Resolving Acne Vulgaris Through Gut and Hormone Support: A Case Study

By Chelsea Smithback, ND

Introduction

Acne vulgaris is a very common skin condition, with a prevalence rate ranging from 25% to 95% among adolescents. It is more common in males than females. Acne can persist into adulthood or have a delayed onset during this stage of life.¹ From a naturopathic perspective, acne is viewed not only as a condition but also as a symptom of an underlying health imbalance. A naturopathic approach encompasses treating the root cause of acne, not just the acne itself. 

In this case, a 24-year-old female presented with a chief complaint of acne. Through a comprehensive assessment and by addressing the root causes of acne– specifically, gut health and hormonal imbalances– her acne improved by 90% at her last visit.

Case Presentation

S is a 24-year-old female presenting with acne and mild bloating. She has experienced acne since her teenage years, but it worsened significantly after stopping birth control four months ago. She previously tried spironolactone for three months without improvement and began using tretinoin (0.25%) eight months ago, which improved her skin texture but did not reduce breakouts. 

She experiences flare-ups during ovulation and has cystic acne with closed comedones on her jawline and forehead, along with mild closed comedones on her back. Her menstrual cycle is regular, and she reports mild bloating after meals. She rates her acne severity as an 8 out of 10.

• Her current skincare routine includes:
  PCA creamy cleanser
• Benzoyl peroxide
• PCA collagen hydrator and rebalance serum. 

Clinical findings

The patient was experiencing cystic acne with erythema along the jawline and forehead, along with closed comedones. She also had mild comedones on her back. Additionally, she reported symptoms of fatigue, hair loss, anxiety, and depression. Her physical exam was otherwise normal.

She denied abdominal pain, heart palpitations, chest pain, heat/cold intolerance, and shortness of breath.

Therapeutic intervention

Initial visit:

The first visit aimed to identify the root cause of her acne. Top considerations for her acne included androgen-related factors, gastrointestinal issues (such as leaky gut), or acne stemming from blood glucose dysregulation. I ordered comprehensive labs to assess her general health and potential causes of her acne, including estrogen, progesterone, testosterone, CBC, CMP, lipid panel, HbA1c, TSH, free T3, free T4, rT3, TPO, TG, SHBG, DHEA-S, IGF-1, androstenedione, iron panel, ferritin, vitamin D, B12, and cortisol. I recommend either saw palmetto or DIM, depending on her results. 

Treatment Plan

Acnutrol supplement for acne-specific nutrients

Liver cleanse herbs to support detoxification and excess hormone excretion

Insomnitol supplement for occasional insomnia

Probiotics to help with bloating and support acne treatment

Elimination diet: avoid dairy, gluten, and sugar

Bentonite clay mask for skin care

Positive affirmations for promoting a positive mindset regarding skin

Box breathing exercises to manage stress

GI map test (consider for the next visit to assess gut health in depth, if needed)

Follow-up and Outcomes

First Follow-up Visit (3 weeks later):

The patient’s acne improved after following the diet and supplement protocol.

Lab Results revealed:

• Low Progesterone and normal estrogen, indicating estrogen dominance
• Low Testosterone, ruling out the need for saw palmetto

To address estrogen dominance and PMS symptoms, I added vitex through a supplement and St. John’s wort, passionflower, dandelion, dong quai, and wild yam root to promote progesterone balance. 

Since DIM can exacerbate acne in testosterone-sensitive patients, I opted not to introduce it at this moment. Currently, my primary working diagnosis for the cause of her acne is a GI/leaky gut issue, as she has been experiencing constant bloating and is responding well to the previous treatment plan. 

• Her elevated ALT suggested mild liver inflammation, so I continued the liver cleanse for three months to reduce ALT levels. 
• We continued with previous supplementation, added the vitex supplement, and started reintroducing foods from the elimination diet.

2nd Follow Up Visit:

The patient reported that after taking the PMS support tonic, her acne, mood, and cramping worsened, and her menses were delayed. Suspecting sensitivity to vitex, I advised her to discontinue the PMS support. 

At her next visit, she reported:

• 90% improvement in her acne, with only occasional jawline breakouts.
• Bloating is significantly reduced, occurring only before her period or after consuming certain foods. 

Given her progress, I:

• Continued Acnutrol and the probiotic while reducing the liver cleanse to one cap daily.
• Instructed her to discontinue the liver cleanse in one month if her acne stayed stable.
• Reduce Acnutrol to 3 capsules daily if her skin continues to improve.
• Incorporated fish oil for its benefits on mental health, skin health, and gut health.

Due to her significant improvement, no further GI testing or treatments were needed at that time. 

Discussion

Acne can have many causes, so it is essential to understand the root cause of acne to treat it properly. Acne results from inflammation of the pilosebaceous gland, which is theorized to involve increased sebum production, follicular hyperkeratinization, and C. acnes proliferation.^2,3 Potential causes for the inflammation of the pilosebaceous gland and increased sebum production are vast and include medication use, oil-based cosmetics, endocrine disorders, hormonal imbalances, leaky gut, genetic factors, mechanical trauma from scrubbing with soaps and detergents, high glycemic load diets, psychological stress, and insulin resistance, among others.⁴

In this case, eliminating sugar, dairy, and gluten significantly contributed to the reduction of acne. Dairy consumption has been linked to a higher risk of acne. Milk-derived amino acids can stimulate the synthesis of insulin-like growth factor-1 (IGF-1), which increases sebum production, follicular epithelial growth, and keratinization, all contributing to acne. Plasma levels of IGF-1 have also been associated with the severity of acne. A similar mechanism occurs with hyperglycemic carbohydrates, which promote insulin and IGF-1, leading to acne through increased sebum production. Both dairy and high glycemic load foods and meat can activate the mTORC1 (mammalian target of rapamycin) pathway, resulting in excess sebum production and hyperkeratinization, ultimately leading to acne.⁵ I often prefer to conduct an elimination diet with patients to assess their IgG food sensitivities and identify acne triggers.

Therefore, gut health is critical to assess in patients with acne. The mTOR pathway has been observed to be more heavily expressed in individuals with skin diseases. Bacterial metabolites have been shown to interact with the mTOR pathway, which is influenced by gut microbiota. This can lead to alterations in the intestinal barrier and potentially exacerbate acne. In some studies, 54% of acne patients were found to have gut dysbiosis.

Probiotics are a viable adjunct treatment option for modulating the intestinal microbiota, which creates an anti-inflammatory response and influences IGF-1 levels.^6,7 Many probiotics are helpful, with Lactobacillus, specifically Lactobacillus rhamnosus, and Bifidobacterium ranking among the top probiotic strains.⁸

I recommended a liver cleanse supplement to her to promote optimal hormonal balance. The liver is the primary source of IGF-1 and plays a crucial role in mediating growth factors. IGF-1, insulin, and growth factors are all implicated in metabolic status, which, as mentioned earlier, is related to acne pathogenesis.⁹ The liver is also responsible for metabolizing hormones. Patients with severe acne exhibit increased levels of dehydroepiandrosterone sulfate, sex hormone-binding globulin, and androstenedione, all of which can contribute to excess sebum production and acne.¹⁰

Conclusion

Acne has various causes; therefore, it is essential to understand its root cause and the many factors that can contribute to its appearance. Hormones, diet, lifestyle, topical products, gut health, and stress all need to be assessed thoroughly with acne patients. In this case, the patient was able to resolve her acne by 90% at the last visit by modulating her gut health, mTOR pathway, hormones, and achieving optimal liver function and nutrient support for acne.

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References

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