Anabolic Steroids and Acne

What are Anabolic Steroids?

Arnold Used Lots of Anabolic Steroids
Arnold Used Lots of Anabolic Steroids

Anabolic Steroids (aka Roids, Juice, AAS, etc) are molecules that mimic the shape and function of androgen hormones (eg. Testosterone). Anabolic Steroids are generally used to stimulate protein synthesis and muscle growth.

Anabolic steroids should not be confused with corticosteroids, which are immune suppressants and can actually inhibit muscle growth. Corticosteroid injections are sometimes used to treat acute inflammation in severe acne lesions. Anabolic Steroids are never used as an acne treatment, and their use can cause or worsen acne symptoms.

There are numerous medical conditions for which Anabolic Steroids are legitimately used as treatments, but Anabolic Steroids are better known for their use as performance enhancing drugs. Virtually all major sporting leagues ban the use of Anabolic Steroids, although this doesn’t necessarily prevent their use by athletes. Anabolic Steroids use by individuals for aesthetic purposes is also common in some populations.

Risks and Side Effects of Anabolic Steroid Use

There is widespread concern and controversy about the danger posed by both aesthetic and performance enhancing use of Anabolic Steroids. While some of the danger may be overstated, there are many well-known side effects associated with the use of Anabolic Steroids, including: Growth disruption in adolescents, hormone balance problems, accelerated male pattern balding, cardiovascular problems, contaminated/counterfeit medications, psychological problems (e.g. roid rage) and acne vulgaris.

Androgens Drive Muscle Growth
Androgen Hormones Drive Muscle and Body Hais Growth

Research shows that negative side effects of Anabolic Steroid use tend to occur in a dose dependent fashion. Higher and more frequent dosing of Anabolic Steroids is generally associated more frequent and severe side effects. The side effect profile is also dependent on the precise type of Anabolic Steroid being used. With the rapid expansion in designer Anabolic Steroids over the last two decades, a tremendous diversity of options now exists in the marketplace.

How Anabolic Steroids Work

Testosterone is an Androgen Hormone
Testosterone is an Androgen Hormone

Androgens are the primary hormones responsible for many of the masculine characteristics that differentiate males and females. While females naturally produce androgen hormones like testosterone, they tend to produce much less than males. Anabolic Steroids are usually compounds that are structurally similar to the testosterone.

Focused scientific development of Anabolic Steroids was pioneered by the Soviet Union to improve their competitiveness in international athletic competitions (e.g. the Olympics. The first Anabolic Steroids were simple blends of testosterone and its naturally occurring derivatives. However, these first generation steroids not only increased muscle growth but also had potent masculinizing effects on the user. These effects were most evident in female athletes, with the women of the East German Olympic teams of the 1970’s and early 80’s being the most famous examples. Starting in the 1970’s doctors and scientists began researching new testosterone derivatives that would encourage muscle growth with fewer side effects, so called “designer steroids”.

Many of the cells that compose the human body have sensors called “androgen receptors” that mediate cellular responses to androgen hormones. When the androgen hormone is detected by the cell it stimulates changes in gene expression and metabolism in the cell. However, not all cells respond the same way when they are activated by an androgen hormone. Whereas muscle cells may be stimulated to grow and multiply, other cells, like those in the testes, may actually slow their growth.

Diagram of how Molecular Modifications Affect Anabolic vs Androgenic Profile
Diagram of how Molecular Modifications Affect Anabolic vs Androgenic Profile

Androgen receptors are not exactly the same from cell to cell. There are slight differences between the androgen receptors (and their downstream signalling pathways) depending on the type of cell.  The androgen receptors on certain have a high affinity for some androgen hormone derivatives, but a low affinity for others. Over the last thirty years, scientists have been working to develop “designer steroids” that preferentially stimulate the androgen receptors on muscle cells. Significant progress has been made in this pursuit, and today’s designer steroids have far fewer androgenic side effects than those used by the Soviet Union thirty years ago. That said, virtually all Anabolic Steroids still have some level of negative side effects.

Anabolic Steroids and Acne

One of the most common side effects of Anabolic Steroid use is the development of acne on the face, chest and back. The development of acne symptoms is generally caused by the increased activity of the sebaceous glands in response to elevated levels of androgen hormones. High concentrations of androgens (eg. Testosterone) in the body can increase the size and growth rate of the sebaceous glands.

Effect of DHT Androgen on Sebaceous Gland Activity (Akamatsu)
Effect of DHT Androgen on Sebaceous Gland Activity (Akamatsu)

The increase in sebaceous gland activity generally leads to a corresponding increase in sebum production. High levels of sebum production can increase the incidence of clogged pores and induce the growth of acne-causing bacteria, such as Propionibacterium acnes. P. acnes bacteria use sebum as a nutritional source. Increased sebum levels can also contribute to increased inflammation in and around the follicle, worsening acne symptoms, contributing to tissue damage and increasing the risk of acne scarring.

Different types of designer Anabolic Steroids have different profiles of androgenic side effects. Anabolic steroids like testosterone and dihydrotestosterone have a relatively high androgenic to anabolic (muscle building) profile, while some synthetics like Oxandrolone tend to have fewer androgenic side effects, relative to the dose.

Sebaceous gland activity is not only regulated by androgens, but also by other compounds that may be used in “performance enhancement” applications. For example, Human Growth Hormone (hGH) is a commonly used muscle building supplement that can also potentially contribute to acne symptoms. Human growth hormone stimulates the production of another growth factor Insulin-Like Growth Factor 1 (IGF-1) which has also been shown to increase sebaceous gland activity.

There are a lot of variables and cross-reacting factors when it comes to Anabolic Steroids and their side effects, like acne. As always, it is strongly recommended that any steroid therapy be done under the supervision of a qualified medical professional. Illicit steroid use can be quite dangerous not only because of the known side effects and legal restrictions (in many countries), but also because of the high incidence rate of poorly labeled, impure and counterfeit product being sold as Anabolic Steroids in the unregulated market.

Treatment of Anabolic Steroid Induced Acne

Obviously, stopping the use of Anabolic Steroids is one solution, although maybe not realistic in all cases. Additionally, stopping use might not actually be enough to completely resolve acne symptoms that were caused by prior Anabolic Steroid use. In most cases of acne (steroid-induced acne included), a central feature of acne is a persistent infection of P. acnes bacteria within hair follicle. Once established, this infection may persist for long after steroid use is stopped. Fortunately, individuals with steroid related acne have many treatment options available to them, including:

RETINOIDS

Isotretinoin Roaccutane Packaging
Isotretinoin (Roaccutane, Accutane)

Both oral retinoids and topical retinoids can help decrease sebaceous gland activity and improve acne symptoms in many individuals. However, there is some research that indicates that oral retinoids (Accutane) may negatively impact athletic performance and recovery times. As a result, oral retinoids are rarely prescribed to competitive athletes who are in active competition. Topical retinoids are effective in some cases, but they tend to be less effective against inflammatory, nodular and cystic forms of acne. Unfortunately, inflammatory acne is fairly common with steroid use.

ANTIBIOTICS

Tetracycline Antibiotic Capsules
Tetracycline Antibiotic Capsules

There are a wide range of topical and oral antibiotics that have been shown to be viable anti-acne treatments. Like topical retinoids, topical antibiotics usually have reduced efficacy against inflammatory forms of acne. Some oral antibiotics have been shown to have both antibacterial and anti-inflammatory properties.

ANDROGEN INHIBITORS

Finasteride Tablets (Propecia)
Finasteride Tablets (Propecia)

While it is unlikely that an individual who is using Anabolic Steroids would be interested in using a systemic androgen inhibitor, there are some topical androgen inhibitors available which have a minimal systemic impact. These topical androgen inhibitors have been used to decrease the effect of anabolic steroids on the skin in a targeted fashion. However, there is not much research on this approach and minimal evidence about its efficacy.

OVER THE COUNTER MEDICATIONS

Over The Counter (OTC) Acne Products
Over The Counter (OTC) Acne Products

For mild cases of steroid induced acne, Over The Counter (OTC) medications that contain benzoyl peroxide, salicylic acid and other antibacterial/keratolytic compounds may be helpful in improving acne symptoms. These medications are generally most effective with mild, non-inflammatory (Acne Types: 1-2) and are less effective against moderate and severe acne symptoms (Acne Types: 3-4).

Common Anabolic Steroids and Their Chemical Structures

Commonly Androgenic Steroids
Common Anabolic Steroids
Chemical Structures of Common Anabolic Steroids (Fragkaki)
Chemical Structures of Common Anabolic Steroids (Fragkaki)

References

A league of their own: demographics, motivations and patterns of use of 1,955 male adult non-medical anabolic steroid users in the United States. Cohen, et al. 2007.
Adverse health effects of anabolic androgenic steroids. Amsterdam, et al. 2010.
Anabolic steroid abuse: Psychiatric and physical costs. Talih, et al. 2007.
Pharmacology of anabolic steroids. Kicman. 2008. 
Social capital: Implications from an investigation of illegal anabolic  steroid networks. Maycock, et al. 2007.
Structural characteristics of anabolic androgenic steroids contributing to binding to the androgen receptor and to their anabolic and androgenic activities: Applied modifications in the steroidal structure. Fragkaki, et al. 2009. 
Control of Human Sebocyte Proliferation in Vitro by Testosterone and 5-DHT is Dependent on the Localization of the Sebaceous Glands. Akamatsu, et al. 1992.