Contrary to popular belief, acne doesn’t go away once you turn 18.
In fact, for many women, acne doesn’t even get started until their 20s, 30s, 40s, or even in menopause.
For me, I had some acne throughout my teenager years, though it didn’t become unbearable until I was about 22 or so.
What gives? Why do so many women get acne later in life? Why do women suffer from acne at nearly twice the rate of men?
The answer is hormones. It’s always hormones.
Fortunately, I have done enough research, experimented enough on myself, and worked with enough clients to figure out exactly where acne comes from and what to do about it.
Here’s everything you need to know.
These key things are causing your Cystic Acne
Acne – including the cystic sort – comes from many different sources.
Dermatologists would have you believe that acne is caused by bacteria overgrowth in the pores of your skin. This is somewhat true -bacteria does play a role. Yet this is a very limited understanding of the processes that cause acne. Every person in the world has bacteria all over their skin. Yet some people get acne, and others do not.
How do we account for that difference?
It’s not simply because of genetics.
Acne is caused by many different internal factors. You can think of these factors like the trigger on top of genetics: genes predispose you to acne, but you only get acne if you “trigger” them with the right signal.
You may have a set of genes that codes for hypersensitivity to inflammation in the skin, for the “stickiness” and therefore clumping quality of skin cells, and for the rapid production of skin cells which can accelerate pore clogging.
Bacteria is also important (you can read more about bacteria and their role in acne in this post). Bacteria help modulate inflammation levels in the skin. They can also, interestingly, be aggravated by excessive vitamin B12.
How can healthy food give you acne?
Inflammation in the Pores:
Perhaps more than anything, acne is caused by inflammation in the pores of your skin. This is typically a result of systemic inflammation in the body. You wouldn’t be able to inflame a cyst without inflammation.
Poor Nutrient Status:
Acne is also caused by poor nutrient status. Vitamins like A, D, and K are critical for maintaining healthy skin cell membranes and pores. Replenishing stores of those vitamins can help. Things like eating liver, or taking desiccated liver capsules, and/or taking a vitamin A, D, and K rich cod liver oil supplement – can go a long way towards healing many skin problems, including cystic acne.
Finally, acne is caused by hormones. Hormones play a critical role in oil production in the skin. Some hormones – particularly the male sex hormones like testosterone – cause more oil production. Some hormones – like estrogen – cause less.
Cystic acne and hormones: The imbalances that can occur
There are two primary hormones that cause cystic acne: testosterone and DHEA-S.
Testosterone is a male sex hormone that is still produced by healthy female bodies in small amounts. Testosterone levels often become unhealthfully elevated, mainly because of insulin resistance. (Insulin – the molecule that’s responsible for storing sugar in the blood as fat – can become unhealthfully elevated in the blood when there is a problem with gut health and/or inflammation.)
When insulin is high, the ovaries produce excess testosterone.
This causes many problems – including the fertility condition Poly Cystic Ovarian Syndrome.
Other reasons for elevated testosterone:
- High DHEA-S levels.
- Estrogen, acting as a balance for testosterone, may be low.
- Because of exercise and fasting. You can read more about that in the post How Fasting After Workouts Can Cause Acne, High Testosterone, and PCOS.
DHEA-S is another hormone that acts like a male sex hormone in the body and which stimulates oil production. It is different from testosterone however because it is not produced in the ovaries. It is produced by the adrenal (stress) glands.
When you are stressed out, DHEA-S levels rise.
This is a problem for many women with PCOS, since it exacerbates symptoms like cystic acne. It is commonly a problem for women with hypothalamic amenorrhea, too, since women with HA have already put a lot of stress on their bodies.
This is an even greater problem for women who may have both hypothalamic amenorrhea and PCOS (like I did – read about how that is possible and what to do about it here).
Then there is one more hormone that causes acne, though not as much as testosterone and DHEA-S. It’s progesterone.
Progesterone does not increase oil production in the skin, so it is not quite as cystic as testosterone and DHEA-S are. But it does block estrogen activity in the skin. Estrogen is protective to the skin, so many women who have high progesterone levels – often because of the pill or the progesterone IUD – suffer from increased acne. You can read more about birth control options and how to manage their health effects in this PDF I wrote on birth control, here.
Finally, estrogen heals the skin. It reduces oil production and calms down inflammation in the pores. This is a great hormone for helping sooth hormonal imbalanced cystic acne.
Yet if testosterone levels or DHEA-S levels are so high, not even high estrogen will be enough to curb their effects.
Cystic acne and hormones: oil production in the skin
There are three separate layers to the skin, and pores traverse these layers. To adequately protect your body and keep toxins on the outside, the outer layer of the skin must be hydrated and strong.
To do this, pores deliver oil from the bottom layer to the top of the skin. In healthy skin, oil comes up through the pores and oozes onto the surface, lubricating the skin and making it look soft and glowy. Think of it like a well, or a hot spring, or an oil rig.
In acne-prone skin these 3 things can clog pores:
1) Debris from the surface
3) Too much oil rising from the bottom layer of skin
Then all this oil oxidizes and bacteria go on a feeding frenzy – which makes the pores become infected and inflamed. This is acne.
When there is an excessive amount of oil and a bigger, deeper-feeling infection, this is cystic acne.
What is cystic acne? Cystic acne is a normal little pimple on hyperdrive.
Cystic acne comes about often when inflammation is particularly high – or when an infection is particularly bad – or, as is the case with so many women, when hormone imbalance causes oil production to really be in excess.
When oil production is really high, it becomes easy for pores to become clogged, and for there to be a lot of material stuck there in the pores to hurt, get infected, and just be begging to be popped.
So cystic acne may arise as a result of many factors – and in fact it most likely is a result of many factors – but the most important cause for women is hormone imbalance.
Cystic acne and hormones: Is your acne caused by hormone imbalance?
These factors may indicate a hormone imbalance:
- The cysts are located around the mouth, chin, and jaw. This is where most, or at least the worst of, hormone-imbalance acne occurs because it’s where the skin has the most hormone receptors.
- The shoulder blades, buttocks, and thighs contain hormone receptors, so this is another place to look for cystic, hormonal acne.
- Oily skin is the result of hormone imbalance, too. If you have a lot of oil on your skin this may point to hormone imbalance, probably excess testosterone or DHEA-S levels.
Other symptoms of this kind of hormone imbalance include:
- male-pattern hair growth like facial hair
- male-pattern hair loss like balding
- increased irritability
- low libido
- and maybe even irregular menstrual cycles.
Cystic Acne and Hormones: What now?
If you suspect your cystic acne is hormone-related (and it almost certainly is, to some extent), I recommend first and foremost getting as many tests done as possible.
Get bloodwork done – you can test your testosterone, DHEA-S, progesterone, estrogen, LH, FSH, and thyroid hormones T3, T4, and TSH to get a good idea of what is going on in your body hormonally. You may suspect then that you have PCOS. If so, I couldn’t recommend my own highly detailed guide to PCOS which you can check out here. If you are curious about treatment options, I have elaborated on a few here.
Check out the risk-free PCOS Unlocked Manual Here for everything you need to know about PCOS
You also may find that you do not have PCOS, but that you still need to correct your insulin issues, your stress issues, or your hypothalamic amenorrhea issues. You can read more about stress and hormones here, and about overcoming hypothalamic amenorrhea here.
You can read more about hormonal acne, it’s causes, and treatment in this blog post: Hormonal Acne: Where It’s Coming From and What to Do About It. Or in this one: The Ultimate Hormonal Acne Treatment Plan.
Most of all, I direct you to the program I wrote specifically for women suffering from cystic and hormonal acne: Clear Skin Unlocked: The Ultimate Guide to Acne Freedom and Flawless Skin.
Clear Skin Unlocked was written specifically for women like you in mind. It’s for when you’re frustrated, looking for answers, and tired of falling through the cracks. In Clear Skin Unlocked I discuss everything I did in this blogpost here at much greater depth, as well as provide a Four Week Jumpstart to Acne Freedom to get you on your way to robustly healthy and radiant skin, for good.
And that’s a wrap! With all the links I provided here at the end you should have a good chunk of reading available to you for your cystic acne needs. In the meantime – what do you think? What is your experience with cystic acne and hormones? I would love to hear all about it!
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Great info! I have struggled with HA which was worsened by BC. After going off BC I had terrible and painful acne that popped up along my neck by my ears. Since I have balanced my hormones and got my estrogen up on my own enough to ovulate it has been so much better. Stress reduction is always a work in progress for me.
I just turned 39, mom of three. Always struggled with acne. Got better as I got older but in past 45 days I am breaking out like crazy, along my jaw line and down my neck. Nothing has changed with my diet/cleansing/workout routines. What is going on?? Not cystic acne but painful until the head come through then the red “scar like” spot lasts forever!! Please help, any suggestions would be great. I use Burts Bees Coconut Cleansing oil and Noelle’s recipe for ACV toner. Thanks for any follow up!
Hi, Stefani! I’m loving your blog and the great info about Paleo. I’d like to point out that when you talk about progesterone contributing to acne in this post, you are talking about progestin (synthetic progesterone that can indeed cause acne as a side effect). You are correct that synthetic progesterones found in the Mirena and the pill can contribute to acne. I speak from experience after having horrific estrogen dominance (as you know, a very inflammatory condition) with acne for ten years starting at puberty followed by the Depo Provera shot for 9 years in my twenties that reduced the estrogen symptoms with synthetic progestin without resolving my acne at all. In contrast, higher levels of progesterone (natural) during my pregnancy gave me completely clear skin. Now in perimenopause, I’m supplementing with a bioidentical progesterone cream to reduce severe estrogen dominance. Increasing progesterone has left me with zero hormonal acne issues. Natural progesterone reduces inflammation throughout the body and improves skin tone by balancing both estrogen and testosterone. Synthetic progestins block the action of estrogen but do not have the protective benefits of actual progesterone.
Yes, thanks Daisy, this is very helpful and true and I appreciate the input. i DO think that progesterone has been maligned for this reason (And estrogen too) – that we often use ‘estrogen’ and ‘progsesterone’ as short hand for things that are actually a bit chemically different. Thanks for sharing how important those differences were for you, I hope it’ll be helpful for people who read the comments – it certainly feels helpful for me to know this, and I will do some more research about progesterone receptors and skin 🙂
Thank you very much for this info. Still, I have a question: since I started pregnancy I’ve been having some bad acne around hormonal area in the face (chin , around mouth). I know during this period body does a naturally insulin resistance to ensure fetus nutrition, but, would that still be the origin of acne?
It very well could be. It could also be that your progesterone and/or testosterone are out-competing estrogen at the time. Also, if you are taking a B vitamin supplement, that could be a part of it, as even though B12 is very healthy it can cause some acne. Unfortunately the best thing you can do is continue to eat as well as you can and simply wait it out – making sure also that you are working with your doc to make sure your insulin levels are in a healthy range
I was taking estrogen for menopausal hot flashes. After my breast cancer diagnosis, I had to stop the estrogen and take an estrogen blocker. I now have cystic acne around my ears and jaw. Not sure how to deal with it.
That’s hard. I would work on lowering testosterone and DHEA-S as much as possible. Perhaps a lower carbohydrate diet? Perhaps de-stressing a lot and sleeping a lot? I would also recommend considering topical probiotics which can help alleviate inflammation in the skin
What do you recommend for treatment, I have all these issues at age 30.
I have cystic acne on my chin area that would not go away until I found dermalmd blemish serum. I have put it on morning and night and I am happy to say after a week I have no acne. This is a miracle for me! I am happy!
Hi there – I’m 38, female, and have been experiencing increased levels of acne, mood swings/irritability, and some hirsutism for the past year or two. Because of this I had my blood tested, which revealed slightly elevated DHEA-S of 379 (normal range 23 – 266). My testosterone and thyroid levels are normal, as well as cortisol levels. My doc is telling me there’s not much else to do at this point, but the fact is that I’m still experiencing these negative symptoms, so I’d like to figure out what’s causing this and how I can treat it. I had to push for an endocrinologist appt so am waiting to be seen by them. I did have a stressful year leading up to this so I could see that being the start of all this. Any thoughts on my situation and what could be underlying, and the best way to treat? It feels like my doc and the endo are saying “yes, it’s slightly high, but there’s nothing that we can treat” – but I’m not willing to settle for that and just live with these negative symptoms. I appreciate any insight you could provide to point me in the right direction.
that’s definitely a sign of stress. is there any way stress reduction strategies or better sleep could make their way into your life? <3
Im 37, I have hypothyroidism and Hashimoto Syndrome. I get horrible white heads on my chin the dermatologist called comodones, and the general physician misdiagnosed as staph infection once when inflamed writing me an RX for Bactrim. Anyhow, I’m always fatigued, Struggle to keep my weight where I want it and I do not drink anything with sugar, not even my iced tea, I use organic Stevia. I’m an LPN and have a decent understanding of health and the human body. I just became re-educated on nutrition by a friend who’s a Physician’s assistant on how and what to eat. It was an eye opener! The American diet is LOADED with HIDDEN sugar. That’s what is sad and scary the HIDING they do. Everyone should be aware of this. Having hypothyroidism, I cannot tolerate refined carbs unless they’re complex and in moderation. SO WHY WON’T MY CHIN CLEAR UP? I HAVE TRIED EVERYTHING???
OTC AND RX!! I AM DESPERATE!!! Please, Open to Suggestions! TY!! Amanda E, Kentucky
I’d focus on gut healing (probiotics, fermented foods, elimination of grains and dairy) and finding the right hashimoto’s treatment first and foremost <3
I am waiting on some test results but my main concern is cystic acne around my cheeks/ chin that started about a year and a bit ago when i turned 23. I have normal levels of testosterone (0.9nmol/L) & free testosterone (5pmol/L), a SHBG of 145nmol/L so it seems like androgens would not be the main issue for me? I had glucose test done and A1C and they also came back great… I’m just at a lost because I never had acne like this before and it seems like everything is “normal”…..
What about DHEA-S? This is a derivative of stress hormones and acts like a male sex hormone in the body, often giving rise to acne in this area. Also, sometimes for women this is just the most sensitive area but not necessarily because of or just because of the hormones. A good topical treatment (such as a vitamin A or vitamin C serum, I enjoy GoPure brand currently) and lots of other healthful tweaks in the diet can help make your skin more robust in all areas <3
It is important to note that cystic acne can be a complex condition, and that it may take a combination of treatments to achieve the best results. It’s always best to consult with a dermatologist for an accurate diagnosis and personalized treatment plan.