Blemish alert! I’ve suddenly got pimples

Q: I should have outgrown my zits by now, so why has my horrible high-school complexion returned?

A: Male hormones, which even women's bodies produce, are to blame.

As teenagers, about 85 percent of women suffer from acne. No, it doesn't come from eating chocolate or not scrubbing your face (or scrubbing too hard). It comes from the outpouring of those male hormones, or androgens, which occurs at puberty.

These androgens stimulate the skin to secrete oil. This oil then “feeds” the bacteria that cause acne. If you want to impress your friends and dermatologist, tell them the name for this microbe: propionobacterium acnes.

These bacteria release chemicals into pores, attracting white blood cells and causing inflammation. That, in brief, is how you get zits.

For some women, this is an ongoing issue. As we age, most of us overcome our androgen problem as our ovaries produce appropriate amounts of estrogen and our liver makes proteins that bind to the androgens and render them less potent. But some of us are not so lucky. We may be genetically inclined to continue to produce oil, or we may develop problems that foster acne development.

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Here are some factors that can make adult acne raise its ugly head:

Polycystic ovarian syndrome (PCO)
This medical condition affects up to 10 percent of women. It begins at puberty and is probably due to an increase in production of insulin and male hormones, leading to acne and excess hair growth. Ovulation may be abnormal, causing irregular periods and subsequent infertility. The high levels of insulin also cause weight gain and a future risk of diabetes and heart disease.

A premenstrual increase in progestin and male hormones
For acne caused by these conditions, treatment includes birth control pills. The best pills to clear up adult acne contain enough estrogen (at least 35 micrograms per pill) and/or the newer progestins.  These newer progestins, which have less male-hormone activity, include norgestimate and desogestrel, found in brands like Ortho Tri-Cyclen, Desogen, Ortho-Cept and Demulen, or their generic equivalents. One pill, Yasmin, contains a progestin very similar to that produced by the ovaries. This has an excellent anti-male hormone effect on skin. Some doctors may add a diuretic (which causes fluid to be eliminated by the kidneys) called spironolactone. This pill, too, has anti-male hormone activity and reduces oil production. Yasmin has some of the activity of spironolactone.

Other causes of adult acne

• Cosmetics and hairsprays that block pores, letting oil build up and bacteria multiply.
• Stress, which increases production of adrenal cortisol and male hormones.
• Certain birth control pills, especially those with a progestin component, which is derived from a male hormone-like base.

For these, the obvious therapy is to change cosmetics, decrease your stress level or, in the last scenario, change birth control pills.

The most potent treatment for severe acne — regardless of cause — is isotretinoin (Accutane), made from a substance similar to Vitamin A. It can profoundly reduce oil production, but has side effects, including extremely dry skin and mouth, joint pain, tendonitis and elevated blood lipids (fats).

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Most important, it causes birth defects, so it is imperative that a woman on this medication use effective birth control.

Another Vitamin A derivative, which comes in cream or gel form and can simply be applied to the acne-prone area is tretinoin (the brand names are Retin-A, Renova and Avita). These creams exfoliate the outer layer of skin and increase the rate of cell division and turnover so that pimples run their course more rapidly.

A new Vitamin A derivative, tazarotene (Tazorac), has just been approved for use in acne. It too comes in a cream or gel.

Dr. Reichman's Bottom Line: Skin problems needn’t “blemish” your after-teen years. Talk to your doctor. The right therapy can restore the clear complexion you deserve now that you’re a grown-up.

Dr. Judith Reichman, the “Today” show's medical contributor on women's health, has practiced obstetrics and gynecology for more than 20 years. You willl find many answers to your questions in her latest book, "Slow Your Clock Down: The Complete Guide to a Healthy, Younger You," published by William Morrow, a division of HarperCollins.

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