By Dr. Yazdani
Recently, I was approached by a patient age 21 years who had a perfect complexion until she had a hormone based IUD, a form of long term contraceptive device inserted into the uterus by her gynecologist to protect against unwanted pregnancy. Within a cycle or two, her skin started to breakout in horrible, pustular acne. The kind that leads to disfiguring permanent scars. She was devastated and began her foray into the world of anti-acne treatments, both online and in doctor’s offices.
She hadn’t changed her diet, the cosmetic products she was using or any other major change in her environment other than the IUD initiating an avalanche of problems for her once flawless face.
The basis of acne can be summarized into a three-prong illness constituting 1) bacterial overgrowth, specifically propionibacterium acnes 2) sebum oil glands and 3) androgenic hormones like testosterone or dihydrotestosterone.
The young woman in my office suffered from an imbalance of hormones. You have to understand one crucial truth about hormones, and you will already know a lot more than many doctors: Hormones coexist in harmony, in that their absolute numbers have less meaning than the rate of change or the relation they have with one another. For example in this case, an over abundance of testosterone and dihydrotestosterone overpowered her low estrogenic state that resulted from placement of the IUD. With less estrogen to balance its ‘male’ counterpart, lots more sebum sat atop the sebum glands, a type of oily substance that normally protects against dehydration and trauma within the skin. Acne pustules grew relentlessly, unchecked by the usual balance of hormones.
Anti-acne medications or chemicals such as retinol, Accutane, spironolactone and some oral contraceptives target the hormonal basis of acne. Agents such as benzoyl peroxide or salicylic acid, popular in the famed over-the-counter lines, Proactiv and Neutrogena, followed by stronger antimicrobials, like clindamycin and minocycline target the bacterial component of acne. Finally, scrubs, masks, cleansers and toners are designed to control sebum and dead skin cells which tend to clog up the pores. Doctors have found that targeting all three of the components, the sebum, hormones and P. acnes yields some of the best outcomes in eradicating acne in patients.
Many times we succeed with this approach, and help our clients regain their clear complexions once again. Some less fortunate patients, like the one who landed in my office this Summer, don’t respond to conventional therapies. Here is where you need to step back and look deeper into treating hormonal acne.
Can we ameliorate the hormonal imbalance?
This surely will result in immediate relief of her acne. An IUD is removed every 5 years and the risk of getting pregnant is not fathomable, so the option of IUD removal is out of the question for the time being.
Can we reduce the level of testosterone or work on controlling cortisol, another hormone notorious in disrupting the harmonious balance of all hormones?
Yes, treatment with spironolactone, an androgen blocker will help. Reducing stress, practicing meditation, eating an anti-inflammatory diet void of overly processed foods will help. In her book, Eat Pretty, former beauty editor Jolene Hart shares how she permanently and naturally cured her own acne following a clean beauty diet. My patient definitely would stand to benefit from both. Her diet consisted of artificial meats, snack bars, and sweetened beverages. She was under pressure in her new job and her commute long.
What are the safe topical agents to use?
Certainly, scientific data pointed us in the direction to destroy Propionibacterium acnes with benzoyl peroxide or antibiotics, to temporarily reduce acne blemishes. But new data has proven that the high prevalence of P. acnes on healthy skin is a relationship of commensalism or mutualism rather than parasitism. The sebum in facial follicles is the food supply of P. acnes, and in exchange we derive mutualistic peptides and enzymes with which human cells protect against other microbes. To deplete P. acnes with topical antibiotics could potentially alter the host’s susceptibility to other, more dangerous infections such as Methicillin-Resistant Staph Aureas, MRSA. Then it bears the questions, wouldn’t the logical path in management of acne prone skin focus less on obliteration of skin’s microflora, instead rely more on lightweight plant extracts like tea tree, rosemary, willow bark, arnica or aloe to provide important nutrients to these beneficial microbes? Can organic, natural compounds derived from plants and fungi help human cells function better? As it turns out, yes they can. A 2010 study out of Germany showed an aqueous solution of willow bark extract bathed with monocytes, a type of white blood cell reduced the protein expression of a very powerful inflammatory marker known as TNF⍺, and reduced expression of another type of similarly pro inflammatory marker NF-kB found in macrophages. Where plenty of scientific research has backed claims of anti-inflammatory and antimicrobial properties of plant derived constituents such as Melaleuca alternifolia (tea tree oil) as in this thorough article in the Journal of Clinical Microbiology Reviews points out, aboriginal tribes in Australia have shown us that bathing in a lake where an abundance of M. alternifolia leaves had fallen and decayed in its waters over time heals much the same way. Nature provides us with our most intelligent defenses, and this is the basis of nontoxic skincare.
Boosting the skin’s natural defenses with stem cells and fibroblasts
This is where PRP Microneedling steps in to save the moment. It’s done wonders for many of our patients by resetting the milieu of humoral factors present in the deep layers of skin. Microneedling is organized trauma followed by instillation of Platelet Rich Plasma, one’s own collagen and growth factor boosting substances. It’s as if the skin becomes smarter in dealing with P. acnes, hormones and sebum all at once.
After a bit of persuasion I successfully averted my patient from use of Accutane. We gave her 2 solid rounds of PRP Microneedling to face, décolleté and back, adjusted the dose of spironolactone, and had her use Seaside Medical Technologies’ Complexion Renewal System. She gradually transformed her way of eating, and began a modest exercise regimen. An app on meditation was advised and she endorsed using it at least 2 minutes every day.
In her 1 month check up, her skin began a transformational change for the better. Her scars were less noticeable, and any new lesions cleared away in a couple of days leaving no ugly trace of themselves on her renewed glowing skin. We made plans for removal of her IUD at its completion of 2 years and to give it a 6 month holiday before reinserting a new one.
The expression of happiness, not the P. acnes, was the only thing infectious on her face that day.
In good health,
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