By Dr. Nicole Sundene
Acne, formally called "Acne Vulgaris" is an inflammatory skin condition characterized by pimples on the face or body. Acne can be an especially frustrating women's health condition when hormone imbalance is to blame. Topical treatments are often useless or even worsen the acne by drying out the skin or causing too much chemical irritation.
You can watch my full presentation on "Holistic Dermatology: Acne, Eczema and Itchy Skin" to see my own acne before and after photos. I never had acne as a teenager because the acne I struggled with in my 20's and 30's was triggered by hormone imbalance and my diet. Nothing I ever tried for my acne ever worked until I found Naturopathic Medicine! At the time I was working for 3 Dermatologists and nothing they tried could ever help my skin.
The body continues to send negative messages such as acne to us when we are missing the "Root Cause" of the acne, especially if it is caused by a Hormone Imbalance, which is the most common cause for women. Women have a much higher rate of acne than men, despite the fact men have 10 times higher testosterone levels. Testosterone is not the only hormone that causes acne. If it did then men would have acne more often than women?
Estrogen dominance and progesterone deficiency are often the culprit behind female adult onset acne. While I am happy to discuss all the latest research for treating acne topically in the naturopathic realm...it is imperative we address and treat the root cause of the acne. Which is often triggered by diet and hormone imbalance and requires a full work up by a women's health doctor that understands hormone imbalance and dermatology such as myself. In 1999 I started my first job in medicine working for a Dermatologist and also a Hormone Doctor.
Interestingly enough life has been training me for many years to understand the delicate balance of female hormones and dermatology conditions which is now my considered area of expertise as a women's health doc. I often receive referrals for patients from Dermatologists and other Naturopathic Doctors to help solve the mysterious hidden link behind complex Dermatology conditions.
How Do I know if I have Hormonal Acne?
Signs that acne is caused by hormone imbalance can be determined at no cost to the patient by simply downloading a period tracker app and tracking when the acne breakouts are occurring. If they are constantly occurring prior to a women's menstrual cycle, or worsening around that time, then we know the underlying cause of the acne is likely hormonal. And until we investigate, test, diagnose and treat the hormone balance, topical treatments will generally continue to fail women and simply do not work until we address the acne at the root cause. I discuss this in my Dermatology webinar that explains the simple 3 step process I use to treat acne naturally.
Generally, acne affects the face, chest, forehead, chin, shoulder, neck, and upper back. In Acne, the hair follicle gets clogged with oil, hair, bacteria, and dead skin cells that result in whiteheads, blackheads, cysts, and other types of pimples. Both estrogen and testosterone can impact the skin and make it more oily. Testosterone especially stimulates the sebaceous glands to secrete MORE oil which then causes bacteria to adhere into the pore and cause a breakout. Women commonly complain about their skin becoming dryer with menopause and too oily with PMS and Perimenopause.
Acne is not just a physical ailment but can also scar women emotionally. I know first hand how much acne can impact a woman's self esteem. When my acne was at its worst I didn't want to go anywhere or even worse, have my photo taken. I wanted to go to college with a paper bag over my head. I would not even smile for my mom in the acne photo I share in my webinar, because I was so unhappy having my cystic acne documented. I was embarrassed of my skin and while I don't ever judge other people for how they look, I bring this up because it may be impacting teens, and young adults adversely by causing them low self esteem, depression, anxiety, stress and isolation.
Studies report that Acne can occur at any age but is highly prevalent among adolescents or young adults and teenagers. Research shows Acne significantly impacts the lifestyle of both teens and adults, causing discomfort, distress, permanent skin scarring, low self-esteem, disfigurement, anxiety, and embarrassment. These negative effects highly contribute to poor social and mental well being. [1, 3]
Around 80% of acne cases are related to genetic factors. However, medical studies reported that the majority of acne cases are highly connected with the following factors. [3, 4]
Moreover, other factors such as poor diet, stress, excessive oil secretion, and smoking also increase the risk of developing Acne. [1, 3]
Signs and Symptoms of Acne
Signs and symptoms of Acne include the appearance of whiteheads comedones, blackheads comedones, microcomedones, nodules, papules, pimples, cysts, and pustules. Acne can also cause permanent skin scarring and permanent changes to pigmentation. Making it even more important to address as soon as possible for young women and teens so they do not end up with permanent damage to their skin as I have today. We can prevent scarring with Naturopathy and Hormone Balancing! [1, 3, 5, 6]
Acne treatments should be targeted towards balancing the skin from the inside rather than just applying topical medication to treat and suppress symptoms. For many years I attempted to suppress my acne with 1) Retinol 2) Differin 3) Doxycycline 4) Tetracycline 5) Facials 6) Proactive. I literally tried everything up until the Dermatologist said Accutane was the only other option! That was when I discovered Naturopathic Medicine for Acne in 2002 while attending Bastyr University.
Natural topical treatments for acne involve managing existing lesions and other symptoms, reducing skin scarring, arresting further progression, and decreasing the risk of other acne-associated complications. The application of treatment interventions depends on the acne severity, the patient’s current medical condition, the patient’s endocrine history, and the nature of lesions. Both topical and systemic therapeutic options are available for the treatment of acne. Moreover, along with pharmaceutical drugs, natural herbs and other treatment modalities also help manage acne symptoms. It is important to know that the application of multiple treatment modalities of acne significantly performs better than single therapy. [2, 6]
Topical Acne Treatment
*Topical treatments will 100% NOT CURE A WOMAN'S ACNE!
Please keep in mind the following information I have compiled for educational reasons for my patients to have a list of treatments that have research behind them and I believe are generally safe to try and understand their different options compared to pharmaceutical agents for acne. Likewise some of my Natural Medicine Acne patients may want to learn about stronger prescription options to utilize while we treat their acne from the inside out. But none of these treatments ever seem to cure acne. The cure is in investigating and treating the hormone imbalance.
My #1 Dermatology pet peeve with treating acne is strictly relying on topical treatments when there is always a Hormone Mystery for me to solve.
Whether the agent is natural or prescription, these topical Dermatology treatments all share the same problem, they are only helpful in controlling the acne via the pore, slowing breakouts, calming the skin down, exfoliation, reduction of inflammation, repair and prevention of scarring. Until we balance a woman's hormones properly they will continue to just suffer with acne especially when they already are diagnosed with PMS, PCOS, PMDD, Perimenopause, CAH, Hirsutism, Infertility or Amenorrhea.
So ladies if you have learned nothing from me today...please take home with you from this "Acne and Hormones" blog that acne is an internal medicine problem not a failure to find the right topical treatment problem. Nothing bores me more to tears, than having patients that want me to treat their acne from the outside with topical treatments. Which is why I have compiled this list of topical natural and prescription treatments for acne. I know this sounds horrible... but I don't really care WHAT you put on your skin. I care about WHY your skin is behaving this way in the first place and I want your skin to go into remission so you no longer need to ever worry about applying things to your acne again.
Nothing on this list will actually cure acne, until we treat the underlying hormone imbalance with your female hormones. But that is just my opinion as a Women's Health Naturopathic Doctor that has helped hundreds of women with their hormones and skin conditions over the past 14 years as well as what I saw over an 8 year period working for 3 Dermatologists. While mild symptoms can be treated and resolved with prescriptions, I would often see my Prescription Dermatology patients with chronic acne, psoriasis, eczema, dermatitis, MRSA, seborrheic dermatitis also fail to improve in the conventional Dermatology model simply because we had not sat down and taken a proper history to address and examine the Root Cause of the skin condition. Sometimes it has nothing to do with Naturopathic Medicine, but it's the time I take to create a thorough history of health complaints and the development of the skin condition that help us solve the Dermatology Mystery. So when you watch my Free 30 minute Webinar at www.DermatologyDetective.com you will realize that I have an inquiring mind that wants to know the cause and that I am not happy as a doctor just giving people ``band-aids" to slap on their skin. Which is why I made the webinar so that patients understand the simple 3 step process we need to go through to get to the root cause of their skin condition.
It is easy to cure skin problems when patients are on board with what I need them to do, and it's nearly impossible for me to ever help patients that want to "put a magical herb from the rain forest on their skin to make it perfect" ...if there was such a thing I would be using it myself but unfortunately Hormone Imbalance in women is such a powerful problem that no magical herb we apply will usually be enough and we need hormone labs to determine the cause.
Natural treatment of Acne
Many different natural herbs and supplements also help the management of acne symptoms. These remedies act on sebum production, bacterial growth, inflammation, and keratinization. Plus, they also provide moisturizing and soothing effects upon topical application that aid the acne treatment. [2, 6]
The latest research for acne natural remedies include:
Herbal Medicines also gaining popularity in the treatment of acne vulgaris: 
Natural Topical Treatments for Acne
Generally Harmless Topical Prescription Acne Agents:
Topical Retinoids: Retinoids such as Isotretinoin, tazarotene, tretinoin, motretinide, adapalene, and retinoyl-β-glucuronide control the formation of comedones and lesions. Plus, they help existing lesions, reduce sebum production and improve epithelium integrity. Studies reported that retinoids show anti-inflammatory action and suppress the formation of both microcomedones and comedones. Further, they support the therapeutic action of other anti-acne agents, decrease pigmentation, and repair skin scarring. The common side effect of retinoids includes the flare-up of acne during the first week of application, dryness, irritation, sensitivity to the sun, and chemical sensitivity. [2, 6]
Topical Antibiotics: Antibiotics such as clindamycin and erythromycin are intended for topical application to manage the severity of mild to moderate inflammatory acne. They inhibit the growth of bacteria and decrease their colonization on the skin surface and within hair follicles. Thus, their agents are highly effective against P. acnes bacteria responsible for inflammation of the lesions. Note that topical antibiotics are preferred for a short period of up to 3 months due to the high risk of resistance. Medical research studies recommend using topical antibiotics combined with benzoyl peroxide, zinc, or retinoids to minimize the risk of bacterial resistance. It is recommended to avoid topical and oral antibiotics for acne as long term antibiotics can impact the microbiome and natural flora of the skin. [2,3]
Oral Acne Medications Not Recommended:
When topical prescriptions fail, Dermatologists prescribe oral agents for the treatment of acne. The oral-systemic options significantly improve the nodules, lesions, and scarring. The commonly recommended systemic therapeutic interventions include oral retinoids, antibiotics, and hormonal agents. [2, 6]
Oral Retinoids: Retinoids such as Isotretinoin is a first-line agent for acne associated with severe nodular or inflammatory lesions. It significantly benefits mild to moderate acne and acne resistance to topical agents. Isotretinoin relieves the symptoms of severe acne on the trunk and face. Note that the course of Isotretinoin therapy ranges from 16 weeks to 24 weeks. It decreases sebum production and reduces the risk of bacterial colonization that help the management of acne conditions. [2, 6]
Oral Antibiotics: Antibiotics such as erythromycin, levofloxacin, minocycline, lymecycline azithromycin, roxithromycin, doxycycline, and co-trimoxazole are indicated for the treatment of moderate to a severe acne condition. They inhibit the growth of acne-causing bacteria and also provide an anti-inflammatory activity that manages the acne symptoms. Remember that the use of antibiotics increases the risk of bacterial resistance. So, they are always preferred combined with topical benzoyl peroxide or retinoids to minimize the risk of resistance. Also, don’t use antibiotics for more than 12 weeks. [2, 6]
Birth Control Pills: Synthetic hormones antagonize the effect of androgen on the sebaceous gland and control sebum production. Most oral contraceptives, especially progestins, are used for this therapeutic approach. They halt the action of androgen and increase the sex hormone-binding globulin level in the body. Moreover, the hormonal agents work better in combination with other options such as antibiotics, retinoids, and spironolactone in the treatment of acne. [2, 6]
Topical Corticosteroids: Cystic Acne and Inflammatory acne.
Benzoyl Peroxide: Provides antibacterial properties, prevents pores clogging, and decreases the comedones formation. Benzoyl peroxide helps mild to moderate acne and can be applied for 6-8 weeks as a monotherapy for acne management. Do not combine with topical retinoids as will cause dryness and irritation. Side effects of topical benzoyl peroxide include dryness, erythema, stinging, and burning.
Dapsone, Sodium Sulfacetamide, and Triclosan: Also show antibacterial and anti-inflammatory activities that help the treatment of acne. Note that they are not recommended as first-line agents for acne management.
Other prescription topical options for acne involve chemical peels, dapsone, corticosteroids, niacinamide, sulfur, triclosan, salicylic acid, and sodium sulfacetamide. [2, 6]
Other Oral Acne Medications Not Recommended:
Along with the previously discussed options I don't recommend, other random oral therapeutic agents I consider dangerous when Naturopathic Medicine is safer and more effective anyways include: corticosteroids, ibuprofen, and clofazimine also provide an anti-inflammatory activity that helps manage acne symptoms. Systemic corticosteroids like oral prednisolone help treat the severe form of inflammatory Acne vulgaris, Acne fulminans and Pyoderma faciale.
Types of Acne
Acne is divided into four groups or grades based on the severity of symptoms. 
Antibiotics, steroids and accutane are hard on the liver and best for children and teenagers with acne to avoid. Especially when there are much better natural options for acne as long as your child is open to making diet changes and taking herbal supplements. It is important to treat acne immediately at the ROOT CAUSE in order to prevent permanent damage to the skin and acne scars.
Always check with your Naturopathic Doctor before starting new natural treatments or herbal remedies for acne!
Dr. Nicole Sundene
Naturopathic Medical Doctor
Dr. Nicole Sundene, NMD
Dr. Sundene is a Naturopathic Doctor in Scottsdale, Arizona, and is considered a Female Hormone Expert in Women's Health and Bioidentical Hormones. She specializes in Holistic Women's Health for Menopause, Thyroid, Hashimotos, PMS, Perimenopause, Autoimmune, Postpartum, Chronic Fatigue, Depression, Anxiety, Food Allergies, Digestion, Dermatology , Acne, Psoriasis, Eczema and Adrenal Hormonal Conditions. In 1999 she began working for a Hormone Doctor prior to starting Naturopathic Medical School. With over 22 years of experience in both Prescription and Natural women's health and hormones she presents to women the best integrated health solutions for their Chronic Disease. She has been an Herbalist for over 27 years and enjoys teaching women how to use herbs to balance their hormones, nutrition and optimize their health. Dr. Sundene relies on blood testing for her hormone metrics. The hormone testing is covered per the patient's insurance plan and conducted at certain points in the woman's menstrual cycle. To learn more about Hormone Testing for Women Visit: Bioidentical Hormones. Follow Dr. Sundene on Instagram, Twitter and Facebook for more tips on Women's Health, Female Hormones and Naturopathy!