Understanding Acne Symptoms and Their Causes: A Case Study

Acne affects an estimated 85% of adolescents and young adults, as well as millions of people worldwide in all age brackets. The physical discomfort and emotional distress associated with this multi-factorial skin disorder can feel overwhelming and frustrating. Rather than just temporary relief in-between breakouts, true healing starts from understanding the symptoms, causes, and testing options, so that the right treatments and changes can be made towards clear skin long term.

Acne Symptoms

Acne manifests in various forms, and recognizing its symptoms is the first step toward effective treatment. The most common symptoms include:

• Comedones: These are part of the non-inflammatory type of acne, which include open comedones (blackheads) and closed comedones (whiteheads). They occur when hair follicles become clogged with oil and dead skin cells.

  
  

• Papules: Small, raised, red bumps that can be tender to the touch. They are often a sign of inflammation.

  
  

• Pustules: Similar to papules but filled with pus. These are usually what people commonly refer to as "pimples." Pustules are red bumps with yellow or white centers, often linked to bacterial imbalance and overgrowth of bacteria or fungus such as Staphylococcus aureus, Streptococcus pyrogenes and Cutibacterium acnes. The bacteria trigger an inflammatory immune response to fight infection, creating pus within the clogged pores.

  
  

• Nodules and Cysts: These are larger, painful inflammatory lesions that can extend deep within the skin. Nodules are solid to the touch, while cysts are filled with fluid. If managed poorly, they can lead to long-lasting scarring.

  
  

  These skin symptoms can occur anywhere on the body, but are most commonly in areas with higher sebum oil production or higher concentration of hair follicles such as the face, chest, upper back and shoulders. The local causes of clogged pores and acne include one or a combination of the following: increased sebum (oil) production, increased skin cell (keratinocyte) growth, reduced shedding of cells within the hair follicle and sebum oil gland, and inflammation. These also promote growth of C.acnes, and other harmful bacteria which feed on sebum and cell matter, leading to further inflammation.

Acne Causes: The Bigger Picture

Acne is a complex and multifactorial skin problem, so the root causes can be a combination of genetic, hormonal, and environmental factors.

• Genetics: Family history plays a significant role in acne susceptibility and severity. Individuals with a family history of acne are up to 80% more likely to also have acne due to the genes coding for the above local causes and the below root causes being passed down. Fortunately, disease is not 100% determined by genetics since lifestyle and environment can change gene expression.

  
  
  
  

• Hormones: Androgens, commonly known as male hormones, are actually present in both men and women. These can increase the size and activity of sebaceous glands, leading to excess oil production. An increase in androgens, such as during puberty or with conditions such as tumors or Polycystic Ovary Syndrome (PCOS), results in higher conversion of androgens to dihydrotestosterone, a more potent androgen that strongly promotes the production of fats and the growth and differentiation of cells that produce sebum. In addition to increasing sebum, androgens can also induce irregular keratinocyte skin cell multiplication, leading to hyperkeratinized sebaceous ducts. Over time, the accumulation of sebum and cells in the sebaceous duct results in micro-comedomes forming, and that gradually worsens and evolves into larger skin lesions visible to the naked eye.

  The female hormones estrogen and progesterone can also be linked to acne. Progesterone, one of the regulators of the menstruation cycle, can also increase sebum production, especially in the week leading up to the period and the beginning of menses. While estrogen is usually decreasing sebum production to counter-act the effects of progesterone, essentially making it “anti-acne,” a sharp decrease or increase in estrogen can also trigger an outbreak. The close interactions between these hormones during the fluctuating menstrual cycle where too much of either or too little of either can lead to a breakout, combined with their complex interactions with androgens and other hormones, means that a wide range of hormones needs to be thoroughly tested for a holistic understanding of the true hormonal triggers of each person.

  
  

• Stress: Corticotropin releasing hormone, a stress-related stimulating hormone can increase sebum production in reaction to stress and lead to clogged pores and increased inflammation. Psychological and emotional stress often leads to hormonal fluctuations in male and female hormones as well, which may worsen acne per the mechanisms above. In addition, acne itself can cause a huge amount of stress, further feeding in to a vicious cycle.

• Bacteria: The presence of C. acnes, a bacteria that thrives in clogged pores, can exacerbate inflammation and contribute to worsening acne. They activate immune and inflammatory responses with their secretions, and their enzymes promote damage of the skin cells and structure. When many harmful skin bacteria congregate together, they can form a biofilm to protect themselves from antibiotics, and lead to further inflammation.

  
  

• Diet: High glycemic index foods, dairy products, and certain fats have been linked to increased acne severity. Insulin and insulin-like growth factor-1 (IGF-1) are hormones that are part of this pathway closely linked to food. Diets high in simple sugars and carbohydrates increase these hormones in the blood and this activates androgen receptors signalling for the growth of sebaceous gland cells and increasing sebum production, leading to acne. Studies have shown that dairy also activates this signalling and increases IGF-1 by 10-15%. This is also the most commonly targeted pathway by prescriptions such as retinoids, benzoyl peroxide, antibiotics and hormonal agents (spironolactone, OCPs, flutamide).

  
  

• Environmental Factors: Pollution, humidity, sweat, diet, and exposure to certain chemicals can also trigger or worsen acne. These can clog pores directly or in combination with triggering an increase in sebum production and causing oxidative stress. UV-related acne usually present as non-inflammatory comedones or cysts, which is quite different from the usual acne.

  
  

• Medication & Skincare products: :Certain medications, such as corticosteroids and some contraceptives, can also trigger acne. Conversely, some anti-acne agents like retinoids and benzoyl peroxide are often associated with side effects such as redness, dryness, peeling, irritation and eczema which can weaken the skin barrier and allow for bacteria to enter more easily and worsen acne long term. What works for someone may not work for everyone, so it's essential to patch test skincare and makeup products and consult a naturopathic doctor or dermatologist to find out which ingredients to avoid.

  
  

  Recognizing which underlying factors are at play is crucial for developing a targeted and effective treatment plan that leads to long-term acne free skin.

Acne Testing

While acne is often diagnosed based on clinical examination, further testing can provide valuable insights into the underlying causes of acne and guide treatment options, especially in more severe or atypical cases.

• Hormonal Testing: Hormonal imbalances can be a significant factor in both men and women. Blood tests can help identify associated conditions like polycystic ovary syndrome (PCOS), diabetes, and high cortisol. However, these are only a snapshot and often not in-depth enough, covering only a few markers. That's why a more thorough test such as the DUTCH test which includes many female and male hormone metabolites, stress hormones, melatonin, inflammation markers, and multiple vitamin and nutrient markers is usually recommended for a more comprehensive and holistic view.

  
  
  
  

• Imaging: A Wood's Lamp can determine certain types of bacteria and fungal infections as well as rule out other skin conditions that may mimic acne. A dermatoscope can magnify areas and identify lesions unseen by the naked eye as well as reveal features to differentiate skin conditions.

  
  

• GI Testing:Bacterial overgrowth on the skin is often linked to overgrowth in the digestive tract through the gut-skin-axis. If there are also digestive symptoms, a GI-Map can determine which types of bacteria are causing issues. Rather than using broad-spectrum antibiotics that have increasing bacterial resistance, knowing the family and species leads to more effective treatment choices and targeted prescriptions.

  
  

• Allergy Testing: I: If allergies or food sensitivities are involved, testing can pinpoint potential environmental and food triggers to decrease inflammation and avoid breakouts. Environment and food induced acne has been found to be quite resistant to conventional treatments, with the only effective management being to remove the inducing factor.

Case Study: *Sarah

Cystic jawline acne with pustules over the cheeks

To illustrate the complexities of acne and the importance of holistic treatment, consider the case of Sarah, a 32-year-old woman in finance who had been struggling with persistent acne since her teens. She came to me with acne papules along the jawline, forehead and cheeks, as well as prominent whiteheads. Her outbreaks were always worse before her period and included painful cystic pustules. She had previously been prescribed courses of Accutane and antibiotics without lasting effects and wanted a natural long term solution without GI side effects. She was also suffering from poor digestion of protein and fats, as well as bloating and abdominal pain with certain food triggers.

After taking a thorough history of her symptoms and performing a physical exam of her skin and digestive system, we decided to run a DUTCH test to see a comprehensive view of her hormones  and a GI-Map for the bacteria on her skin and digestive tract.

While waiting for the results, we started with a few foundational supplements to ensure adequate nutrients for healing, energy, and detox. In addition, we added glutathione and R-lipoic acid for liver protection and enhanced regeneration. For diet, we removed likely trigger foods such as dairy and alcohol from her diet while simultaneously decreasing high glycemic foods and sugar, and increasing greens and hormone modulating seeds. In terms of skincare, we chose a clean natural cleanser and a toner that was right for her skin, careful to avoid potentially aggravating products since she was reactive to certain sunscreens.

After a month, her digestive symptoms had improved and her acne flares decreased. While there were still some occasional slip-ups in her diet, the resulting breakout and digestive discomfort were less severe than before. Her GI-Map results showed she had an overgrowth of Streptococcus, one of the bacteria on the skin commonly involved with acne, high anti-gliadin IgA, an anti-body reacting to a protein in gluten, and low beneficial bacteria. Her markers for leaky gut were also high. This visit, we added two different probiotics and a herbal antibacterial to promote a healthy rebalance of bacteria in her digestive tract

The next visit, her forehead and jaw were clear of acne. While she still had a few acne papules on her cheeks, she was also under a lot of family stress triggering self-hate during this period. During this visit, we did some emotional work to release her from the false beliefs she had about herself that were harmful, and added a homeopathic to help with her mood and overall symptoms. Her DUTCH hormone test came back with low estrogen, low progesterone, and low testosterone. Her melatonin, B12, and dopamine metabolites, usually a signifier of happy mood, were also low. We added DHEA, a precursor to estrogen, progesterone and testosterone, so her body could supplement the levels accordingly. While there are cases where DHEA can worsen acne, especially when testosterone and androgens are high, the results of Sarah’s DUTCH test showed that it would be safe and beneficial for her.  

After 3 months of treatment, Sarah reported that her acne was under control and her mood had become much more positive. While there was still the occasional cystic pimple when eating out, she was much better about controlling the triggers in her diet. Her digestion had significantly improved, and her skin’s sensitivity had decreased.

This case highlights the treatment of Sarah’s acne on a multi-factorial level. However, each person’s acne presentation and personal situation is unique. What worked for her will not work for everyone. Please consult a naturopathic doctor to find your unique root causes and put together a treatment plan tailor made to your specific needs.

*Names and identifying details have been slightly modified for patient confidentiality.

Conclusion

Acne is a multifaceted condition that requires a comprehensive understanding of its symptoms, causes, and management strategies. By recognizing the various factors that contribute to acne, individuals can take proactive steps toward achieving clearer long-term acne-free skin.

Whether through a combination of lifestyle and natural or pharmaceutical treatments, the journey to managing acne is a personal one. A naturopathic doctor can navigate this challenge and find balanced long-term solutions that work for each individual.