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Adult Acne – Warning Sign of Underlying Health Issues

Acne in adult females is a prevalent condition that drives these women to find help from different specialties: dermatologists, aesthetic doctors, cosmetic salons, etc. Recent studies have shown an increasing number of cases of acne in adult women. They are surprised to have this condition that is typically present in adolescent boys and girls, and often it would be their first presentation in adulthood. Clinically, adult females have moderate acne involving the lower face and lateral neck. In contrast, the typical presentation in adolescents involves the forehead area, nose, and malar area.

Adult acne is always a sign of an underlying metabolic condition. Therefore, it must not only generate a cosmetic concern in these ladies (which is usually true!)Seeing and treating adult acne only as a cosmetic problem increase the danger of missing significant metabolic and hormonal derangement in the body that can lead to more severe health issues.

Why do adult females get acne?

The most usual presentation of adult acne comes with associated insulin resistance. Typically, insulin resistance leads to direct stimulation of male hormones (androgens) from the ovaries in females. Overproduction of these androgens, primarily testosterone, may lead to excessive sebum production in the skin, which, in turn, may increase the risk of sebaceous glands inflammation, leaving these areas more prone to growing bacteria (P.acnes). These circumstances can trigger acne outbreaks. Almost all patients with acne present increased sebaceous glands secretion. Some studies have demonstrated increased 5α-reductase activity (potent testosterone enzyme) and higher androgen receptors expression in sebaceous glands in some patients. That is why each patient always presents an individual acne presentation.

According to the literature, about 55% of females with adult acne will have increased androgen levels in the blood, mainly testosterone, and DHEA. These cases will guide the Functional Medicine doctor to do additional investigations, find the causes of insulin resistance, and establish the actual stage of insulin resistance and all associated pathologies. By further investigating the causes of acne, we can find undiagnosed PCOS, prediabetes, etc. Adult acne can be a warning sign of many insulin resistance presentations that could appear in the near future: type 2 diabetes, cardiometabolic syndrome with high cholesterol, hypertension, fatty liver, depression, osteoporosis, type 3 diabetes (IR-related Alzheimer’s), etc. Naturally, these patients need complete Functional Medicine investigations to find the root cause of insulin resistance, which, once addressed, will lead to the spontaneous cure of adult acne too.  

Patients that are treated with localized treatments only will have a temporary improvement of acne, as the real cause and high androgens will remain unchanged. The symptoms of acne will escalate again. In one study, a topical gel containing 15% azelaic acid (although it decreased acne temporarily) did not change androgen levels since its systemic absorption was negligibly less than 4%. Therefore it is possible to conclude that although this medication may block the local effect of androgens on sebaceous glands, it will not alter the actual cause of insulin resistance and associated high androgen levels.

A challenging position in diagnosing and treating adult acne in female patients comes from the complex metabolism of androgens in the female body. Surprisingly, one large group of female patients with adult acne presentation does not have increased testosterone and DHEA in the blood.

However, there are additional male hormones metabolites that represent total androgenic metabolism. If we don’t look for them, we might assume that androgens levels are normal and unrelated to adult acne. These metabolites (mainly androsterone glucuronide) are products of androgen detoxification. It is essential to have adequate androgens detoxification. Androgens need to be metabolized as water-soluble substances to be excreted, and if they do not, their level increases. We have seen cases of fast improvement of adult acne just by helping to establish adequate androgen detoxification. Inadequate detoxification (glucuronidation) of androgens can happen in the following situations:

  • Genetically poor detoxification
  • Gut issues with gut dysbiosis
  • Increased inflammation
  • Underactive thyroid with the poor conversion of T4 into T3 hormone

It is remarkable how the Functional Medicine approach to identifying the cause can fix the problems that initially look entirely unrelated. ( gut-acne, thyroid – acne, eating ‘junk” inflammatory food-acne, etc.)

How to treat adult acne in females 

One of the critical etiologic factors in acne is an increase in sebaceous gland activity, which is androgen dependent. Addressing high androgens is one of the reasons why conventional doctors use contraception pills, something that the Functional Medicine approach does not approve of at all! But what is estrogen in birth control pill has to do with high androgens? The mechanism of how the contraception pill decreases androgens is partly due to the increase in the synthesis of SHBG (sex hormone-binding globulin) induced by the estrogen from the contraception pill. SHBG is a vehicle that transports estrogen and androgens; increasing the amount will diminish free androgens-active androgens. Functional Medicine approach can never accept this method because of 2 reasons:

  1. The danger of the contraception pill outweighs the benefit.
  2. Treating high androgens without understanding the cause of their increase never solves the problem- it always gives temporary relief. Once the contraception is stopped, the problem will arise again.

As mentioned above, the presence of adult acne is a warning sign that the body is in a state of insulin resistance or is struggling with the detoxification of androgens. Both situations will require a Functional Medicine approach to finding the actual cause of insulin resistance and cause of impaired detoxification. Therefore, treating acne with aesthetic (localized, topical) procedures is inefficient, as the cause of acne is systemic. Aesthetic procedures can be used as a complementary treatment, especially in patients with skin amplification of androgens, but not as an exclusive treatment. Patient education in addressing the problem systemically and internally and understanding the actual cause remains the most crucial factor in successfully curing female adult acne.


All references are obtainable on request from Dr. Nedic and A2 magazine

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Disclaimer: Treatment results will vary on a patient to patient basis. No guarantees can be made.