The patient: “Liz,” a 38-year-old social media manager.
Why she came to see me: For years, I learned, Liz had enjoyed a radiant, enviable complexion, but by the time she arrived at my office, her head was literally hanging. After introductions, she finally raised her eyes to point out the swath of red spots covering the lower half of her face. Her dermatologist’s diagnosis of adult acne was hardly debatable, but after a spate of costly, uncomfortable and unsatisfactory cosmetic procedures and prescription medicines, she wanted to find a way to manage her acne naturally.
How I evaluated her: I began my assessment as I always do: With a long and in-depth discussion about Liz’s medical history, present status and future aims.
Liz had suffered a brief bout of acne when she began menstruating at age 13, but her skin had cleared with time and dedication to a skincare routine. Throughout college, graduate school and the first few years of her most serious (and present) relationship, she had hardly given any thought to her skin—it was that clear and lustrous. Three months ago, however, she’d woken up to find the lower half of her face covered in pimples. This sudden flare up was disturbing and its source baffling: She had not changed her skincare routine, hair products or laundry detergent, nor had s.e made any major shifts in her diet or exercise program. Indeed, overall, she felt “quite healthy.”
Like any hard-working woman, it was true, she said, that she had a few late nights per month at her desk, which she powered through with caffeine and sugar. It was also true that “period cravings” made her feel okay about eating ice cream for dinner one or two times per month. That said, she strove to balance out her less-than-virtuous moments with daily bike rides, weekend Zumba classes and fresh, healthy meals she whipped up with her partner.
She strived to be as healthy as possible in part because she and her partner had decided to have children. To that end, Liz had stopped taking birth control pills, which she had been on since her late teens. “Life has been stressful but delightful,” she said, but the acne was taking a toll on her relationship and career—Liz’s partner was “big” into the social scene and Liz’s profession required frequent, in-person client meetings. “It’s now taking me more than an hour to get ready,” she said, citing a vigorous cleansing routine and two to three layers of foundation and powder before she felt “acceptable enough” to leave her condo. Even then, she found that her usual vivaciousness had taken a massive hit. “The first thing people see is your face,” she said. “And I don’t want to show mine to anyone. I may sound vain, or like a teenager, but these spots have started to rule my life.”
Her diagnosis of adult acne was clear; what wasn’t certain was why now. To get to the bottom of this, I ordered a 24-hour urine test on the 21st day of her cycle to evaluate her hormone levels. (This is when progesterone levels are often at their peak, thereby providing one of the clearest assessments possible). I also asked Liz to message me a full list of the skincare products she was using. Finally, I ordered a blood test to determine her insulin levels.
What my evaluation revealed: While Liz’s insulin levels were normal, her hormone test revealed what I suspected: Going off birth control meant that the hormones she had suppressed for more than two decades had, in essence, been turned back on, rendering her skin similar to that of a teenager’s. Her hormones were imbalanced, with her free and total testosterone higher than normal. This alone can cause adult acne, and the primary location of her acne—on her jawline and chin—is typically thought to be caused by hormones that have been thrown off-kilter. As I explained to Liz, acne can emerge when androgens, such as testosterone, transform into its more powerful form, Dihydrotestosterone (or DHT). DHT increases sebum production, often resulting in excess oil, blocked pores and acne.
How I addressed her problem: As the body’s largest organ, it’s no wonder that skin directly reflects the health and vitality of your entire body—including the balance or disharmony of your hormones. To restore equilibrium, I recommended a holistic approach that would not only make Liz look better but, more importantly, feel better.
We began with Liz’s diet. While the link between diet and acne isn’t firm—yet—the American Academy of Dermatology has emphasized “growing evidence” that dairy and high-glycemic foods, such as candy and chips, exacerbate acne. I asked Liz to give herself a month without dairy—including that splash of cream in her coffee—and to refrain completely from refined sugar. (Those all-nighters she pulled could be avoided with better time management, I explained, while period cravings could be sated, at least to a degree, with healthier alternatives such as apple slices with almond butter, chia pudding with blueberries, or a calming walk around her block.)
I also urged her to begin drinking mint, spearmint and/or licorice root tea. All three have been shown to reduce testosterone levels. To further support healthier testosterone levels—and healthier hormone levels in general—I encouraged her to fill her plate with anti-inflammatory, digestive-boosting foods, such as flaxseeds, walnuts and almonds, dark leafy greens, and probiotic foods like yogurt, kefir and kombucha. Finally, in terms of diet, I urged Liz to raise her intake of zinc-rich foods (like sunflower seeds, legumes and shellfish), as this vital mineral helps treat acne, and to supplement with Chaste Tree Berry, which organically supports hormone balance.
As I then explained to Liz, she was also not alone: Not only were more and more of my adult patients coming in complaining of acne, but a 2018 review published in Clinical, Cosmetic and Investigational Dermatology reported a considerable increase in adult acne. While the direct cause of this has yet to be determined, doctors speculate that the jump in cases is due in part to a collective rise in stress. (Stress revs up cortisol and can send oil glands into high gear.) Managing a high number of clients’ social media…spending a few nights out on the town with friends, being in a serious relationship…striving for a child, skimping on sleep…and getting by on occasion with dessert for dinner all may have been contributing factors to Liz’s complexion. With this in mind, we devised a plan for her to relax—and to weave in some solo downtime. Liz was especially interested in my suggestion to try acupuncture, which has garnered an enduring reputation for lowering cortisol levels.
Furthermore, I suggested Liz try evening primrose oil supplements. High in essential fatty acids and a natural anti-inflammatory agent, evening primrose fosters hormone balance and acne-free skin. After examining her skincare products—which included more than 13 on any given day—I also asked her to pare down to no more than four: a gentle cleanser, sunscreen, moisturizer, and a therapeutic product containing salicylic acid (but zero products containing harmful ingredients such as parabens, petroleum distillates, and sodium laurel sulfate). This would ensure against a surplus of irritating ingredients affecting her sensitive complexion.
As for an ingredient she could and should put on her skin? Manuka honey. The New Zealand elixir is a favorite among dermatologists, thanks to its anti-bacterial, anti-inflammatory effects. To get her fix, I suggested she create a homemade mask and use it once or twice a week. The ideal mask is comprised of 1 teaspoon of raw, organic Manuka honey, 1 teaspoon of plain yogurt (preferably full-fat Greek yogurt), and 1-2 drops of tea tree oil—an oil that helps prevent infection and diminish redness due to its antiseptic and anti-inflammatory properties. After letting it dry for 20 minutes, rinse off the honey with a warm, wet washcloth and end with a moisturizer.
The patient’s progress: Eight weeks later, Liz returned with her head held high. While her acne had not been completely eradicated, it was radically reduced and, as such, her confidence was “happily returning.” She’d taken to the prescribed diet well—she and her partner were especially fond of broccoli “crunch” salads with dried currants and red onions—she was sleeping better and, as a bonus side effect, her moods were brighter and she experienced fewer PMS symptoms in her last cycle. What’s more, she was thrilled she was no longer enslaved to pricey skincare products that were taking up more than her fair share of space in the bathroom. She and her partner were hoping to use that extra room for all-natural baby products, which, with her hormones stabilized and her health stronger, would be happening not too far in the future.
Click here to buy Dr. Laurie Steelsmith’s books, Natural Choices for Women’s Health, Great Sex, Naturally and Growing Younger Every Day: The Three Essential Steps for Creating Youthful Hormone Balance at Any Age.