What is the connection between increased hair growth and acne?
Dear Dr. Redmond: I have noticed that many of my clients with hirsutism also have acne. Several have told me that they expected it to go away after their teens but that it did not. What is the connection between increased hair growth and acne?
INCREASES IN HAIR GROWTH and female acne do, unfortunately, go together because the hormonal cause of the two conditions is the same. In both cases, androgens (testosterone and related hormones) act to trigger the condition.
The initial event in acne is increased oil production. The oil is produced in the sebaceous glands which, as we know, are closely associated with the hair follicles. The two are part of the same skin structure, called the pilosebaceous unit. While the sebaceous gland responds to testosterone by making more oil, the hair root responds by growing hair that is longer, thicker and darker.
At puberty, androgen levels normally rise in girls; this is what causes the appearance of underarm and pubic hair as well as the increase in facial oiliness. When the latter is marked, acne can result.
Because the sebaceous gland can respond immediately to testosterone, acne usually appears before hirsutism — which generally takes several years to develop. Yet for some women, acne or hirsutism begins long after adolescence. And many women notice that their acne is worse in the week before their period. The exact reason for this common pattern is not known, but obviously it is related to hormonal changes during the cycle.
Hormones are not the only factors causing acne, but they are the first in a chain of events leading to unpleasantly visible lesions. After the oil is secreted, bacteria grow in it, chemically altering the sebum so that it becomes more irritating to the skin. Keratin (the protein that makes up the surface of the skin) is another factor in acne. In women with acne, it is stickier and tends to plug up the pores, trapping the irritating oil and leading to swelling in the form of pimples.
There is some evidence that people with severe acne tend to have very active immune systems, so that they show worse inflammation in response to the bacterial growth. In part this may be hereditary, so it is not unusual for acne problems to run in a family.
Studies show that when acne appears early it is more likely to be severe, so the popular idea that acne is only a teenage problem, is erroneous. Young women in their twenties and thirties may develop acne, and at any age it can cause great psychological distress. Making this distress even worse is the nearly universal misconception that acne is related to diet. But acne is not caused by chocolate or greasy fast foods — blamed, perhaps, because they are popular with teenagers. (This does not mean that high fat foods are healthy, but acne is not one of the health problems they cause.)
Acne is not due to poor hygiene, any more than greasy foods are. Regular face washing helps the condition, but many with acne notice that their skin becomes extremely oily again only an hour or two after washing.
In addition to pimples the increased oil can cause flat areas of inflammation on the skin. In the midline this is called seborrheic dermatitis; in the butterfly area of the nose and the skin next to it, the inflammation is called acne rosacea. The latter can be very embarrassing because it sometimes leads to a red nose, which can be confused with the signs of excessive drinking.
What can be done medically for teenage girls and women with acne? When acne is very mild — a few whiteheads and blackheads without inflammatory lesions — simple topical medications may be enough. When acne is more severe it should be regarded as an urgent medical problem, because permanent scarring may result. A few acne scars may not show, but an accumulation of scars over time can cause considerable damage to the complexion.
For more than very mild acne, hormonal testing is useful. This is the same as carried out for hirsutism, and consists in measuring androgens to see if elevated levels are involved in causing the acne. However, even if androgen levels are normal, they are still involved in starting the acne process. Some, but not most, women with acne, have a hormonal disorder. Evaluation by a physician experienced with these conditions is a good idea for severe acne that is not controlled by dermatological medications, or when there are also irregular periods, increased hair, or a weight problem.
The most common acne treatments are topicals to make the skin surface less sticky (tretinoin, Retin-A®), or antibacterials such as benzoyl peroxide, and antibiotics such as clindamycin or erythromycin. Oral antibiotics are also used by themselves or in combination with topicals. Tetracycline is common, and cheap, but can cause photosensitivity and yeast infections. Minocycline is more effective than tetracycline, yet much more expensive. Erythromycin in moderate doses is inexpensive and works out well for many women.
The problem with all these treatments is that they usually do not produce complete control for anything more than mild acne. This is because they work after the acne process has begun.
There are excellent hormonal treatments for acne, but many women never hear about them. (I have discussed them in more detail in my recent book, The Good News About Women’s Hormones.) Hormone therapy* has the advantage of blocking the initial step — the stimulation of sebum secretion by androgens — and it is not unusual for severe cystic acne to clear completely with proper endocrine treatments. The simplest of these treatments is birth control pills. For many women they provide a great reduction in acne.
The most effective hormonal treatment is an antiandrogen such as spironolactone (Aldactone), which has good results with both acne and hirsutism (with acne often responding more completely than hirsutism).
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