PCOS and Acne - How can PCOS contribute to acne?
Let’s talk PCOS and acne. When I started to consider whether I wanted to come off of hormonal birth control pills, the main thing I was worried about was my acne returning. It had been under control for years while I was on the pill, and I was terrified to go back to the days when acne plagued my skin. I have vivid memories of being a freshman in college anxiously awaiting the transition from summer to fall, and fall to winter. “The sooner the sun goes down”, I thought, “the less light there will be for people to see my skin”.
Fears Confirmed
A few months after coming off of birth control, my worst fears were confirmed. My skin erupted with cystic acne so painful, it would wake me up in the middle of the night. At 26 my skin inflamed with cherry red mountains. I refused to leave the house without makeup, and my hair was always in my face, covering my cheeks where my angry skin reigned. So what’s the deal? Why can PCOS cause severe acne? There are a few key reasons why this may be the case, and while this isn’t an exhaustive list, excess androgens, insulin resistance, and chronic low-grade inflammation can all contribute to acne.
PCOS and Acne: Excess Androgens
Let’s start with excess androgens, or hyperandrogenism. This is one of the Rotterdam Criteria for PCOS diagnosis. Androgens in females are produced in the ovaries and adrenal glands, which are regulated by the pituitary gland in the brain. While they are seen largely as a “male” hormone, androgens are key to reproduction, sexual function, cardiac health, bone health, muscle tone and mass, and brain function. Androgens help to regulate the female reproductive cycle, and are converted into estrogen. Excess androgens can stem from overproduction in the ovaries or adrenals. Increased androgen levels can lead to higher production of something called sebum. Sebum is oily and waxy, comprising of a mix of fatty acids, sugars and waxes. In excess, it can cause clogged pores, leading to bacterial growth that causes pimples.
PCOS and Acne: Inflammation
Inflammation can also play a role in causing acne given it is intertwined with excess androgen levels. While it is not entirely clear whether excess androgens cause inflammation, vice versa, or if another underlying factor causes both, there is a clear association between the two. A meta-analysis of 85 research articles showed significantly higher inflammatory serum levels in those with PCOS versus those without PCOS, even when controlling for obesity. Excess androgen presentation with PCOS is associated with a three-fold increase in levels of inflammatory markers versus those with PCOS who do not have excess androgens. In any case, this means that increased levels of inflammation in our body can lead to more acne.
PCOS and Acne: Insulin Resistance
Insulin resistance is present in up to 70% of those with PCOS. Insulin sensitivity is also reduced by about 40% in those with PCOS, regardless of weight. Excess androgens and inflammation are also associated with insulin resistance. While we do not yet know exactly which of these causes the other, we know this: increase one, you are probably going to increase the others as well. Effectively the three are part of what can be a vicious cycle. Insulin resistance may cause cravings for foods that upset inflammation, or exacerbate androgen levels, for instance.
A Note on Stress:
when we do not manage our stress levels, we increase adrenal androgens, which as we learned earlier, can lead to excess sebum production. Research has shown that stress can both trigger and worsen acne.
It Doesn’t Have to Be Complicated
Yes, the interrelatedness of excess androgens, insulin resistance and inflammation is incredibly complex. But the treatment for all three doesn’t have to be. We can take similar precautions to remedy all three because of how closely intertwined they are. All of these issues are exacerbated by factors we can control like eating too many processed foods, over-exercising, under-exercising, consuming too much alcohol, not getting enough nutrients, getting too little sleep, or dealing with too much stress. So, balanced lifestyle choices and prioritizing our health can help with what may be at the root cause of our acne.
My 5 Tips to Dealing With PCOS-Related Acne
1. Identify your triggers
I started to keep track of what I was doing on a daily basis to see how my lifestyle choices were impacting my skin. This can look like whatever you are able to stick to - it might be a running list in a Notes document on your phone, a physical journal, or mental notes. I learned that my acne was exacerbated by:
Red wine (cry, sigh, cry again): If I had even one glass of red wine, I would wake up the next morning with at least one new pimple (and a painful one at that). Alcohol in general was never great, but my skin apparently loathes red wine
Gluten and dairy: I have a somewhat lower tolerance for gluten and dairy to begin with, and when my skin was acting up, gluten and dairy only made the pimples more painfully inflamed
Wearing makeup under masks: To this day I swear I could feel them forming while I was sitting in class with a mask over my face
Wearing makeup multiple days in a row: My skin was desperate to breathe. I needed as many rest days as possible where I had a clean face
Exercising with a mask on: Trapped sweat was a huge no go while I was dealing with inflammation and flare ups. If I couldn’t avoid it, and in general, I had to wash my face immediately after sweating
2. Get a blood test and work with relevant doctors
My endocrinologist ran a full metabolic panel as part of my annual check-in on my PCOS. I knew I had to work on keeping down my inflammation levels, as well as my androgen levels. While I did whatever I could to support this naturally through lifestyle choices, I also decided trying an androgen blocker was the right move for me at the time. I started 50 mg of Spironolactone a day and supported my body with extra water, enough food and enough salt because it can act as a diuretic. My dermatologist also gave me a custom topical blend of tretinoin and azelaic acid, and recommended a gentle hydrating cleanser and moisturizer, like CeraVe. Note: while insulin resistance was not a concern for me, it may be for you. Explore this as well, and something like an inositol supplement or Metformin may be recommended.
3. Move your body
I kept working out, I didn’t stop because sweat contributed to acne episodes. I knew the underlying issue to my acne was a hormonal imbalance and inflammation, and that working out would help both of those things. I was confident it would eventually help things fall into place.
4. (Try) to manage stress
This one was tough for because I was in grad school while enduring this acne episode. Nevertheless, I stuck to working out because of the wonders it did for my stress levels and mental health. Plus, I knew that feeling strong and toned would help correct for some of the confidence I was losing because of my acne struggles.
5. Cut yourself a break
Even though there were extremely difficult days where I didn’t want a soul to see my face, I tried to limit the time I spent in the mirror lamenting over my skin. I did not speak to myself negatively, and reminded myself I was doing what I could to help my skin, and that eventually my skin would improve. Reassure yourself that you are more than your acne. You are a whole and complete person the way you are today.
The Bottom Line
Acne sucks. There is no other way to put it. It’s painful, it dilutes self confidence and it makes you waste a ton of time and money trying to figure out how to make it just go away. But know this: even on days when you feel like your skin insecurities or acne are running your life, you can take it into your own hands. Change won’t happen overnight, and it takes consistency, but know that you will gain control over your acne.