If I had to pick the single most common, frustrating and embarrassing skincare issue—that is also rarely treated for the root causes—it would be adult acne. Who's with me on this? I've struggled with it in the past and chances are you have, too, along with dozens of women you know. According to the Canadian Dermatology Association, it impacts up to 30 percent of adults aged 20 to 40, and 75 percent of the sufferers are female.
"Thanks, hormones," you might be thinking. Meaning estrogen and progesterone, probably, and their fluctuations throughout the menstrual cycle. I certainly blamed them, always attributing the spots that would inevitably arise before menstruation to that week's hormonal dip. I've even had dermatologists draw out little charts like this for me to explain it:
It's cute, it makes sense... but it still didn't tell me why. I was healthy, I ate right, I exercised—how could "hormonal" acne be normal?
Early on, I realized that nothing I used topically had any effect whatsoever. Doctors told me the only solutions were the birth control pill or spironolactone (a diuretic medication that's prescribed off-label for acne because it has an anti-androgen effect). But those meds always seemed drastic to me for a once-a-month breakout, and I just couldn't accept that I needed to take artificial hormones with serious side effects in order to make my own ones work. (Yes, I am stubborn.)
Then I discovered I was focusing on the wrong hormones the whole time.
I won't leave you in suspense—the hormone I believe is the key to acne is thyroid. Thyroid! Nobody talks about that one.
Well, hardly anyone. The person I learned about this from is Dr. Ray Peat, endocrine physiologist. His entire body of work as a scientist, professor, author and nutritional counsellor has been focused on how to improve thyroid health (and we're talking half a century, folks). As you may recall, I've been following his nutritional and hormonal suggestions for more than a year now, with great results, which is why I occasionally bring him up here. (To call his work life-changing would not be over-stating it.) Things got a little heated the last time I shared his ideas about polyunsaturated oils, and some of the foods that are important for anti-aging, because his views are not mainstream.... yet. But if you're at all interested in nutrition and hormones, I encourage visiting his website, learning more about him and reading his articles. He definitely has the science to back things up, and unlike so many health "gurus" nowadays, is not trying to sell you anything.
But back to the topic at hand, acne. Here's what I've learned, via Dr. Peat and other experts, about the connection between the state of your skin and the state of your thyroid.
Disclaimer: This article is for strictly informational purposes only and is NOT medical advice.
The Very Important Role of Your Thyroid
So let's just go over what your thyroid actually does. It's a small, butterfly-shaped gland located in your neck that is part of your endocrine system, a complex system of glands that produce and secrete hormones directly into the circulatory system to influence, regulate and control metabolism and many of the body's processes. Metabolism means the rate at which food is burned to form energy.
Think of the thyroid as the boss of the endocrine system, and in turn the boss of your metabolism. The hormones it produces reach every cell in the body, and are essential for feeling warm, happy and energetic.
In fact, you can't be in good health unless your thyroid is working properly. "Health begins and ends with the proper balance of the endocrine system," said the late Broda O. Barnes, MD, PhD. An American physician who dedicated more than 50 years of his life to researching and treating thyroid and related endocrine dysfunctions, Dr. Barnes is considered the "granddaddy" of the thyroid field (and someone whose work Dr. Peat cites quite frequently).
Family nutritionist and naturopathic endocrinologist Laura Thompson, PhD, agrees that when metabolism is broken, there can be many consequences to our health. (Acne, in fact, is one of the least serious.) "Thyroid dysfunction affects our health systemically," she says. "Since the endocrine system is responsible for growth, repair, metabolism, energy and reproduction, any slowing of the thyroid can have significant implications for our overall health."
Scary, but it couldn't possibly apply to you... or could it? Most people don't think they have a thyroid problem. But low thyroid (hypothyroidism) is actually very common, and is most often the underlying cause of acne breakouts.
Why You Might Have Low Thyroid Function
In his book, Hypothyroidism: The Unsuspected Illness, Dr. Barnes states that 40 percent of Americans suffer from hypothyroidism, or an inadequate supply of thyroid hormone. That was written in the 1970s, so I imagine we're closer to 50 or 60 percent of the population today (and Canada would be no different).
From the book jacket:
"Of all the problems that can affect physical or mental health, none is more common than thyroid gland disturbance. None is more readily and inexpensively corrected. And none is more often untreated, and even unsuspected. Hypothyroidism—low thyroid function—is one of the gland disturbances that many people suffer from without even realizing it. It can be the cause of low energy or constant fatigue that is one of the most common complaints brought to doctors. It may be responsible for chronic headaches, repeated infections, unyielding skin problems [emphasis mine], or circulatory difficulties. Even more frightening, it can be a major factor in heart disease, lung cancer, and emphysema. And it is responsible for many emotional and mental disturbances."
Okay, so there are more serious health concerns there, but I'm not too proud to admit that skin was the main reason I started researching thyroid (and then discovered that lo and behold, mine was not working properly). I'm in beauty, what can I say? Skin matters.
You'll probably be mildly shocked when you read this next bit about what causes hypothyroidism, according to Dr. Peat:
"Besides fasting, or chronic protein deficiency, the common causes of hypothyroidism are excessive stress or 'aerobic' (i.e., anaerobic) exercise, and diets containing beans, lentils, nuts, unsaturated fats (including carotene), and undercooked broccoli, cauliflower, cabbage or mustard greens. Many health-conscious people become hypothyroid with a synergistic program of undercooked vegetables; legumes instead of animal proteins; oils instead of butter; carotene instead of vitamin A; and breathless exercise instead of a stimulating life."
OMG! I don't know about you, but I was doing everything on that list. No wonder I was getting breakouts, among other low thyroid symptoms.
How Low Thyroid Leads to Acne
Fortunately, Dr. Peat has gone into more detail about the relationship between acne and thyroid function, and what we can do to remedy it.
"Thyroid and vitamin A are the basic things that help with acne," he says. This is because when thyroid hormone is deficient, the body cannot convert cholesterol to the steroids pregnenolone, progesterone and DHEA. Of these, progesterone is the most important in the prevention and cure of acne—and thyroid hormone plus natural vitamin A work to ensure its formation.
So why not just take straight progesterone? You can (I take this, which Dr. Peat himself patented), but if you have a thyroid deficiency, it's most important to correct that, since thyroid plays the greater role in overall metabolic health. Personally, I've never noticed any skin differences from supplementing progesterone, but I did see results once I started supporting my thyroid. (More on that in a second.)
Where vitamin A comes in is that it's a nutrient critical for skin health—but how much you get needs to be in proportion to your metabolic rate. As thyroid function improves, your vitamin A needs increase also. If you aren't consuming enough vitamin A for your body's metabolic requirements, then you can get acne; the reverse, however, is that too much vitamin A can suppress thyroid. So it can take a bit of self-experimentation to get the balance right.
"Yes, it's definitely hard to get them coordinated when there's an imbalance in one direction or the other," says Dr. Peat. "For several years, when I had an extremely high metabolic rate, I needed 100,000 units [of vitamin A] per day during sunny weather to prevent acne and ingrown whiskers, but when I moved to a cloudy climate, suddenly that much was too much, and suppressed my thyroid. The average person is likely to be hypothyroid, and to need only 5,000 units per day. Avoiding large amounts of carotene, and getting plenty of vitamin B12 to be able to convert any carotene that's in your food, helps to use vitamin A efficiently."
I've talked about the wonders of vitamin A for acne for some time now; I no longer recommend cod liver oil as a source because of these findings, and instead suggest either Nutrisorb-A or a serving of liver once a week (read more about those here). However, I suspect that for many hypo people, acne won't really improve until the thyroid gets help.
Julia T. Hunter, MD, agrees. "[A] PRIMARY [cause of blemishes] is low thyroid function," she says. "Low thyroid function increases internal inflammation and OFTEN is seen in acne patients. Unless you treat this, your acne will be at best VERY difficult to eliminate and at worst will NOT [be eliminated], because the internal inflammation seems to activate your acne gene and you experience blemishes."
Yikes, so many caps! I don't think there is any such thing as an "acne gene", but I agree with her about thyroid being a primary cause, and needing to correct that before anything else.
By the way: to be sure I wasn't missing some critical female hormone part of the puzzle, I asked Dr. Peat directly about premenstrual acne. His response: "Premenstrual stress suggests that the thyroid function is low, at least during that time." Alrighty then. It all comes down to the thyroid.
How to Check for Low Thyroid
There are a few ways to determine if your thyroid (and therefore metabolism) is low, and causing your acne:
Low Body Temperature: Because low thyroid function often manifests as low body temperature, Dr. Barnes developed the "basal body temperature" test. Immediately upon waking, before you get out of bed, place a thermometer under your tongue or armpit and leave it there for 10 minutes while you lie still. (It's best to use the kind of thermometer you have to shake, as opposed to the new digital kinds, which tend to be less accurate.) Menstruating women should do the readings on the first three days of the menstrual cycle. If your average waking temperature is consistently less than 36.6°C (98.6°F), you may have hypothyroidism.
Slow Pulse Rate: "The resting heart rate helps to interpret the temperature," says Dr. Peat. "The combination of pulse rate and temperature is much better than either one alone." He came to this conclusion after observing that some people, who were obviously hypothyroid, had body temperatures that were perfectly normal, especially in warm climates. You can measure your pulse rate at sites like this one. "Healthy and intelligent groups of people have been found to have an average resting pulse rate of 85/minute, while less healthy groups average close to 70/minute," says Dr. Peat.
Hypothyroidism Symptoms: Above are some dramatic examples of people before and after receiving thyroid treatment. But the symptoms of hypothyroidism can be even more subtle than that. Cold hands and feet are the most common sign of sub-par thyroid function. "In a cool environment, the temperature of the extremities is sometimes a better indicator than the oral or eardrum temperature," says Dr. Peat. Others include acne (obviously), PMS, low energy, depression, constipation, thinning outer eyebrows, inability to lose weight and so many more. Stop the Thyroid Madness has an excellent "long and pathetic list" of low thyroid symptoms. Check it out and see if you identify with any of them.
Blood Tests: Blood tests come last, because even though most modern-day MDs will tell you that's how you measure thyroid function, they're actually one of the least accurate ways to diagnose hypothyroidism. Until the 1940s, hypothyroidism was determined based on the signs and symptoms I mentioned above, but that changed with the advent of the PBI test—protein-bound iodine test. Dr. Peat explains:
"Between 1940 and about 1950, the estimated percentage of hypothyroid Americans went from 30% or 40% to 5%, on the basis of the PBI test, and it has stayed close to that lower number (many publications claim it to be only 1% or 2%). By the time that the measurement of PBI was shown to be only vaguely related to thyroid hormonal function, it had been in use long enough for a new generation of physicians to be taught to disregard the older ideas about diagnosing and treating hypothyroidism. They were taught to inform their patients that the traditional symptoms that were identified as hypothyroidism before 1950 were the result of the patients' own behavior (sloth and gluttony, for example, which produced fatigue, obesity, and heart disease), or that the problems were imaginary (women's hormonal and neurological problems, especially), or that they were simply mysterious diseases and defects (recurring infections, arthritis, and cancer, for example)."
Wow. Is your mind blown? More on that in Dr. Peat's article here.
It can still be useful to have a thyroid panel blood test done—just know that it may not tell you whether you really have a thyroid problem. "The TSH [thyroid-stimulating hormone measurement] can lag a long way behind the appearance of low thyroid symptoms," says Dr. David Derry, a now retired Canadian thyroid expert and researcher. "One clear case I remember is a lady who started to lose her hair at age 26 and had lost it all by the time she was 35, but the TSH did not turn up until she was 48. To follow the TSH while you are treating someone for low thyroid is also going to lead to under-treating the patient."
How to Boost Your Thyroid Function Through Diet
Okay, so you think you have the signs of low thyroid. What can you do to start boosting your metabolism, and heal your acne?
There are two ways to go about it: diet and supplementation. I'll start with the dietary changes, which are easier to implement but also slower to produce results, especially as you get older. In general, you want to eat real foods that are high in nutrients and thyroid-supportive, and exclude the foods that are not.
Dairy Products: Milk has the ability to significantly increase metabolism. Everyone's all anti-milk these days, especially blaming it for acne—but that's because it increases metabolism so much that people need to also increase their intake of vitamin A to fulfill the resulting higher metabolic requirement. You see? It finally makes sense now. Dairy is not the enemy. Besides milk, you can also eat cheese, strained yogurt (i.e. Greek yogurt) and ice cream (I suggest Häagen-Dazs, the most pure). Dr. Peat busts the myths out there about milk safety/purity and supposed milk allergies in this article. I personally get most of my calories from milk or milk products, aiming for a litre or two per day.
Coconut Oil: Coconut oil is extremely pro-thyroid. It contains butyric acid, which helps thyroid hormone move into the brain, and it opposes the anti-thyroid unsaturated oils that I wrote about here. According to enzyme nutritionist Lita Lee, its short and medium chain fatty acids, such as lauric acid, stimulate the immune system, modulate blood sugar, are anti-allergenic and protect mitochondria against stress injuries. I cook everything in this refined coconut oil, which is less allergenic than virgin, and has no smell or taste.
Animal Protein: I have to say it... you need adequate animal protein in order to produce thyroid hormone and convert it from T4 (inactive thyroid hormone) to T3 (active thyroid hormone). Dr. Peat recommends at least 80 grams daily, and this can come from dairy, meat, poultry, fish or shellfish. You can also try Great Lakes Gelatin, which is an excellent source of protein and contains pro-thyroid amino acids that balance the anti-thyroid amino acids in muscle meats.
Fruits and Fruit Juice: The natural sugars in fruit help to regulate blood sugar and calm down the adrenal glands. Oranges and other sweet fruits containing very little starch are best; they're also high in magnesium, which people with hypothyroidism are often deficient in (magnesium works with the thyroid to moderate stress). Having some fruit or fruit juice when you consume protein can also make the protein assimilation much more efficient, so that less is needed. I try to drink least a litre or two daily of freshly-squeezed orange juice, which I use as my carb source instead of starch.
Salt: "Increased salt helps to increase your metabolic rate," says Dr. Peat. "Low thyroid makes you lose salt too easily, and temporarily just eating more salt helps to make up for low thyroid-adrenals-progesterone." Just go for regular table salt—sea salts often contain dirt and toxins. You can read more about the health benefits of salt here.
Caffeine: "Caffeine increases your metabolic rate, so it's important to take it with food, including enough sugar," says Dr. Peat. Coffee and cocoa are good sources (and high in magnesium). I used to be a life-long tea drinker, but I started drinking coffee last year purely for the health benefits. Ha!
Shellfish: Besides providing some of the protein essential for good thyroid function, shellfish such as oysters and shrimp provide trace minerals (like zinc) that are often lacking from other foods and can help with acne, says Dr. Peat. A serving once a week is usually sufficient... and delicious!
Liver and/or Vitamin A Supplement: Ugh, yes. I know nobody eats liver anymore, but is this not convincing? "When people supplement thyroid and eat liver once or twice a week, their acne and dandruff (and many other problems) usually clear up very quickly," says Dr. Peat. I usually try to force down an organic chicken liver pâté... because unless you grew up eating liver 'n' onions, that smell will make you die. Shout-out to my people at The Healthy Butcher. The other option, as I mentioned, is Nutrisorb-A, which is a safe vitamin A supplement that you can read more about here. Cream, butter and eggs are other sources of vitamin A, but are much less potent.
Of course, you'll also want to avoid PUFAs—a subject I wrote about extensively here—because they suppress thyroid function.
How to Boost Your Thyroid Function With Thyroid Supplement
Some people are so very hypothyroid that it would literally take years to make any significant changes with diet, and even then they may not fully heal. For them, using a thyroid hormone supplement is a much faster and more effective way to repair thyroid function.
There are a few different types of thyroid hormone available:
Synthroid (Levothyroxine Sodium): This is the most common form, and what the majority of mainstream medical doctors will want to prescribe. As a synthetic form of T4, the inactive thyroid hormone, it needs to be converted to T3, the active thyroid hormone, in the liver. Problem is, only very healthy people convert it well. Women have more difficulty than men because low thyroid sufferers tend to also be estrogen dominant, and estrogen inhibits the conversion of T4 to T3. According to Dr. John Lowe, "T4 does not increase the metabolism of many patients' tissues, no matter how high the dosage."
Glandular Thyroid: Also known as natural dessicated thyroid (NDT), this is thyroid hormone extracted from the thyroid glands of pigs. It contains protein precursors to T4 and T3, which are digested to produce the active units of T4 and T3 in a balanced ratio. Most endocrinologists oppose the use of natural thyroid because they think the batches are unstable—although it is Synthroid, in fact, that has been repeatedly recalled. (I don't put much weight behind what endocrinologists say, since there's a long-standing financial relationship between their organizations and the Synthroid manufacturers.) Fortunately, there are many naturopathic doctors who advocate this form of thyroid supplement, and some MDs (probably not endos) will prescribe it.
Cynoplus and Cytomel: These are synthetic thyroid supplements; Cynoplus contains T3 and T4 in a balanced ratio, while Cytomel is active T3 only. In my opinion (and Dr. Peat's), these are the safest and most effective thyroid hormones to take. Although many people do well on the NDT, I've experienced it to cause allergies due to the binders and fillers in the tablets; I don't have that problem with the synthetics.
Obviously, the decision to take thyroid supplement is not one to be taken lightly, and since these pills are prescription-only in most countries, you'll need to talk to your doctor about whether you're a candidate. Just to warn you: it's not easy getting an MD to help you with this condition, since they tend to be married to the blood tests (which may or may not reveal a problem). Consider working with a thyroid-minded naturopathic physician as well; I've found them more open to treatment based on symptoms. Since low thyroid function has far more serious consequences than just the acne, I really believe it's worthwhile to be persistent about this, and to take charge of your own health.
To learn more about thyroid function, metabolism and nutrition, I direct you to Dr. Peat's website (best place on the Internet!), and the large number of email exchanges with Dr. Peat that were compiled here.