Acne vulgaris is an inflammatory condition of the integumentary system. It presents with redness, inflammation and bacterial pustules. 

The appearance of acne can cause psychosocial effects, such as low self-esteem, social withdrawal and depression.¹ However, by addressing the patient in a wholistic manner, internally and externally, we can begin to reduce the appearance of acne and improve psychosocial wellbeing.

Case Background + Patient Details 

A 26-year old female presented with a six-year history of acne vulgaris. Active pustules and scarring from previous acne lesions were present on her cheeks, jawline and forehead. 

She had a history of oral contraceptive pill use from 2011-2018, identifying that when she transitioned off the synthetic hormone acne vulgaris pustules were exacerbated. 

Doxycycline 100 mg oral antibiotic was taken for a duration of 18 months, which provided improvement, but when discontinued acne vulgaris returned.

She was experiencing an irregular menstrual cycle, ranging from 35-45 days, with a 5-day bleed length. Premenstrual hormonal fluctuations increased the quantity, severity and inflammation of lesions. 

Presenting symptoms included: 

• Acne 
• Irregular menstrual cycle 
• Dysmenorrhoea 7/10
• Low libido 
• Fatigue 
• Stress: 9/10
• Anxiety & nervousness
• Low mood due to skin appearance
• Frequent urination
• Low water consumption 

Pathology - Serum 21/08/2019

Marker	Result	Reference range
DHEAs	11.7	2.7-9.2
Hydroxycalciferol (vitamin D)	49	50-150
TSH	2.3	0.3-3.5

Treatment Aims 

Reduce C. acnes bacteria overgrowth

Modulate DHEAs

Balance hormones 

Improve energy levels 

Initial Recommendations 

Liquid herbal tonic:

• Hydrastis canadensis (Golden seal) 1:3                                         100 mL
• Calendula officinalis (Calendula) 1:2                                               100 mL 
• Vitex agnus-castus (Chaste tree) 1:2                                              50 mL 
• Paeonia lactiflora (Paeonia) 1:2                                                       100 mL
• Glycyrrhiza glabra (Licorice) 1:1                                                       50 mL
• Zingiber officinale (Ginger) 1:2                                                         10 mL
• Echinacea blend (60% E. Purpurea 1:2, 40% E. angustifolia 1:2)   90 mL

Dose: 7.5 mL twice daily - morning and afternoon. 

Compounded Nutritional Formula Containing:

High quality magnesium powder 120g, NAC powder 30 g (providing 27 g N-acetyl-cystine) and a probiotic containing 5 billion CFU from 9 clinically trialled strains (10 x 2 g sachets). 

Dose: 1 heaped teaspoon in glass of water once daily. 

Zinc + Cofactors: 2 capsules at night. 

Oral Vitamin D spray: Five sprays under tongue once daily providing: 1000IU D3 per spray.

Dietary Changes: 

Increased consumption of seafood (salmon, tuna, oysters) to improve intake of omega-3, zinc and vitamin D. 

Reduced consumption of smoothies and raw salads- more warm cooked foods were advised. 

Elimination of dairy as potential to exacerbate acne. 

Increased water consumption to support lymphatic detoxification. 

Facial Hygiene Recommendations: 

• Regular cleansing + moisturising regime.
• Do not pick or squeeze activated pustules. 
• Facial acupuncture to reduce inflammation of lesions.

Lifestyle Recommendations: 

Stress management techniques: meditation (insight timer meditation app), regular walking, yoga.

4-Week Follow-Up 

Patient reported a 30% reduction in active pustules, her skin appearance was less inflamed and red. Oil sebum production was beginning to reduce and she was having to wash her hair less frequently.

Water consumption was increased with less frequent urination. Energy levels were still feeling depleted due to high stress - patient stated she felt that she had reached “burn out”. 

Follow Up Treatment Plan + Recommendations: 

Herbal formula was altered slightly, echinacea blend was decreased to 60 mL to allow for addition of Withania somnifera (withania) 2:1 80 mL to support adrenal function and energy production. 

Compounded nutritional formula, zinc + cofactors and vitamin D spray were continued at same doses. 

10-Week Follow-Up 

Patient reported that skin is continuing to improve - with fewer active pustules present within the skin and reduced inflammation. Skin is healing at a faster rate. 

Patient also reported a slight flare in skin prior to period. Her menstrual cycle reduced to a 29-day cycle with a 5-day bleed. Dysmenorrhoea reduced to 3/10 from 7/10 as reported at the initial consultation.

Energy was starting to increase; however, stress levels were still high. 

Lifestyle Recommendations: 

Psychologist recommendation to discuss stress management tools. 

Herbal formula continued: 

Golden seal 1:3 100 mL, Calendula 1:2 100 mL, Chaste tree 1:2 50 mL, Paeonia 1:2 50 mL, Licorice 1:1 50 mL, Ginger 1:2 10 mL, Echinacea blend 60mL, Withania somnifera (Withania) 2:1 80 mL. 

Dose: 7.5 mL twice daily - morning and afternoon. 

Patient continued taking the compounded nutritional formula, zinc + cofactors and vitamin D spray at the same dose.

16-Week Follow-Up 

Patient has reported no new active bacterial pustules, some skin redness still present however, skin is healing at a faster rate. 

Patient has started seeing skin therapist- skin needling was performed to reduce scaring.

Consistent 29-day menstrual cycle with 5-day bleed, NIL dysmenorrhoea present. 

Updated Pathology Results: 

• DHEAs dropped from 11.7 to 9.1 
• Vitamin D increased from 49-81
• TSH reduced from 2.3 to 1.6

Pathology - Serum: 20/07/2020

Marker	Result	Reference range
DHEAS	9.1	2.7-9.2
Hydroxycalciferol (Vitamin D)	81	50-150
TSH	1.6	0.3-3.5

Conclusion: 

The appearance of acne can cause psychosocial effects, such as low self-esteem and social withdrawal. This emotional stress may exacerbate acne breakouts, while acne flare-ups will trigger further emotional stress. Stress management was paramount in supporting the patient as part of her treatment goals. 

Balancing hormonal fluctuations and decreasing androgen levels with lymphatic and antimicrobials were beneficial in reducing C. acnes and associated inflammation.

The treatment time for this case was a duration of five months which resulted in significant improvements of the acne and initial presenting complaints for the patient.

References: 

1. Hazarika, N., & Archana, M. The Psychosocial Impact of Acne Vulgaris. Indian Journal of Dermatology. 2016 61(5), 515–520. http://doi.org/10.4103/0019-5154.190102