Module 1:
Welcome to your acne treatment course! In this first module, we’ll explore what acne is, how it is created by the body, and the causes behind it. In the first section, you’ll learn about how acne develops, the types of acne, and who most commonly suffers from it. Next, we’ll look at how hormones can cause acne, with sections on testosterone and DHT, periods, pregnancy, PCOS, teenagers and birth control pills. The next section is all about diet, showcasing two important studies that have indicated a strong link between diet and acne. Following that, you’ll learn about various lifestyle habits that can contribute to acne, before the module finishes up with a discussion about how genetics is relevant here.
1.1 What is acne?
1.2 Causes – Hormones 1.3 Causes – Diet 1.4 Causes – Lifestyle 1.5 Causes – Genetics
1.1 What is acne?
Acne is a disease which affects the oil glands in the skin. In this section, you’ll learn the science behind how acne develops, and learn about who can get acne. This will serve as a preparation for
you as this module teaches you about a number of different causes of acne, showing you why people suffer from this condition.
1.1.1 How does acne develop?
There are small holes in your skin, which are known as pores. Pores are connected to oil glands underneath your skin, via a follicle, a narrow channel. The oil glands produce sebum, and this sebum carried dead skin cells to the surface of your skin through the follicle. In addition, a very thin hair grows through the follicle and out of the skin.
The cells that form the walls of the follicle are called keratinocytes. These are the dead skin cells that, in healthy skin, are pushed out of the skin by the growing hair inside the follicle.
Sometimes, the hair, sebum and skin cells clump together in what is known as a plug. The bacteria in this plug cause swelling, and when this plug breaks down, a blackhead or whitehead will form.
Blackheads and whiteheads are known as comedomes. If the clogging is so severe that it causes the follicle wall to break under pressure, sebum leaks into nearby tissue and forms a papule or pustule.
This is how inflammatory acne develops.
This clogging can happen because there is 1. an excess growth of the skin cells, and/or 2. a condition called hyperkeratinization. Keratin binds the skin cells together, but when there is too much, the bonds between the cells can’t break so they stick together and clog the follicle.
The oil glands where this can happen are mostly located in the face, chest, back, neck and shoulders.
1.1.2 Types of acne
There are different types of acne and pimples. People with acne may have one or more of these types simultaneously, and one or more may be dominant.
Blackheads – pimples which rise to the skin’s surface and have a black appearance. It is important to note that the black color does not come from dirt
Cysts – deep, painful pimples filled with pus, which can cause scarring
Nodules – pimples which are solid, large, painful, and deep inside the skin
Papules – small bumps which can be tender, pink in color
Pustules – pimples which are red at the closest point to the skin, and have pus on top
Whiteheads – pimples with pus, under the surface of the skin
1.1.3 Who gets acne?
Acne is by far the most common skin disease, and people of all races and ages can suffer from it. Both genders have acne, though suffer from it to different degrees at different life stages, which we’ll explore further in this section.
Acne is the most common in people between the ages of 11 and 30, with 80% of all people in this age group reporting acne outbreaks at some point. The most common ages for acne onset are ages 10 to 13.
Teenage acne generally lasts five to 10 years, subsiding in the late teens and ending in the early 20s. At this age, teenage boys tend to have the most severe cases, though the condition is present in both genders.
However, older people can also have acne. People in their 40s and 50s report outbreaks, and 20% of all acne cases occur in adults. Above the age of 30, women are more likely to suffer from acne than men.
Though not nearly as well-known as teenage acne, there are two forms of the disease that occur in young children. These are acne neonatorum, a pimply skin rash which affects babies but does not leave any scarring, and acne infantum, which can be more severe and leave scarring. At this age, boys are more likely to have acne than girls.
Some studies have found that traditional societies in remote locations do not suffer from acne the way the developed world does. Further along in the module we will discuss this research further and the potential reasons behind this.
1.2 Causes– Hormones
Hormones have a huge part to play in the production of acne.
In section 1.1.1 we covered two potential reasons for cells clogging the follicle, and thus causing acne.
These were 1. the production of too many skin cells, and 2. hyperkeratinization. Researchers suspect that hormones are involved in keratin levels, and hormones are known the control the rate of skin cell growth.
In this section we’ll examine one of the main culprits in causing acne, testosterone, and look at many different hormonal influences that can cause breakouts.
1.2.1 Testosterone and DHT
Testosterone is a natural hormone that is found in the bodies of both men and women. The average adult male has between 4 times to 75 times more testosterone than the average adult female. This hormone is essential for sexual behavior, building protein, bone formation, the production of blood cells, liver function and carbohydrate metabolism. In women, it is produced in the ovaries.
DHT (Dihydrotestosterone-alpha)is a natural steroid, produced in the gonads in men. (It is also present in women, but to a much lesser extent). It is an androgen (male) hormone, and is responsible for the biological characteristics of males, such as increased muscle mass, hair on the chest and a deep voice.
5% of free testosterone is converted into DHT, by the 5-alpha enzyme. DHT is about five times more potent than testosterone, and is considered a very potent androgen.
DHT can cause acne because it over stimulates the sebaceous glands, the same oil glands that cause your skin to product more sebum. This can result in more acne as pores become clogged.
This is not always the cause of acne, but it can be, particularly in females.
1.2.2 Periods
Women can experience menstrual acne, which is a flare up on the skin that coincides with their period.
Generally, the acne will start to be more severe around seven to 10 days before the period begins, and
will subside when bleeding starts. Around 63% of women who are acne-prone experience these flare ups, according to a study in the Archives of Dermatology.
The reason for this is hormonal changes. In the first half of the cycle, estrogen is the main hormone, while in the second half, progesterone is dominant. As the period approaches, the levels of both hormones fall significantly. Testosterone stays at a constant level throughout the month, and when the other hormones dip, it becomes dominant and makes the oil glands produce more sebum, which increases breakouts.
1.2.3 Pregnancy
Acne is very common during pregnancy. More than 50% of women develop some level of acne in pregnancy. Some of these women will have had acne before pregnancy and find it gets worse, while others will have never suffered from acne before. Women who have a history of acne or acne flares during menstruation are more likely to suffer from acne during pregnancy.
Acne in pregnancy is mostly caused by the increased levels of hormones in the first trimester, which increases the skin’s production of sebum. Specifically, it is the release of progesterone that causes breakouts around the sixth week of pregnancy. If acne does not break out in the first trimester, it is unlikely to during the second or third trimesters.
1.2.4 Polycystic ovary syndrome
Polycystic Ovary Syndrome, also known as PCOS, is a condition caused by an imbalanced secretion of hormones by the pituitary gland. This affects the ovaries. PCOS usually occurs when insulin levels or luteinizing hormone levels are too high, which causes the ovaries to produce extra testosterone.
The consequences of this imbalance include weight gain, acne, and extra hair on the face and body.
The acne and extra hair are caused because the hair follicles and skin cells are very sensitive to even slight increases in testosterone in the body.
1.2.6 Teenagers
Acne in teenagers begins because of a surge in hormone production.
During puberty, both girls and boys start to produce higher levels of androgen. These are the male sex hormones, which include testosterone. The function of this hormone in boys is to stimulate the growth and development of the testicles and penis, while in girls it is for maintaining bone and muscle strength. This surge in testosterone sparks increased sebum production, causing breakouts.
1.2.7 Birth control pills
Though some women use birth control pills to control their acne, some women find that birth control actually causes acne for them, or makes existing acne worse. Contraceptives which are injected, or IUDs (intrauterine birth control devices) can also cause acne, because of the hormones they contain.
Birth control pills contain progestin (a synthetic form of the natural hormone progesterone), estrogen or a mixture of both. The pill that most people use is estrogen dominant, while the ‘mini pill’ contains progestin.
When taking estrogen containing pills, acne is possible because low progesterone levels, coupled with estrogen dominance, can cause acne. Some people, however, find their skin is cleared on these pills.
The mini pill, progesterone pills, and contraceptive implants can cause acne because of their high progestin content, which boosts sebum production.
1.3 Causes– Diet
The official stance of the medical profession and academia has been that there is no link between diet and acne. This conclusion was based on a set of studies conducted in the 1970s, but now researchers and scientists are coming forward to say that these studies were poorly designed and executed, and that there is still much research to be done.
In this section, we’ll explore two studies which point to there being evidence of a link between diet and acne.
1.3.1 Cordain’s study
Scientist of health and exercise at Colorado State University, Loren Cordain PhD, conducted a study to find out what the effect of diet was on the acne.
With an international team of researchers, he studied 1,200 in Papua New Guinea, and 115 in remote Paraguay. This included 300 teens from Papua New Guinea and 15 in Paraguay. In two years of study, there was not a single zit found. Cordain says that populations who eat all-natural foods do not suffer from acne. Cordain believes this is down to diet, as the people in these studies eat only fruit, seafood, vegetables and lean meats. They do not eat any processed or refined foods, and eat only what they grow, gather or hunt for themselves.
Cordain and his researchers wanted to make sure the difference in acne prevalence was not due to genetics. To test this, they studied South Americans and New Guineans living a westernized lifestyle, to check their acne levels. It was found that people of these ethnicities do develop acne when they started eating an American-style diet, which indicates that it is not genetics, but rather the diet.
But what is it about the American diet that causes acne?
Cordain noted that most of the American diet is based on high-glycemic foods, a group of foods which includes staples such as white bread, cereals, milk, and russet potatoes. High glycemic foods lead to a spike in blood sugar levels, which has been linked to increasing risk of cholesterol, obesity, diabetes and other conditions. Cordain said that half of the intake of U.S. food is of high glycemic foods, and that 85% of the grains in the western diet are highly glycemic and refined.
Cordain says that foods with a high glycemic load cause acne because of the hormone responses in our bodies. When we consume these foods, the levels of insulin and insulin-like growth factor, IGF-1, rise. In response, more testosterone is produced, which leads to too much sebum being produced. This can lead to acne.
This effect is particularly pronounced in teens because, Cordain says, “The teenaged years are a time of natural insulin resistance. The teens are growth years; for tissues to grow, they become insulin resistant.”
Following on from his research, DrCordain created the Paleo diet for the treatment of acne, which we will look further at in Module 4.
1.3.2 Mann’s study
Dr. Mann, an associate professor at Royal Melbourne Institute of Technology, has also pushed against the assumption of there being no connection between diet and acne.
Mann and his research team conducted a study on 43 young men aged between 15 and 21 years. These men were divided into two groups, each of which was given a different diet to follow for 12 weeks:
GROUP 1 was given a diet of low glycemic foods, including whole grain pasta and breads, lean meats, legumes, low fat dairy, fish, and lots of vegetables and fruits.
While GROUP 2 was told to eat sugary drinks and snacks, white bread and potatoes.
After 12 weeks, the study of the young men’s acne showed some outstanding results. The boys in group 1 showed a 50% reduction in acne lesions, which is a better result than is usually seen when patients use topical acne solutions. There were no new infections and no new lesions found.
The acne in group 2, however, was exacerbated by the diet they were following.
Mann said, “The results were astounding. And this is the first time there has ever been a proven connection between diet and acne.”
1.4 Causes– Lifestyle
Though acne is generally not caused by minor lifestyle habits, if you are already prone to acne, certain lifestyle choices and habits could aggravate your skin and make your acne worse.
1.4.1 Sun exposure
Opinions are divided on whether exposure to the sun improves acne or makes the condition worse.
Some sources say that short exposure to the sun (10-20 minutes per day for those of lighter complexion and 20-30 for those of darker complexion), may help with acne symptoms. Some people with acne have reported that getting burned causes them to break out for up to weeks afterward, as the skin has been irritated and is working to heal itself, while others report that after a burn or tan their acne has decreased.
Another theory which has gained support is that a vitamin D deficiency is the culprit behind the acne of some sufferers. As vitamin D is a hormone, when it is low, it has the ability to affect other hormones in
inflammation, which can improve acne, which is an inflammatory disease. This vitamin also reduces the amount of oil released by the sebaceous glands.
Many acne sufferers have reported up to 100% healing from acne when taking a vitamin D supplement, while others prefer to get sun exposure directly.
1.4.2 Stress
Research has shown that acne can flare up because of stress. The Archives of Dermatology published a Stanford University study which found that college students had flare ups of acne during exams. They reported higher levels of stress during this time, and higher levels of acne than usual. As a result, researchers concluded acne severity correlated strongly with higher stress levels. The results of this study were backed up by a test of high school students in Singapore, who were found to have worse acne during exam periods than in low stress times such as summer break.
At this stage, scientists are not entirely sure why stress makes acne worsen. The cells that produce oil do have receptors for stress hormones, which indicates a strong link, but they are as yet unsure of exactly how it works.
Originally it was thought that stress led to an increase in sebum production, causing more acne, but it was found that psychological stress did not cause significantly more sebum to be produced. This has led scientists to conclude that there definitely is a link between stress and acne, but that the process by which stress can aggravate acne is unclear biologically.
1.4.3 Picking blemishes
Picking blemishes can make acne worse, but it is something that many people with acne find themselves doing. Dermatologists say that when people are anxious or stressed, about their acne, or about something else, they are more likely to make their blemishes worse by picking them.
When someone picks their blemishes extremely frequently, even compulsively, because they’re embarrassed by and worried about their skin, they have a condition known as acne excoriee. This compulsion to pick acne means that they create scabs on their skin, which are likely to lead to scarring.
Most kind of picking at the skin makes healing take longer and increases the risk of permanent scars. In addition, infected debris and material can get pushed deeper into the skin, which leads to more redness and swelling. When a pimple is popped, the skin is left open to bacteria, which can lead to infection.
1.4.4 Over-scrubbing
Many people who have acne end up scrubbing their skin, but this can actually make the condition worse.
It is important to remember that acne does not come from dirt. Over-washing and scrubbing the face does nothing to decrease acne, but actually worsens it, because it increases irritation and can compromise the protective barrier of the skin.
1.5 Causes– Genetics
1.5.1 Evidence that genes have a role to play in acne
There are many studies that illustrate that genetics has a large role to play in the development of acne.
A study of 40 pairs of twins – 20 identical, and 20 non-identical, looked at how sebum production was influenced by genetics. The study found that identical twins had exactly the same rates of sebum excretion, but had different levels of acne. Non-identical twins had different levels of acne and of sebum production. From this, it would seem that sebum production is under genetic control, but acne itself is not.
A study of around 1000 pairs of non-identical twins, and 450 identical twins, found that genetics accounted for around 80% of acne, while 20% could be explained by other factors like diet and stress.
In a study with around 200 acne patients and 150 people without acne, researchers found that having a first-degree relative (child, parent or sibling) with acne, made it four times more likely you would also
1.5.2 How genes can influence acne
As shown in section 1.5.1, genes can affect how much sebum is produced by the skin.
In addition to sebum production, genetics determine how your immune system might respond to bacteria, which can determine whether you’ll break out or not, and how severely, under exposure to certain bacteria. Those with acnre-prone skin have a strong inflammatory response to bacteria and minor injuries in the skin.
Genetics also play a role in how easily your pores become plugged and how many dead skin cells are produced in your skin.
Another important influence genes have is over how sensitive your skin is to the hormones in your body. Androgen hormones such as testosterone, have different effects on healthy skin as opposed to acne-prone skin.
In people with darker complexions, acne may look less severe, because the color of the skin at least partially hides the redness caused by inflammation. But when acne clears on darker skin it often leaves a pinkish-brown spot, known as postinflammatory hyperpigmentation, which can stay for months or even years.
1.5.3 Other factors
If acne runs in your family, it is likely you will suffer from it to a certain degree. But having genes that make your skin acne-prone doesn’t mean you will automatically get acne or that there’s nothing that can be done to prevent it or heal from it.
Many acne experts say that if you have a genetic predisposition to acne, it is likely you will have to make lifestyle changes to prevent acne, even when other people would not. In the rest of the modules in this course, we will be looking at various lifestyle changes and treatments that can make the difference between suffering with acne and having clear skin.
