The skin is extremely sensitive to our emotions due to its close connections to the nervous system. As an embryo, the skin develops from the neuroectoderm, which also forms into the brain and nerve tissue. In other words, your skin is your external nervous system. You may notice that your skin turns very pale when you feel fear. When you experience embarrassment or excitement, you may blush as a direct result of your emotional state. Similarly, acne and other skin diseases can occur or worsen when we are making attempts to define who we are in our relationships to other people. In fact, many dermatologists recognize that patients may need treatment for their skin and their minds and emotions simultaneously.

Acne occurs when the skin glands become plugged with oil and bacteria. In most cases, adult acne is caused by hormonal imbalances in which the body produces too much androgen (male sex hormones), or an increased sensitivity to normal levels of androgen at the level of the skin. In addition, anything that compromises the immune system, whether it is emotional stress or nutritional deficiency, is likely to upset your cortisol and insulin balance, which can affect your skin, as well. That is why some people get acne flares before a big date or major event. Even so, you can tame midlife acne.

In fact, emotional factors can be a key cause of acne. I often say that midlife is like adolescence in reverse because the same stormy emotions can often be present. Both adolescence and midlife are key developmental periods when you learn to individuate and define who you are in relationship to others. And, your skin is literally the boundary between you and other people—a sort of suit. Many researchers believe that skin disease may be thought of as a subliminal attempt to define who we are in relationship to other people and what the healthy boundaries should be. I definitely agree.

It is well known that androgens, such as testosterone, can influence the immune response in the skin. Androgens affect the secretions of sebaceous glands, which consist of fatty substances produced by the breakdown of oil-producing cells. Androgens can play an important role in the development of acne in women, particularly at midlife. Numerous studies have shown that sebaceous gland activity is heightened by androgens such as DHEA and testosterone, and reduced by estrogen or removal of the ovaries, which reduces androgen levels.

Women with the most severe forms of acne usually have a genetic predisposition toward androgen sensitivity in their skin, even with hormone levels that are within normal range. Excessive production of male sex hormones resulting from adrenal or ovarian disease in women not only causes acne, but can also cause hirsutism (excessive hair growth), menstrual disorders, and fertility problems. That is why acne in women may be a sign of an underlying endocrine problem.

Treating the underlying problem of excess male hormone usually corrects the acne, and can also improve the effects of excess hair growth, menstrual irregularities, PMS, polycystic ovaries, and other reproductive problems, as well.

Most studies show that estrogen can help acne. That is why some doctors prescribe birth control pills for acne. However, some women will suffer from acne problems when they are taking estrogen replacement therapy, including birth control pills, or when they are experiencing estrogen dominance during their perimenopausal years. The reason for this is that hair follicles and the attached sebaceous glands contain a specific enzyme known as 5–alpha–reductase, which can convert estrogen to testosterone. A thorough evaluation by a physician specializing in endocrine balance can help determine what medication or treatment plan is best.

Most conventional treatments for acne address the factors that lead to breakouts. For example, some treatments work on the hormonal level, others treat the bacterial component, and some target rate of skin cell turnover or immune system function. To put these treatments in perspective, it can be helpful to remember that two women who are on identical hormone replacement regimens, eat the same diet and have the same stressors in their lives may have skin reactions that are completely different. This is why all treatments have their place and can be useful.

Treatments for midlife acne include:

• Retinoic acid and other topical vitamin A derivatives: These products increase skin turnover and allow sebum to be released more easily, without getting trapped. Retin–A Microgel can be prescribed by a dermatologist and can be very helpful for some women. It can also be very irritating, and should not be used by women who are pregnant or trying to get pregnant because it can cause birth defects.
• Accutane: This is oral vitamin A. It is most often used to treat cystic acne. It is not recommended for women of childbearing age because it is proven to cause birth defects.
• Benzoyl peroxide, salicylic acid, sulfur and resorcinol: Lotions, creams, and gels containing these antibacterial agents penetrate the hair follicles, produce oxygen, and generally suppress the bacteria that play a role in acne, Propionibacterium acnes (P. acnes). These products are very effective and work by preventing new acne, so it may be a month or two before you notice improvements. These agents can also be irritating.
• Tetracycline and erythromycin: These are antibiotics that can be administered orally or topically. They work by preventing the P. acnes from breaking down sebum into free fatty acids, leaving less "food" available to the bacteria. I do not recommend long-term use of antibiotics because it destroys the body’s beneficial bacterial flora and can lead to numerous associated problems, including diarrhea, sub-optimal absorption of nutrients, and yeast infections. If you do have to use antibiotic therapy of any kind, be sure to replenish your native beneficial bacteria with a daily probiotic supplement.
• Birth control pills (BCPs): Many doctors prescribe oral contraceptives because they reduce sebum production by decreasing the brain’s cue to manufacture hormones from the ovaries. Some women are helped by birth control pills, some see no change, and others actually experience worse acne. Ortho Tri-Cyclen now has received an FDA indication and is being heavily marketed for treatment of acne; however, I prefer treatments that do not involve a daily does of synthetic hormones. Nevertheless, if you require birth control and cannot or will not use other methods, then this approach can be ideal.
• Glucophage (metformin): This drug is used in the treatment of diabetes and insulin resistance. Certain people with insulin resistance can have polycystic ovaries, which can result in the overproduction of male sex hormones.

When dealing with acne, it is also important to wash your face gently; do not scrub your skin or use harsh abrasives. Be sure to wash in the morning and in the evening, and after exercise. Use a gentle cleanser and toner to remove all traces of the cleanser and any dirt or bacteria left on the skin. Make sure that you do not pick, squeeze, or pinch blemishes; this can cause scarring or ongoing infection.

Some other factors that may make acne worse include:

• Tight exercise clothes that do not "breathe" or irritate the skin.
• Oily lotions or cosmetics.
• Some sunscreens.
• Certain medications, including steroids.
• Hard scrubbing of the skin.
• Over drying the skin.

If your acne is severe, you may want to investigate the use medications or follow the advice of a skin care specialist. For mild to moderate acne, I recommend the following natural treatment program:

• Eat a good diet: Follow the low-glycemic index, insulin-lowering diet I recommend in The Wisdom of Menopause. A diet high in refined carbohydrates ("white foods") is associated with excessively high levels of insulin and insulin resistance. This can cause the body to produce abnormally high levels of androgens. For many women, dietary modifications are all they need to control acne.
• Take nutritional supplements: Take a comprehensive vitamin-mineral supplement daily. In addition, you may want to take zinc, vitamin C, the B vitamins, and omega-3 fats are essential for healthy skin.
• Lose excess body fat: Excess body fat is associated with insulin resistance and the production of higher than normal androgen levels. Losing even five to ten pounds can make a big difference.
• Follow the regimen for the general care of midlife skin: Fruit acids remove dead skin cells that can clog pores. A good antioxidant skin care program usually helps reduce or completely eliminate acne scars. Intense Pusled Light (IPL) treatments can work wonders for old scars.
• Try home remedies for pimples: When you notice a pimple forming, apply tea tree oil at night. Its antibacterial properties will often cause the pimple to regress by morning. Some women use tee tree oil daily. You may also want to try mixing baking soda and lemon juice into a paste and applying it to the pimple.
• Remove blackheads: I suggest getting a professional facial to remove blackheads once per month, if possible, until your skin has cleared. After that, you can use one of the readily available blackhead removal strips, such as Bioré. Limit use to one time per week to avoid over-drying the skin.

Remember to give any treatment for skin problems six weeks to two months to work.

To determine if you need to deal with emotional factors that might be influencing your acne, ask yourself these questions:

1. Does your skin condition worsen when you experience turmoil?
2. Is your skin condition more stubborn, severe, or recurrent than your doctor expects?
3. Do your treatments fail to work, or work only for a short time?
4. Do your symptoms change according to your social environment (vacations, business trips, or arrival of family members)?

The more questions to which you answer "yes," the more likely it is that emotions are playing a significant role in your skin’s condition. The good news is that if you can see the connection, there are steps you can take to lessen the impact of emotions on your skin.

1. Take a full, deep breath. Breathe all the way down to your belly. Exhale and continue to breathe fully. When we feel a strong emotion, we often stop breathing as a way to stop feeling.
2. Close your eyes.
3. Identify the place in your body where you are feeling the emotion.
4. Describe what you are feeling. Does it have a shape or color or sound?
5. Don’t try to change your feeling. Allow yourself to feel it fully, exactly as it is.
6. Keep breathing and moving. Move around while you breathe and you will be able to move the emotion through your body.

Here is what you will most likely notice: If you give yourself the chance to feel your emotion fully, it goes away. You can use this technique anytime you feel any difficult emotion.

Keep a journal of your efforts and feelings, while you continue to care for yourself daily with affirmations and the best choices you can possibly make. The benefits of this approach are bound to show up on the outside, and are certain to make a difference in your wellbeing on all levels.