofsebum.
Menopauseis a complicated process that is endured by all women when they reachthe middle age. This process is characterized by the end of menstrualcycle and hormonal changes. The decline in ovarian activity, whichresults from a decrease in production of estradiol acts as theprimary cause of most of the changes experienced by women duringmenopause. 5(1)These changes in production of hormones can cause various symptoms,including intense warmth in the skin. The reduction in production ofestradiol, which is caused by age-related factors in the ovary,reduces the sensitivity of follicles to stimulation by hormones thatare produced by the pituitary glands. This results in reducedproduction of corpus lutea, which in turn leads to lesser productionof estrogen. 5(1)This causes a hormonal imbalance that is responsible for theoccurrence of acne in women during menopause. During this period, thelevel of estradiol is too less to mask testosterone. Unmaskedtestosterone expresses itself by stimulating sebaceous glands torelease thicker oily substance called sebum that causes adult acne.
Manywomen expect to live free of acne problems after menopause, but itgets even worse in some of them. Post-menopause refers to a period inwhich women become completely infertile and it takes place aftermenopause. However, the problem is caused by factors (imbalancebetween female and male hormones) similar to other stages of women’slife. Levels of estrogen drop significantly in post-menopause in somewomen, which worsens the severity of acne. 6However, a significant decrease in secretion of estrogen is the majorcause of post-menopause acne. These women may eventually suffer fromtumor and other medical completions.
Sebumis an oily product that is produced by sebaceous glands found inlarge numbers in the scalp and the face. The major roles of sebuminclude reducing the loss of water from the surface of the skin,preventing infections, and immune regulation. 7The process of sebum secretion is controlled by male hormones,including 5-testosterone, testosterone, and 5-androstene-317diol,which are made by the sex glands (ovary in women) and the adrenalglands. Activities of these glands are in turn controlled by thepituitary gland that is located in the brain. The male hormones(androgens) are activated by different enzymes found in the skin aswell as sexual organs. The activated androgens, especiallytestosterone, stimulate sebaceous glands, which in turn producessebum. A drop in the level of estrogen (during pregnancy andmenstruation) uncovers the testosterone hormone that remains at arelatively stable level in females. This gives testosterone anopportunity to over-stimulate sebaceous glands to produce excesssebum that is responsible for the symptoms of acne.
Propionibacteriumacne isa non-sporulating anaerobic bacillus that grows in deep pores of theskin. This strain of bacteria feeds on sebum that is produced by thesebaceous glands that are located at the base of the hair shaft. 8(1)Although there are other strains of bacteria that grow in thefollicle, P.acneis the only strain that has been associated with symptoms of acnevulgaris. P.acnebacteria utilize sebum as the main source of food by releasingenzymes that digest triglycerides and fatty acids found in sebum. Thebyproducts of this digestive process include propionic acid and shortchain fatty acids that contribute towards the severity of thesymptoms of acne. This implies that the P.acnebacteria do not cause damage to the skin in a direct way, but theresponse of the immune system to comedogenic byproducts released fromthe process of digestion is responsible for the inflammation. 8(1)
Theoccurrence of acne inflammation means that the immune system of theaffected person has over-reacted to P.acnebacteria by releasing large amounts of white blood cells. Theseverity of P.acneinfection varies from one person to another depending on the level ofsensitivity to the bacteria. The wall of P. acne bacteria have manycomponents (such as lipopolysacharides, peoptidoglycans, andproteins) that are easily recognized as enemy molecule by the immunesystem. 8(1)To some extent, the DNA of P.acnebacterium is recognized as foreign by the human immune system. Thismeans that even dead P.acnebacteria can trigger a strong immune response that can increase theseverity of acne vulgaris. An increase in sebum provides optimumcondition and adequate supply of food for P.acnebacteria to reproduce, thus increasing chances for the occurrence ofacne vulgaris. This over-secretion of sebum coincides with pregnancy,menstrual cycles, or hormonal imbalance in different stages ofwomen’s life.
Thecapacity of P.acnebacteria to form biofilms is proven by its ability to form thesefilms in medical devices that are implanted in the human body and inthe in vitro experiments. Biofilms are sticky clumps of acne bacteriathat help in anchoring and protecting bacteria. Studies have shownthat the DNA sequence of P.acnebacteria contain genes that produce WS and EPS molecules thatcontribute to the formation of biofilms. 9An isolated bacteria form biofilms, which increases lipase activitythat explains the pathogenic role played by P.acnebiofilms. In addition, the P.acneforms fatty acids that enhance its adhesion to the follicle ofsebaceous gland and promote inflation. The adhesive properties ofthis bacterium are responsible for the formation of biofilms insebum, which in turn facilitates keratinocytes binding toinfundibular epithelium. Observed trend towards a decline in theefficacy of antibiotics results from the formation of biofilms,especially in the face. The presence of biofilms is associated withP.acneresistance to topical antibiotics that have been in the market for along time. Biofilms have also been associated with prolonged lengthof acne treatment, which leads to long-term infection.
Mechanismof acne vulgaris
Althoughthe mechanism of acne vulgaris is not clearly known, research hasshown that the pathogenesis of acne involves four major factors. 10(1)First, an increase in production of sebum, which is mainly influencedby androgen, acts as the primary cause of acne. This is followed byductal hypercornification (overproduction of epithelial cells thatlines the follicles). Third, the ductal epidermis hyper-proliferationcreates optimum conditions for Propionibacteriumacnecolonization. Fourth, bacterial colonization causes perifollicularinflammation in acne site. Hormonal acne is caused by up-regulationof sebum production in oil glands located beneath the skin. Theup-regulation is caused by high levels of androgen. The DNA of skincells responds to high levels of androgen by up-regulating sebumproduction. The glands are over-burdened by sebum, which then eruptsto the surface. This problem may be exacerbated by inflammation thatdepends on the extent to which sebaceous glands have been irritated.
Effectsof acne on patients
Acneis a skin disease that causes several negative effects on the skin ofthe infected persons. One of the upsetting physical effects isscarring, which occurs when pimples break open. However, scarringoccurs in a few patients suffering from cystic acne. 11Secondly, pimples associated with acne may irritate the skin,especially when they become inflamed. This causes redness of theskin, which is difficult to avoid. Third, acne cysts may at timespeel and become itchy, which increases the risk of developing woundsif the patient tears the delicate skin on the affected section.Fourth, drying out of the skin is a common occurrence, especiallyamong patients who treat their acne using topical creams, such asbenzyl peroxide. Lastly, severe acne may cause sores that arepainful. These physical effects of acne cause discomfort to patients.Research shows that acne patients feel discomfort as a result ofredness, pain, scars, and new eruptions that occur nearly on a dailybasis. 12These physical effects and the subsequent physical discomfortrestrict patients from attending social meetings and opt for socialwithdrawal. These patients also suffer from a feeling ofembarrassment, shame, psychosomatic symptoms, social inhibition, andaltered body image.
Psychologicaleffects of acne on patients
Acnecan affect patients’ psychology in four major ways. First, peoplesuffering from acne have low self esteem that makes the affectedperson feel embarrassed and avoid eye contact. Ladies with low selfesteem may grow long hair to cover their face or use excess make-upsto cover the scars. 10(1)Secondly, people suffering from acne have the difficulty ofestablishing healthy relationships. These patients lackself-confidence and find it difficult to go out and establish strongbonds, especially with individuals of opposite sex. Third, the lowself esteem and lack of self confidence affect the patients’ability to socialize with co-workers or with other students atschool. School children may refuse to go to school while the workingpatients risk losing their jobs by taking sick days from their placesof work. Research shows that people with acne are less successful insecuring employment compared to people with healthy skin. 13Fourth, the distress caused by acne results in depression. Depressionamong this group of patients may manifest in different ways,including wakefulness, mood disturbance, spontaneous crying, feelingunworthy and loss of appetite, behavioral problems, socialwithdrawal, and impaired performance in school or at work.
Treatmentof hormonal acne
Theprimary goal of treating acne is to reduce psychological distress,preventing scarring, and improving disfiguring. Hormonal therapy,which involves the regulation of secretion of hormones that stimulateproduction of sebum, is considered to be the most effective approachto counter hormonal acne. Hormonal therapy can be achieved inseveral ways, but two of them (androgen receptor blockers and oralcontraceptives) are more effective. Androgen receptors are blockedusing several drugs, including cyproterone acetate, flutamide, andspironolactone. 14(18)Cyproterone acetate functions by inhibiting androgen receptorsdirectly or acting as progesterone. When combined with oralcontraceptives, it blocks 3B-HSD activity, thus preventing theconversion of DHEA to a hormone known as androstenedione. Flutamideselectively prevents the binding of DHT to receptors of androgen andenhance metabolism of androgen to inactive compounds. Spironolactonefunctions by competing with testosterone for the receptors ofandrogen, inhibiting the conversion of androstenedione totestosterone, and inhibiting the conversion of testosterone to DHT.14(18)
Oralcontraceptives are the major types of androgen blockers used in thetreatment of hormonal acne. This treatment option is mainly used bywomen who are interested in the benefits of contraceptives and theyfunction by suppressing production of androgen in the ovaries. 14(20)They exert their therapeutic function by reducing production ofandrogen, which in turn decreases secretion of sebum. This isaccomplished by suppressing production of luteinizing hormone by thepituitary gland, which reduces the production of androgen. Thismechanism also affects peripheral production of androgen. Estrogencontained in oral contraceptives reduces the level of freetestosterone. This is an effective therapy for acne conditions thatare caused the unmasking of testosterone. The progestin component, onthe other hand, is responsible for the inhibition of5-alpha-reductase enzymes that catalyzes the conversion oftestosterone to an active androgen. These contraceptives have highclinical efficacy in decreasing acne lesions. This implies that oralcontraceptives are a significant tool for the treatment of acnecondition in women either exclusively or in combination with othermedical modalities.
Themost effective creams, gels, or lotions used in the treatment of acneinclude benzyl peroxide, topical retinoids, topical antibiotics, andazelaic acid. Benzyl peroxide kills bacteria found on the skin, whichmay infect the plugged hair follicles. 15(1)However, the cream should be used sparingly to avoid its sideeffects, such as burning sensation, dry skin, peeling of skin andskin redness. Topical retonoids decreases production of sebum, but itshould not be used during pregnancy. Topical antibiotics areavailable in forms of gel or lotion and they function by killingbacteria found on the skin, which may infect the plugged follicles.Azelaic acid is used as an alternative when the side effects oftopical retinoid and benzoyl peroxide are painful or irritating. Theyfunction by killing bacteria on the skin and removing the dead skincells.
Antibiotictablets also known as oral antibiotics are used together with topicaltreatment to treat acne condition that is perceived to be moresevere. Tetracycline is a class of antibiotics that is prescribed inmost cases, but not for breastfeeding or pregnant women. 15(2)Erythromycin is considered to be safer for breastfeeding and pregnantwomen. Oral antibiotics are associated with some side effects,including the reduced efficacy of oral contraceptives.
Althoughmost of the therapeutic approaches used in the treatment of acnerequire the use of pharmaceutical products, there are severaltreatment procedures that do not require the use of these products.For example, comedone extractor is a pen-shaped gadget that is usedto remove whiteheads and blackheads caused by acne pimples. 15(1)Photodynamic therapy is a non-pharmaceutical treatment procedure thatinvolves the application of light on the skin in order to improveacne symptoms. Some therapists may use chemicals to peel off the deadskin and facilitate the development of a new skin that replaces theold one.
Acnevulgaris is among the most common diseases of the skin that affectswomen physically and psychologically. Acne is a bacterial infectionthat involves over-secretion of sebum, which is a suitable medium andnutrition for the growth of P.acnebacteria. The occurrence of acne in different stages of a women’slife (including puberty, pre-menopause, menopause, andperi-menopause) is a clear confirmation that hormonal imbalance andsurges are important contributors of acne vulgaris. The male hormoneknown as testosterone stimulates sebaceous glands that over-producesebum, thus predisposing women to the risk of suffering from acne.Hormonal imbalance occurs when the level of estrogen goes below thehealthy levels, thus unmasking testosterone that stimulated glands tosecrete more sebum. Hormonal therapy is the most effective treatmentapproach given the fact that the occurrence of acne involves hormonalcomplications. This means that reversing these hormonal complicationscan bring the metabolic process to normal, thus reducing the severityof acne or healing it completely.
Acne vulgaris is caused by
Hormonal surges and hormonal imbalances
Use of some cosmetics
Hormonal acne during puberty is caused by
High level of testosterone
Imbalance between the levels of testosterone and estrogen
Hormonal acne is caused by hormonal imbalance during pre-menopause, menopause, and post-menopause.
Hormonal imbalance and surges increase the secretion of sebum that is used as food by P. acne bacteria.
P. acne bacteria form biofilms that anchor it to the infection site.
The main factors that determine the mechanism of acne vulgaris include
Formation of sebum
Propionibacterium acne colonization
Physical effects of acne on patients include
Painful sores on the skin
Psychological effects include
Low self esteem
Inability to establish healthy relationships
Lack of self confidence
Therapeutic approaches for acne include
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