Did you know that stress can play a role in your acne breakouts?
When I ask patients about stress in my practice, I typically get a lot of chuckles and a few eye rolls about this. Duh! Who doesn’t experience stress these days.
And listen, I get it. I’m a medical practitioner who has done a lot of studying in this area, and I still find it hard to reduce my own stress. But I am aware of my anxious tendencies and am working on it. I am not going to go from a stressed mess to zen overnight. I am a student of relaxation and likely will be lifelong. And while I always tell my patients it’s easier said than done, the road to stress reduction can have major benefits to one’s skin (as well as one’s life in general).
Let’s dive a little deeper into stress. When your body experiences stress, the adrenal glands (small organs that sit on top of your kidneys and regulate a few important hormones) release the stress hormones: cortisol and adrenaline. These activate our “fight or flight” response.
When we were cave men and women, interacting with lions, tigers, and bears, our stress response kept us in high alert and alive. As cortisol is pumped into the system, it increases our heart rate, causes increased breathing, dilates our pupils, stops our digestion, suppresses the immune system, and elevates glucose where it can be used quickly to energize the body.
These days, we still experience jolts of stress in the body, although they’re typically less running away from lions and more nearly avoiding a car accident or even missing the final step in a flight of stairs (you know what I’m talking about here).
But as a society, we’re experiencing a lot more chronic stress. Some examples of this can be: challenging or time-consuming jobs, going through difficult educational programs, traffic jams, or being a mom or dad. People experience chronic stress regarding money, relationships, and workouts, too. Some people even experience chronic stress because of the acne they notice on their skin!
But how does cortisol play a role in our skin? Well, this stress hormone causes an increase in activity of the sebaceous unit (link here to basic understanding of the skin, sebaceous unit?), which causes an increase in oil production (1). When the stress hormones are chronically being pumped throughout the body, we end up having a chronically higher relationship of cortisol on the oil unit, increasing the oil gland activity, and furthermore acne lesions. Adrenaline released during times of stress also increases oil production of sebaceous glands, which is why skin conditions worsen with chronic stress (1).
If you haven’t already read my introduction to the skin and acne, check out that post here. But to tie it in quickly, increased oil production within the sebaceous unit of the skin is one of the four means to acne creation in acne-prone individuals.
While we know that stress can increase sebaceous oil production, I do want to note one study involving Singapore teenagers experiencing an increased number of acne lesions during times of high stress (prior to mid-year examinations) vs times of low stress (summer vacation). Acne lesions were more obviously prevalent during times of higher stress; however, the sebum production measurements did not change significantly between high and low stress conditions. This led the authors to believe that increased acne lesions with stress may result from more factors than increased oil alone. (15)
It has been noted that acute stress increases glucose to provide a quick energy store to our body. It has also been noted that high levels of blood sugar in the body can increase one’s acne. And so potentially the teenagers in this study experienced increased acne lesions during times of stress due to the increase in blood sugar. But there are several more things that occur more system wide during times of stress, like inflammation, immune system suppression, and behavioral changes. Acne is an inflammatory skin condition, and system wide inflammation simply adds fuel to the fire. When our immune system is less robust, it stops being able to fight off infections, including those responsible for acne. And behavioral changes can include less sleep, so less time for our bodies and skin to regenerate, poorer eating habits, or even worse skin habits, like picking skin lesions.
And while stress can lead to direct and indirect causes of acne, the good news is, there are a lot of effective techniques for stress management, and for the most part they are free and easy to try until you find the ones that work best for you. These include but are not limited to:
Regular Exercise:
Nearly any form of exercise, from walking to yoga to strength training, can result in stress relief. You know those people who get a “runner’s high”? It’s a real thing, and can be felt from more forms than just running. Physical activity increases your endorphins (the feel-good neurotransmitter), helps you manage your flight or fight response, works as a meditation in motion, improves your mood, and aids in restful sleep (4).
I do want to make a note on High Intensity Interval Training or HIIT. This is a form of exercise that alternates between short, intense bursts of activity and periods of rest or lower-intensity exercise. It can have amazing cardiovascular benefits that many people love. However, it does awaken our “flight or fight” response because our body perceives our actions as a survival method. Without proper recovery, both short term, such as allowing your heart rate to come down and bringing your breathing back to normal, and long term, like getting enough sleep, proper nutrition/hydration, and recovery, HIIT can lead to elevated levels of cortisol in the bloodstream and heightened symptoms of physical stress, sometimes even long after the exercise has finished (5). If you love this type of workout, consider balancing it with lower stress forms of exercise. All things can be good in moderation.
Journaling:
This is one of my personal favorites. For me, when I’m going through something stressful, I find that writing it down allows me to process it better by asking myself questions like: Why are you upset about this? Where is this pain coming from? Is there a solution? What do you need from yourself to forgive this moment and move on?
Studies have demonstrated that writing is effective at improving well-being because it allows individuals to engage in thoughtful processing and give meaning to moments. Studies furthermore show that “individuals who can find more meaning after stressful life events such as terrorist attacks, chronic illness, spousal loss, or other traumas experience lower levels of stress and distress and higher levels of adjustment” (6).
There is evidence to show that specifically expressing gratitude in writing can also lead to positive effects. “Individuals with higher levels of gratitude experience better psychological well-being, including lower rates of depression, anxiety, and greater emotional functioning, including more positive affect, less negative affect, and higher life satisfaction” (6).
And you don’t need to spend hours writing unless you want to. One popular technique is the “Five Minute Journal,” where you set a timer and write whatever you want.
Meditation:
While medication can oftentimes be considered one of the most difficult forms to master, it is one that can show some of the highest benefits to overall wellbeing.
Meditation is a practice that involves focusing the mind and body to instill a state of relaxation, concentration, and awareness. There are many techniques that can be used to meditate, including mindful breathing, body self-scanning, mantra repetition, among others. (7)
And research has confirmed countless health benefits with this practice including:
Stress reduction
Decreased anxiety
Decreased depression
Reduction in pain (both physical and psychological)
Improved memory
Increased efficiency
Decreased sympathetic overstimulation
Reduced blood pressure, heart rate, lactate, cortisol, and epinephrine
Decreased metabolism, breathing pattern, oxygen utilization, and carbon dioxide elimination
Increased melatonin, dehydroepiandrosterone sulfate (DHEA-S), skin resistance, and relative blood flow to the brain.
Increased brain cortical thickness (which does decrease in general with age)
(8)
There are many options for getting started with meditation. Between YouTube, several apps, books (including audiobooks), or even googling “how to start meditating,” you can find the practice that works best for you.
Breathwork:
We touched on mindful breathing briefly just above in meditation, and they can be very connected. Attention to breathing specifically helps you focus on “slow, deep breaths which aids you in disengaging from distracting thoughts and sensations” (9). When I practice this, I like to place my right hand over my heart and my left hand over my stomach. It helps me focus on the literal activity of breathing, and begins to shift my mind from whatever stressful event is occurring to the rhythm and motion of me breathing slowly and deeply in and out.
There are a few breathing techniques, one of which is box breathing. This encourages you to breathe in deeply for 4 seconds, hold for 4 seconds, breathe out deeply for 4 seconds, and hold again for 4 seconds. Another is the 4-7-8 technique, which encourages you to breathe in for 4 seconds, hold for 7 seconds, and breathe out for 8 seconds. All of this allows you to focus on the breath, and remove your attention from your literal or emotional surroundings.
Adequate sleep:
Sleep is huge, people! I recently read the book Biohack Like A Women by Aggie Lal in which she noted we can go without food for about a month, go without water for about a week, but we can only live without sleep for a few days (12). Sleep regenerates us in many ways and lack of sleep is associated with “higher levels of stress, frustration, depression, and anxiety” (10).
So, when we are getting adequate amounts of sleep, we should experience lower levels of stress, frustration, depression and anxiety. “Following a regular sleep routine can calm and restore the body, improves concentration, regulates mood, and sharpens judgment and decision-making. You are a better problem solver and are better able to cope with stress when you’re well-rested” (11)
Now obviously sleep can sometimes be out of our control (new parents, I’m looking at you). But when sleep is within our control, we should aim for 7-8 restful hours a night. Getting a bedtime routine that involves stopping food and alcohol several hours before bedtime, turning off electronics, dimming overhead lights, and practicing meditation or breathing can all help slow down the body to prepare us for sleep (12).
Nature Exposure:
Have you ever gotten back from a day out hiking and just have that sense of contentment? A growing number of research has shown that visiting outdoor spaces and being exposed to natural environments can reduce psychological stress (13). Spending time in nature can have positive impacts on anxiety, fatigue, inspiration, social behaviors like generosity and empathy, disconnectedness, and angst (14). And you don’t have to live by the grandest hikes to get the benefits. Get out for a walk, head to the nearest park, and maybe every now and then hop in the car to get some distance between you and the city.
Spending Time with Loved Ones
Every Tuesday my fiancé and his best friend call each other. And every time they start the conversation with, did we finallllly make it to Tuesday?? Half the time they call each other with specific needs and the other half they call with no real plan to the conversation, just letting jokes and their days lead the way. But despite what is going on in either of their lives, when he finallllly gets off the phone, my fiancé is happier for it.
Having a strong and supportive social circle can have many benefits on health, importantly stress. My fiancé’s weekly call with his best friend can turn around any bad day (although to be truthful, my fiancé is excellent at mindfulness, and rarely has “bad moments,” let alone bad days).
It has been noted that individuals who enjoy a supportive network were found more likely to turn to friends or family during times of stress rather than seek negative coping mechanisms like drinking, drugs, or smoking. Person’s blood pressures and pulses will stay lower while discussing difficult times if they have a supportive relationship by their side. Elderly patients experienced better memory, more perceptive thinking, and less “wear and tear” on the body and brain when they had supportive relationships in their lives. It has even been found that those with strong social circles experience greater meaning in life (16), and as noted previously, finding meaning in situations can help reduce stress altogether.
And there are many ways to enjoy friends and family. My fiancé and I live across the country from many of our social network, so we call and facetime when we can. We make dinner for and with the friends we have here. We go for walks together, spend time at the dinner table expressing gratitude before meals, and encourage one another during good times and bad. Your social circle does not need to be large to experience the benefit. Just a few good souls that set yours alight with happiness.
Mindfulness:
Mindfulness is defined as a “focused awareness of one’s emotions and purposeful and nonjudgmental [attention] on the present moment” (3). With practice, individuals can learn to process emotions, thoughts, and body sensations (such as a racing heart) when they arise. Once individuals become aware of these acute symptoms, they can learn to modify their usual responses from automatically reacting or worrying about something to a more thoughtful, measured response with greater awareness to the present moment. (3)
A final ending note on mindfulness: In my first job as a physician assistant, I was in constant fight or flight from chronic stress. I moved from Michigan to the Big Island of Hawaii without any friends or family and jumped into a long-distance relationship that felt strong enough to hold onto but new enough that we didn’t know if it would last. That relationship has now turned into my fiancé, who has always amazed me. He has practiced mindfulness since his teenage years, likely without ever realizing there was a name for it. After one of probably several painfully stressful days, he sent me this quote, which has been attributed to Bruce Lee, Gandhi, and Warren Buffet:
“You will continue to suffer if you have an emotional reaction to everything that is said to you. True power is sitting back and observing everything with logic. If words control you, that means everyone else can control you. Breathe and allow things to pass.”
Words, situations, environments: most of these are out of our control. I still have not managed to master this art completely, but my goodness, how freeing would that be?
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