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Adult hormonal acne can start to affect every facet of your life. It can cause self-esteem issues, stress, and anxiety. Especially if you have tried the usual conventional treatments (like birth control pills and antibiotics) and alternative options (like an acne diet) — and still, your acne persists (or gets worse over time).
That’s why digging deeper is so important. Acne (and even hormonal acne) is usually a sign of a bigger problem lurking under the surface pointing towards issues like gut microbiome imbalances, thyroid disease, sex hormone issues, poor sleep, and blood sugar imbalances.
Though diet can play a role, acne diet approaches aren’t a quick fix, nor are they always successful. While many recommend eliminating dairy consumption, there’s a growing number of nutrition professionals pushing back against this.
So if you think that figuring out what’s going on with your acne is confusing, you’re not alone! I hope to help give you clarity on this with today’s guest who answers common questions relating to adult hormonal acne.
Lienna May, MS CNS LDN is a Clinical Nutrition Specialist and licensed clinical dietician/nutritionist who specializes in gut health, acne, and blood sugar imbalances. She received her Master’s Degree in Nutrition from the University of Bridgeport and was certified by Yale University in “The Science of Well-Being.”
By viewing health symptoms as parts of a puzzle, Lienna loves connecting the dots for her clients to help them achieve optimal health through sustainable changes.
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In This Episode:
- Why can blood sugar imbalances trigger acne?
- How do sex hormones drive adult hormonal acne?
- Does high LDL (aka “bad” cholesterol) affect acne?
- How poor sleep can be a hidden acne trigger
- Adult acne diet (Is dairy bad for acne)?
- Why a continuous glucose monitor (CGM) could be helpful for acne
- Who should NOT use a CGM?
- Simple tweaks to help achieve an optimal blood sugar level
Quotes
“Acne is often aggravated by too much blood sugar. If we're eating too much foods that are sweetened with sugar or too many refined carbs, any foods that is going to chronically spike our blood sugar, that's going to lead to more inflammation and the body also starts producing a lot more insulin growth factor 1, IGF-1. And what IGF-1 does is going to just ramp up sebum oil production. So it produces a lot more sebum. We do want some sebum, it's healthy, we just don't want to have too much, because then it leads to more inflammation on your skin as well, more clogged pores. So blood sugar and insulin and IGF-1 go hand in hand.”
“Breakfast will set your day on the right path if you have at least 25 to 35 grams of protein. And that's the same with lunch and dinner, but also having some protein with your snacks as well, because that’s just gonna help keep your blood sugar more balanced. Also adding fiber, we’re all not eating enough fiber in the US, so we know the recommended is 25 to 35 grams, but even more, including lots of nuts seeds with your meals to help balance that blood sugar. Also drinking lots of water, that will help.”
Links
Find Lienna online | Instagram
Healthy Skin Show ep. 220: The Gut Microbiome Of Acne [NEW RESEARCH] w/ Dr. Julie Greenberg
Effects of Diet on Acne and Its Response to Treatment | American Journal of Clinical Dermatology
Acne Severity and Sleep Quality in Adults
A low-glycemic-load diet improves symptoms in acne vulgaris patients: a randomized controlled trial
347: Adult Hormonal Acne + Blood Sugar Dysfunction: What’s The Connection? w/ Lienna May {FULL TRANSCRIPT}
Jennifer Fugo (00:12.709)
Lienna, thank you so much for being here on the show. It's a pleasure to have you. And I think the best way to start things off is, I would love to know how you became so interested in acne.
Lienna May (00:25.228)
Thank you so much Jennifer, I'm so excited to be here. So my journey started, I started having acne when I was 13, I struggled with it well into my 20s. And I've been on this journey of going to the dermatologist, going to all the doctors, and saying I have acne, can you help me? And they said, oh let's do birth control, that made me feel terrible. I quit it after two days. I was like no, I'm not doing that to my body.
I've tried all the creams and lotions, pop procedures, anything you can think of. I mean, I've spent thousands of dollars. And I also want to add that I've actually done that in Ukraine, where I was born. And then I also came to the US thinking, let's try this medical system. Maybe it works differently than traditional medicine. And I've done antibiotics. Of course, it cleared my acne, but then my acne came back with full vengeance and it was just terrible, I started getting UTIs. You know, it was really affecting my confidence, my life, I feel like all my life was surrounded around that. How does my face look? Can I go out today? Can I accept this job or can I do any of those opportunities? And I honestly would say I was starting to feel very depressed and anxious, just because nothing was working. It kept getting worse. And everyone says, you’ll outgrow it. I was like, no, it's getting worse.
So I went to see a functional medicine doctor and he started digging deeper, and it helped a little bit, but I was like, there's still more things going on. And the other side of me too, I'm this Ukrainian fighter where like, I don't know, I just always believed in my heart, there has to be a reason. It's not just my skin acting out. Maybe it was the whole setup for me to be able to be this detective as a nutritionist, to be able to put all those pieces of the puzzle together to find out what's causing my acne. So I just started digging deeper. I've had this slew of conditions, you know, gut issues, thyroid. I was really stressed, I was working, doing school full time. So I started digging into all of that and was able to clear my skin, and that's what really got me excited. I went back to school, got my master's degree in nutrition, really wanted to have the deep understanding of what's going on in the body. And that's what really makes me excited to help other people to get their confidence back and help them clear their skin.
Jennifer Fugo (02:52.58)
Well, it sounds like we've had similar experiences both personally and kind of clinically, noticing that sometimes the sort of, we'll just call it the functional approach, doesn't always work. And it's not to say that it doesn't work, but I think that we have to evolve and think outside of the box sometimes. And I love that we went to the same school, so we have a great way of thinking about things.
And we've talked about how there are different triggers of acne on the show before, which I think underscores the complexity that there can be between cases, like why one thing will work for one person and it won't work for somebody else. And so I noticed in following you and checking out your website, and even the information you shared with me before this interview, is that you really take a strong stance about optimal blood sugar level. So why do you believe that blood sugar imbalances are such a big trigger for ault hormonal acne?
Lienna May (03:59.084)
Yes, great question. So blood sugar, it really started with my journey two years ago where I was working with a company overseas helping them launch continuous glucose monitors, so I got to wear one myself and experiment with that. And, going a little bit into research and science so the listeners can understand the mechanism and the pathways behind it, acne is often aggravated by too much blood sugar. If we're eating too much foods that are sweetened with sugar or too many refined carbs, any foods that is going to chronically spike our blood sugar, that's going to lead to more inflammation and the body also starts producing a lot more insulin growth factor 1, IGF-1. And what IGF-1 does is going to just ramp up sebum oil production. So it produces a lot more sebum. We do want some sebum, it's healthy, we just don't want to have too much, because then it leads to more inflammation on your skin as well, more clogged pores. So blood sugar and insulin and IGF-1 go hand in hand.
And when they've done research, they've taken a group of two people, one were eating a low-glycemic load diet, and the other participants were eating regular diets. And on top of that too, they’ve done like a 10-week study, and they also went step further, they did skin biopsies too. So they noticed that with participants that were eating a low-glycemic diet, they had less oil-producing glands, sebaceous glands, they also had less inflammatory and non-inflammatory acne lesions. So they've seen, at the microscope, a huge improvement in their skin. What's interesting too, I know we'll dive into that a little bit later too, that they didn't remove dairy, the low-glycemic acne diet. So even without removing dairy, they've noticed a huge improvement in their skin.
Jennifer Fugo (06:02.498)
Oh, I love that. We will dive into the dairy question for everybody who's like, wait, dairy, let's talk. No, we're going to hold off. We have so much to talk about, because I think this piece of understanding insulin is really, really important. So what I'm gathering you saying is that the excess insulin is part of the problem. We also have this IGF-1 that helps kind of drive some of the other issues.
Lienna May (06:07.82)
Yes.
Jennifer Fugo (06:32.034)
Does this interact then with different sex hormones that might also, because I mean, obviously some of the interventions involve at least on the conventional side, hormonal birth control.
Lienna May (06:44.908)
Yes, great point Jennifer. And I want to add to the previous point, something I wanted to mention, was what research studies found too, that that excessive chronically elevated blood sugar, they found out that it also stimulates over-activation to a genetic pathway and decreases FOXO1. So that's also implicated in acne where you make more sebum, clogging sebaceous glands. And you're right too, because with higher insulin and chronic elevated blood sugar, that's also going to lead to increased androgen activity with especially testosterone, we know PCOS is really related to blood sugar issues as well. So that will also contribute to more acne and more inflammation and just more issues going on on top of the skin, but also inside the body with inflammation.
Jennifer Fugo (07:40.866)
And I should mention too, one of the papers that you sent that we're gonna put into the show notes, noted that, and I'm gonna read this quote, because I think it was really fascinating, was LDL levels and consumption of sweets correlated with adult hormonal acne severity. So basically the higher the LDL or the quote-unquote, as they call it, bad cholesterol, was equal in a sense to this, or the higher that would go would be equal to somebody who's eating more and more refined sugar and carbs. Is that something that you see in practice?
Lienna May (08:19.116)
Yes, a lot of times I think there's such a strong correlation. We have high LDL, if we look into it a little bit deeper, if we check HbA1c, which is an average blood sugar for the last three months, often it's elevated. And then I'm sure you can relate to that working with clients with skin issues, there's also such a big stress component. Because people are so stressed with all their, can they go out, they're irritated by their skin, they're overwhelmed by all the treatments. So that alone, stress is going to increase insulin. It's going to lead to blood sugar spikes too, which you often can track on the continuous glucose monitors. So absolutely it's also connected. And then a lot of times too, people think I'm eating healthy, but we just forget about all the sauces, or I have to share this too, smoothies that you buy at even the organic juice bar. If you think of like, banana, pineapple, mango, and then orange juice in it, or an acai bowl that, unfortunately even though those are healthy foods, if you stack a lot of high-glycemic foods, just a lot of it also is gonna lead to blood sugar elevation, and someone's still gonna struggle with acne and they’re like, I don't understand what's going on, I'm not able to get rid of my acne, what's happening with my skin. So yeah, it's really, really connected too.
Jennifer Fugo (09:47.935)
It is, and to piggyback off of the point you just made about stress, I was wondering if there was any research on the connection between poor sleep and adult acne. So, interestingly enough, I was able to find a paper from 2019. It was a small study, 40 people, mostly women, 30 of these individuals were currently getting treated for adult hormonal acne. And what they noticed, now mind you, these are all, they're using scoring systems to determine acne severity versus sleep quality, like how good or bad is their sleep and probably their fatigue levels and whatnot. But what they noted was that as the sleep scores dropped, so as they got worse, the adult acne severity increased.
And, I would argue, just anecdotally, that when I consistently do not sleep well, I am more easily irritated, I am fatigued, it is much easier for me to feel, I would say, obviously not energetic, but sometimes even depressed, like to feel very frustrated, like things aren't going well, your mindset is impacted. How do you think sleep could potentially play a role in terms of someone dealing with adult acne?
Lienna May (11:09.932)
Jennifer, great question. Can I share a personal experience too?
Jennifer Fugo (11:12.959)
Please!
Lienna May (11:39.692)
So I was wearing a continuous glucose monitor right when my baby was born. So I was getting some major sleep deprivation, you can imagine. And it was interesting because my husband was wearing one, I was wearing one. We were eating the same meals and my blood sugar would spike during the day. First I was like, what's going on? I just had a really good breakfast. It was full of protein, I got in some fiber. I just had black coffee, I didn't go through the Starbucks drive-thru and get a muffin and sweetened coffee. And then I realized that we do know from research that sometimes even just one bad night of sleep will decrease our ability to handle glucose by 50% the next day.
Jennifer Fugo (11:59.391)
Wow!
Lienna May (12:08.972)
So we know that's going to lead to, like you said, fatigue, sleep deprivation, but also it's going to lead to increased cortisol, increased insulin, so it's going to lead to fatigue. So that's when I noticed too, with my CGM numbers, it was really increased the next day, and then I realized okay, sleep, it's sleep deprivation, it really affects how I'm doing. So that makes total sense really, that it's going to increase your insulin, it's going to increase your cortisol, it's going to lead to more acne and more breakouts. I think it's all connected up.
Jennifer Fugo (12:33.855)
Yeah, and I think that the insulin piece and the hormonal piece is a huge piece. And obviously, there's other factors, right? You could, I mean, let's be honest. There's so much junky skincare that is loaded full of ingredients that are pore-clogging, especially coconut oil, don't use coconut oil on your face.
Lienna May (12:51.756)
Yeah. Oh my goodness, yes. And then gut issues and chronically stressed, fast-paced lifestyle, all of that.
Jennifer Fugo (13:00.575)
Exactly, and mineral imbalance, all sorts of things. But I do think that if we're just looking at it through this lens, which is where we're kind of trying to stay focused today, because I want to make sure people if are like, they're just saying this, we're like, no, no, we're just looking at one facet of this conversation because it is so big. I have to ask now, dairy, because I mean, you know, we're talking about food, how food impacts things. What's your take on dairy consumption and adult acne?
Lienna May (13:34.988)
So I'll share two perspectives, and one of them I'll even piggyback. Jennifer's done an amazing two or three podcasts on dairy and plant-based milks, that was really good. You've done a lot of research. I'll piggyback on some of that. So dairy, we know from research, it does increase IGF-1, and especially with milk, it can lead to hyperinsulinemia. And if we think of something like ice cream, that also has a lot of added sugar, so it does stimulate IGF-1, so it's going to lead to more sebum production. But also dairy is really in high leucine, and we know two components of casein and whey protein also leads to increased sebum production and also again, activates the mTOR genetic pathway too. So that's going to lead to some of that more sebum production and acne.
And for me, Jennifer, I removed dairy when I started working on addressing the root causes of my acne for about three or four years. And to be honest, I was even scared to introduce it back, you know, thinking of like, dairy causes acne, we know that from the research. But then I got pregnant, I was craving some of this wholesome organic cottage cheese I used to eat in Ukraine. I was like, let me have that, it's okay. And you know, I've introduced some of the dairy back, but quality dairy that comes from pasture-raised, cheese from Europe that's raw, higher quality, that doesn't have added growth hormones, all of those things. And you know, I feel like my skin can tolerate it. So I don't overdo it, it's more of, I enjoy it on occasions.
So yes, research does show it does increase IGF-1 and increase the sebum production, but here I am, I worked on underlying gut issues, and nutrient imbalances, and my stress, and balance in blood sugar. And I do feel my skin can tolerate it now. It's not getting triggered or I don't get a breakout. I know it's probably controversial to say that, but you know, even just looking into the research you've done with plant-based milk, we think we're doing all the good stuff, but all the additives, and where they're coming from, and labor, and how there's workers, there's just the whole, all of that behind it too. And then someone is giving up dairy and they’re drinking almond milk every morning with coffee, then they can have trouble with almonds too.
Jennifer Fugo (16:10.905)
Yeah, it's complicated, as you have said. And I want to be clear, anybody listening to this, we're not, we're not poo-pooing on the plant-based alternatives, because sometimes somebody has a legit dairy allergy and cannot consume it. But I think you specifically, Lienna, are a part of a growing trend of nutrition professionals who is pushing back on this question about dairy causing hormonal acne. Because like you said, the research is confusing. I was trying to determine before this interview what exactly it was that seems to be the problem, some research is pointing to whey, then they point to lactose, and I'm like, okay, but what is it? And then it looks like cheese is less associated with hormonal acne. It's very unclear but then I'm thinking, well, most people, if we just take Western society, most people consume dairy in general with loads of carbs, right? They pour it on cereal, pizza.
Lienna May (17:16.62)
That's true. Pizza, right? Pasta? Ice cream, yeah.
Jennifer Fugo (17:29.369)
Exactly. Everything is loaded with sugar, even yogurt. Most people who eat yogurt are eating those little containers loaded full of sugar because they've added fruit, added all sorts of sweeteners. So I do wonder sometimes when we look at this research, did they really account for everything, or was the blame placed squarely on dairy and all of its many parts? I don't know, because there are people like you who have been able to tolerate dairy, who have a history of that. I had hormonal acne as a teenager. I consume dairy without hormonal acne issues. I wouldn't say that I'm the prime picture of that, and I know N=1, we can't assume that what works for us will work for other people. But I think your controversial take is a growing trend of saying, is this really as big of a problem, or are there other factors that we could take action on and then potentially reintroduce?
Lienna May (18:25.868)
Yeah. Jennifer, you're right. And I don't even know if we've seen it in research where they would compare the quality of dairy, something that you can buy at Walmart, how it was raised, quality dairy, the cheese that's been from pasture-raised, raw that has still some of the digestive enzymes intact. I feel like we do need more research and more to dive deeper to see and compare the nutrient density and the quality of dairy as well.
Jennifer Fugo (18:57.305)
Yeah, and another point, and I have no idea, because I cannot find anything on this. So if anyone who's listening to this, if you find the research or know of it, great, send it to me, I'd love to see it. But again, pointing to whey as a problem, going, oh, look, people in the fitness industry, they consume higher levels of whey, and thus they develop acne, there's more prevalence of acne because of whey consumption from whey protein. But the problem that I have with this, and I don't know what the answer is, is that whey is a heat-liable protein, meaning it will denature when it is heated up. And that has been something we discussed on the show with Dr. Stacey Silvers when we talked about dairy allergies, which is why, yes, you can have an IgE food allergy to whey, but some people can tolerate it in heated foods.
So the question would be if the protein changes, if it's heated up, is that maybe the reason that something like cheese on a pizza, or dairy cooked into something, the whey there might not impact IGF-1 and insulin growth factor the same? I don't know, I couldn't find anything, but I just wonder. It just feels, like you said, like we're trying to find answers and blame it on different factors. But it's so complex.
Lienna May (20:14.796)
Yeah Jennifer, and coming back to even what you mentioned too, we are eating as all the studies are usually done, and if they're eating a lot of pizza, then we know it's mostly carbs if you don't have a lot of veggies or salad or optimal protein with that meal, or a lot of pasta. So we know there's also blood sugar that's gonna spike and lead to inflammation, and so, yeah, you're right, where can we blame it on dairy? Where can we blame it on increased blood sugar spikes and high blood sugar signs? What is going on? That's true. Just like you said, with the heated cheese. I have seen in research that cheese, it seems you do much better than just whole milk, or something that you'd be drinking with less.
Jennifer Fugo (20:56.978)
Yeah, it's interesting, the questions. Forever, we'll have questions. So you mentioned a bunch of times already about a continuous glucose monitor or a CGM. What is that, and how exactly could it be helpful for people dealing with acne if they want to spot high blood sugar signs and their optimal blood sugar level?
Lienna May (21:14.636)
It's very helpful. It's a device that usually attaches to the back of your arm that you wear, and it sends the signals, you can install an app. There are currently, as far as I know, two big companies in the US where you can get it independently, so you don't have to have a prescription. If you're not diabetic, it's Nutrisense and Levels. And they send signals, and those apps help you interpret the data because you're going to see, what are you eating, how you're sleeping, walking, exercise, stress, lifestyle, how all of those things will impact your blood sugar. And you know, every time we eat, the blood sugar will go up and that's normal. We just don't want it to go up too high. I always like to tell all my clients, think of it as a valley, not too many mountain tops with blood sugar, because if it goes up too high, then that creates more inflammation. It's gonna produce more IGF-1. It's gonna lead to more sebum production. And I think in general, like you said, it's going to make you feel tired, feel like you need a nap, or you need more coffee or more snacks to get you going.
So something like that CGM is a very helpful tool, because you're going to learn exactly for your own self which foods and what lifestyle factors, how they impact your blood sugar. Because I had a client, she had no idea that raspberries were spiking her blood sugar leading to chronic migraines. She was able to figure that out. She's like, I would have never never known. So sometimes it's some simple like banana. Someone's doing really well with banana, other people can do half of a banana, maybe they need also some nuts to go with it. So it's a really cool tool to help you get more insight into how your body personally response to foods and lifestyle. And that's going to help you know, how can you tweak your meals, how can you improve your lifestyle to help you balance your blood sugar, but also help you clear your acne from the inside out.
Jennifer Fugo (23:11.089)
And just always being mindful of the full landscape of using tools like this. It sounds like having somebody work with you would be helpful, right? Because it could create food fear. Somebody might go, oh my gosh, raspberries are bad, and be afraid of them. But are there some instances or are there some individuals who would be better off maybe not using a continuous glucose monitor to check optimal blood sugar level given certain facets of their case?
Lienna May (23:40.204)
Yeah, I'm glad you asked that because I was thinking of that in my mind. I've learned usually, I would say, people who have a history of emotional eating, disordered eating, those are not the best for that. I usually turn them away, or anyone else that you see that tendency that that could create a lot of anxiety or just food fears. I agree, that could backfire, it wouldn't be helpful, so that wouldn't be the best too. Then maybe working with nutritionists, helping you get more detail, so working on balancing your foods, your lifestyle would be better. Yeah, I agree. That's a good question. I don't recommend it for everyone.
Jennifer Fugo (24:21.105)
Yeah, and I think too, if you have a history of eating disorders, I think that's another clear instance of someone who may not do well with that type of information, right? Information is a tool, but depending on how we process it, and how we use it, and how it impacts us can make a world of difference. And what we don't want ever is for a tool to create more stress in someone's life.
Lienna May (24:47.308)
Exactly.
Jennifer Fugo (24:51.473)
So I'm glad to know that you utilize the tool when it is a good fit for the client, especially considering that everybody has so many different skin issues now, and they have a variety of backgrounds. So I love that you're really mindful of that. And I want to make sure that we offer listeners some great nutritional tweaks or strategies that they could potentially try, because obviously the goal here is to stabilize blood sugar and fasting blood sugar. So what are some simple things that they could start sometime in the next five days, or test out in the next five days? Maybe they pick one out of a few that you share that would be helpful to help stabilize blood sugar and fasting blood sugar.
Lienna May (25:32.236)
Yeah, I'd love to share a couple of really good tips and tricks. So first of all, optimal protein intake, especially women, I've seen in my practice, we tend to undereat protein, especially for breakfast. Intermittent fasting is a different way we could do it. But if you're talking about someone who is having breakfast, breakfast will set your day on the right path if you have at least 25 to 35 grams of protein. And that's the same with lunch and dinner, but also having some protein with your snacks as well, because that’s just gonna help keep your blood sugar more balanced. Also adding fiber, we’re all not eating enough fiber in the US, so we know the recommended is 25 to 35 grams, but even more, including lots of nuts seeds with your meals to help balance that blood sugar. Also drinking lots of water, that will help.
And you know, going for a walk. Now they’ve shown in research even five, ten minutes of a walk after a meal can really help you balance your blood sugar, bring it down if you had something a little bit, maybe, like a dessert, or something sweeter or carb-heavy, that's gonna help just burn some of that. Just move your body in any way. And lots of hydration, electrolytes are helpful with low sugar as well.
And of course, I would say lifestyle, sleep, we've mentioned sleep. And stress management, because we can be eating this beautiful diet, but then, you know, just always stress, we need that. Finding that zen, relaxing, meditations, deep breathing, because all of that will also help bring your blood sugar back into balance.
Jennifer Fugo (27:12.625)
Yeah, it's amazing what two minutes of just a simple breathing exercise can do to help lower cortisol. Like that's right, you said stress. Cortisol comes from stress, that helps lower the glucose if we don't have a lot of cortisol.
Lienna May (27:28.556)
Yes!
Jennifer Fugo (27:29.417)
So two minutes is all you need sometimes. I feel like that's the two-minute gateway into trying out some of these things. I love what you've shared and you actually have a free seven-day meal plan over on your website which we'll link up in the show notes. I love the name of your website. It's luckyavocadonutrition.com. I love avocados.
Lienna May (27:48.94)
We love avocados. We even have an avocado tree. We're obsessed with avocados in our house, we have to eat one a day, my daughter’s totally obsessed, she loves them. Yes. So when you come for a visit, I'll bring you some of my homegrown avocados.
Jennifer Fugo (28:02.696)
Oh my gosh, I'm so jealous, homegrown avocados. It has been such a pleasure to have you here, Lienna. We're gonna link up all of your social media, I know you're on Instagram and anywhere else. We'll put everything into the show notes, and I deeply appreciate you being here and hope you can come back sometime.
Lienna May (28:21.068)
Yeah, I'd love to! Thanks for having me, I love this!
