Discussing hormonal acne, the menstrual cycle, and menopause is a complicated subject and cannot be covered in its entirety in a few pages. To make it understandable, this article will be limited to the major players: estrogen, progesterone, testosterone, and dihydrotestosterone. It will focus on new ways of treating this old nemesis, so professionals can perform an acne transformation in just a few weeks, resulting in very happy clients.

UNDERSTANDING HOROMONAL ACNE
Hormonal acne is usually described as a pattern of acne that follows the jaw bone and chin. It may extend into the mouth area and somewhat down the neck. This is true in many cases, but hormonal acne may not always follow this pattern. It is also described as acne that follows a predictable cycle of flaring and subsiding, which coincides with events in the menstrual cycle. This is a more reliable means of determination and the acne location may be the conformation, in most cases.
As menses flow stops at the end of a cycle, estrogen production begins to increase during the first phase of the following month’s cycle and reaches its greatest abundance within the female body, including the skin. It is the phase of estrogen, abundance, and dominance. These are the days when new acne infections occur the least and acne begins to clear. Before ovulation, progesterone increases, becoming dominant, and estrogen production decreases. The uterus lining changes to prepare for the egg. This event is around the 14th day of the cycle. Females who experience premenstrual acne develop breakouts during the progesterone phase, when progesterone is dominant, and estrogen is less present.
Following the progesterone phase, estrogen and progesterone drop to their lowest levels of the month and the testosterone dominant phase begins, continuing into menses again. Then, the cycle is complete. The volume of testosterone in the body and skin does not change significantly. Testosterone becomes dominant simply because of the decrease of estrogen and progesterone.
There is a yin and yang relationship between estrogen and testosterone. Testosterone is converted to dihydrotestosterone (DHT) by the enzyme 5alpha-reductase (5a-reductase). The presence of estrogen inhibits the actions of 5a-reductase. Subsequently, less testosterone is converted to DHT when estrogen is abundant and dominant, such as in the first phase of the monthly cycle. When estrogen declines and reaches its lowest levels and testosterone is emerging to dominance and freely being converted to DHT, new acne breakouts occur.
Testosterone is not the promoter of acne, but DHT is. DHT attaches to receptors on sebaceous glands, stimulating the sebaceous glands to begin producing increased amounts of sebum. Propionibacterium acnes (P.acnes) is present on the skin and in the follicles. The fatty acids in sebum are a target food for P.acnes. The bacteria feed and breed rapidly, which causes follicular inflammation. Cellular debris from the follicle restricts follicle openings and acne infections result.

PRODUCTS FOR TREATMENT
The power of estrogen in reducing DHT has been the subject of much research and has opened the door for pharmaceutical products that could inhibit 5a-reductase and, thereby, reduce the population of DHT. Multiple pharmaceutical drugs have been developed and marketed, but many are not indicated for use by females. These drugs are of no benefit to the aesthetics industry because they require a
physician’s prescription.
Green tea has been an ingredient in some acne products for years because it works effectively to reduce or prevent acne infections. Initially, its mode of action was not understood, but, through research, green tea is known to be a strong inhibitor of 5a-reductase, similar to estrogen, especially when applied topically. The benefit of agents like green tea is that they can be present and working when estrogen subsides.
In time, and following research, cinnamon bark extract has also been identified as another strong inhibitor of 5a-reductase that provides additional benefits as an antibacterial agent. Specific test results are not always published with specific efficacy results, but green tea and cinnamon bark are usually labeled as strong 5a-reductase inhibitors and can be used in conjunction.
For many years, topical and oral zinc have been associated with effective treatment for severe acne. It was believed that zinc supports and rebuilds immune functions, so the immune system can function normally again and combat acne infections. Zinc is frequently referred to as the clean-up enzyme and is necessary to break down the aftermath of infections and then repair and rebuild the various components of the skin involved. Topical zinc ointments are customary protocol in treating slow healing wounds that can plague the elderly and diabetics. Today, zinc is also a 5a-reductase inhibitor, reducing the production of DHT. Zinc’s role in treating acne is multifaceted and a very important component, especially when dealing with more severe acne cases.
Turmeric and saw palmetto are two additional inhibitors of 5a-reductase. Utilizing products that contain therapeutic volumes of one, two, or three of these mentioned inhibiting agents adds another dimension to being able to treat acne effectively and increases the probability of successful control. They reduce the potential for acne at the first step by reducing the conversion of testosterone to DHT.
Following the DHT trail farther, spironolactone is a pharmaceutical that was introduced in 1959 for the control of acne. As stated earlier, sebaceous gland cells have receptors. When DHT attaches to these receptors, excess sebum is produced. Spironolactone is able to block DHT from attaching to sebaceous cell receptors, and, therefore, block or diminish acne. It is classified as an anti-androgen drug. Spironolactone is available by prescription only.
Estrogen is also an anti-androgen, blocking DHT from attaching to sebaceous cell receptors. Therefore, it is not surprising that the estrogen dominance phase of the monthly cycle is free of new acne infections for most females because it inhibits 5a-reductase and blocks DHT attachment to sebaceous cells. In addition to inhibiting 5a-reductase, green tea, zinc, and saw palmetto are also on the list of anti-androgens and they block DHT cell attachment.
During the last several years, science has shown that specific natural elements and plant extracts can act in the same manner as pharmaceutical products without the side effects. While drugs frequently come in different strengths, it is possible to tailor an aesthetic acne treatment regimen to be of different strengths. Using an acne product containing one or two of the above DHT inhibitors or anti-androgen agents should control mild acne. Using three or four of these agents would be advisable to control moderate to severe acne. This is done by adding or subtracting products with these active ingredients.
A mainstay of acne control for decades has been antibacterial agents capable of killing P.acnes. Oral antibiotics have been used by physicians, yet 81 percent of women report some degree of failure in treating acne effectively with oral antibiotics. Again, this is the old singular mode of treatment which consists of bacterial control only. Many aestheticians use benzoyl peroxide as their acne treatment agent. It is effective, but, like oral antibiotics, it has some degree of failure. When dealing with perimenopausal, menopausal, and postmenopausal females (not to mention younger women with dry or sensitive skin) benzoyl peroxide may be too drying and irritating. There is also the consideration that benzoyl peroxide is a free radical that may damage skin.
Thyme extract is a newer option available in nonprescription acne treatment products. While more tests are still in progress, thyme has already proven to kill P.acnes more effectively than over-the-counter concentrations of benzoyl peroxide. Thyme extract is not drying to the skin and far less than 1 percent of the population experiences any skin irritation from its use. Thyme extract is also classified as an excellent anti-inflammatory agent.
Another option is niacinamide (a form of niacin, vitamin B3) which has shown to be as effective as 1 percent Clindamycin. The combination of niacinamide and zinc is being studied in the treatment for acne and it is now understood why: one kills P.acnes and the other is a 5a-reductase inhibitor and anti-androgen. Curcuminoid (curcumin) is another agent that kills P.acnes. It is a major component in Differin topical prescription products. Thyme, niacinamide, and curcuminoids can all be found in aesthetic industry products and sometimes in combinations with the previously mentioned 5a-reductase inhibitors and anti-androgens.
Glycolic and salicylic acid have been mainstays of acne treatment. They keep follicle openings clear, so the above active ingredients can penetrate the follicles and do their work. It is important to remember that bacteria is not limited to the surface of the skin. P.acnes can and do easily live in the epidermis and dermis and move freely in and out. Penetration by topical agents is frequently dose dependent and bacteria is ever present in the environment. The synergistic approach to acne control has benefits by using the interaction of multiple agents together to produce a combined effect that is greater than the sum of their separate effects. Combinations of agents that kill P.acnes and keep follicles clear and 5a-reductase inhibitors and anti-androgens provide a greater potential for complete
acne control.

CREATING A REGIMEN
An effective regimen for hormonally-induced acne would include cleansing, follicular exfoliation, and treatment (eradicating P.acnes, inhibiting 5a-reductase, and blocking DHT from attaching to sebaceous cells). A product can perform more than one function. Therefore, a cleanser might contain an exfoliating agent and a 5a-reductase inhibiting ingredient, as well as a DHT blocker. Perhaps two products are adequate for a client with light acne during the estrogen dominant phase, but, during the progesterone or testosterone phase, a client may need an additional product containing additional active treatment agents or even a fourth product in difficult or severe cases.
A mineral-rich clay product can be helpful and act as a poultice to draw infection out of the skin. Clay has a magnetic quality that creates channels within the skin’s matrix fluid and draws infection and waste out of the skin. It is highly effective in the treatment of cystic acne. Clay can work its magic as an evening application that is left on the skin overnight. It is a bit of old science but many clay acne treatment products also contain 5a-reductase inhibitors and DHT blockers to increase their effectiveness.
Selecting acne treatment products and regimens is as easy as creating a shopping list of the ingredients to include in the program. Then, look for acne products utilizing the ingredients on the list. Remember, a cleansing product might also contain salicylic acid and thyme, a follicle clearing lotion might have glycolic acid and cinnamon bark and a treatment product might contain green tea and zinc. Products can perform multiple functions and achieve multiple goals.
An effective acne regimen based upon the information in this article should clear or control acne in 90 percent of cases. Sometimes, slight modifications are needed for the other 10 percent to tailor a program to their unique chemistry, which can then prove effective.

THE ROLE OF DAIRY CONSUMPTION
Many medical, clinical, and aesthetic professionals have reported a link between dairy consumption and acne. There is a current theory about this subject that has laid out the specific chemical processes and presents a good case. Subsequently, research has been underway for a few years but it will be a few more years before the truth is known.
To simplify this theory, dairy products contain 5a-prenanedione, along with many other hormonal chemicals. In the human body, 5a-prenanedione, specifically, is a direct chemical precursor for the production of DHT. A precursor paves the way for something else and, in this case, 5a-prenanedione paves the way for the production of DHT. The result is believed to be a greater presence of DHT in the skin which can lead to acne or more severe acne.
It is not uncommon to ask a client about their dairy consumption and receive the response, “I don’t drink milk,” as though that is the only food that contains dairy. Dairy and its hormones are contained in milk, cheese, yogurt, ice cream, butter, cottage cheese, sour cream, and so forth.
All dairy products are not equal in their volume of hormones. As water and whey are removed from milk to produce thicker products, the concentration of hormones, including 5a-pregnanedione, can become very high. For example, one single ounce of cheese is produced from 10 ounces of milk. So, the client who does not drink milk might still consume a couple of pieces of cheese a few times a week. That does not sound like much, but it can be equivalent to roughly eight cups of milk a week. Then, add a little butter, some yogurt a few times a week, and maybe a couple of lattes and some people may, in reality, be consuming a great deal of dairy hormones without realizing it.
Others may be consuming a relatively normal amount, but at the wrong time of the month. As established, estrogen may be able to inhibit or block the development of acne during the phase when estrogen is dominant. But, as estrogen progressively drops to its lowest levels and testosterone becomes dominant, it might be a bad time to consume a lot of dairy products containing 5a-pregnanedione.
Acne cases that prove to be resistant to treatment may require exploration of dairy consumption. If dairy consumption appears to be contributing to acne, the client may choose to limit dairy consumption a few days before the testosterone phase begins and until it ends. Clients who develop premenstrual acne would want to make this modification during the phase of progesterone. The client can try dairy reduction during specific times for two complete cycles to see if it produces improvement.
Females concerned about bone health may be maintaining dairy consumption to add calcium to their diet. If a client is reducing some of their dairy intake to determine if it is influencing acne, she can also find calcium in tofu, sardines, almonds, kale, and a number of other foods. Professionals can search the internet for a more complete listing. Calcium supplements are also possible and the client may speak to a pharmacist about this.

MENOPAUSE
The umbrella term menopause can be broken into its three phases: perimenopause, menopause, and postmenopause. Perimenopause usually begins in the 30s or 40s and can last for a couple of years or as many as eight years. Classic symptoms are hot flashes, breast tenderness, lower sex drive, and more. At the onset of perimenopause, the usual 28 day cycle may initially become a 24-day cycle, but gradually become longer and longer over time, reaching 40 days, 80 days, or longer. Menopause is defined as a 12-month period of time without a menstrual cycle.
During perimenopause, the production of estrogen and progesterone are in decline and the speed of the decline is determined by the duration of time before reaching menopause. Testosterone is also in slow decline, marching to the beat of an entirely different drum. At some point, the volume of estrogen may no longer be sufficient to hold the effects of testosterone in balance and a female who might have been free of acne in the past may develop what is commonly called menopausal acne. She may think it is adult onset acne. This change is caused by an insufficient volume of estrogen and reduced ability to inhibit 5a-reductase and block DHT from attaching to sebaceous cells.
Some females seek medical treatment to supplement their estrogen, thereby reducing acne and other menopausal symptoms. Aestheticians treating perimenopausal, menopausal, and postmenopausal acne clients can use products with 5a-reductase inhibitors and DHT blockers to produce estrogen-like skin actions that prevent acne. The degree of treatment can be altered at any point by increasing or decreasing the number of products with natural active ingredients as named previously. These products would be used in conjunction with ingredients that keep follicles clear and eradicate P. acnes.
Aestheticians clearly have an arsenal of tools available to effectively treat hormonal and menopausal acne. They include safe natural ingredients. In many cases, these natural ingredients are comparable in function to ingredients used in pharmaceutical products and employ the same strategies.

Larry Lockhart has been owner and CEO of BiON Research Skin Care since September 2007. He graduated from the University of Nebraska College Of Pharmacy. He was owner of three Option Care franchises for several years, which involved mixing and administering home intravenous therapy and home health. He is well versed in chemicals and medications that are necessary for the body and which ingredients mix well with others. He was elected as a regional member of the Option Care Inc. National Advisory Council for six years and was a vice president for Option Care Enterprises for three years. His experience in management and sharing his knowledge was celebrated when he was awarded National Man of the Year by Option Care Inc. in 1997.