Testosterone Enanthate and the Skin: Acne and Oiliness

Breakouts on the back, shoulders and face are one of the most noticeable signs that the level of androgens in the body has changed sharply. For dermatologists, "bodybuilders' acne" has long become a separate clinical topic. Our editorial team explains why testosterone enanthate makes the skin oilier, how steroid acne differs from teenage acne, and what medical sources say about treatment and risks.

The Skin as a Target of Androgens

The sebaceous glands are one of the organs of the human body most sensitive to androgens. Their cells, sebocytes, have androgen receptors and enzymes that convert testosterone into the much more active dihydrotestosterone (DHT). It is androgens that trigger the active work of the sebaceous glands during puberty, and that is precisely why acne is a typical problem of adolescence.

When the level of testosterone rises, sebocytes divide faster and increase in size, and the glands produce more sebum. The composition of the secretion also changes: the proportion of linoleic acid in it may decrease, which, according to dermatological studies, promotes clogging of the ducts.

An excess of sebum by itself is not yet acne. For inflammatory elements to appear, several more factors are needed: disturbed keratinization at the openings of the hair follicles (the formation of comedones), the proliferation of the bacterium Cutibacterium acnes (formerly Propionibacterium acnes) and an inflammatory reaction.

The skin also contains enzymes capable of locally synthesizing androgens, so its reaction depends not only on the level of hormones in the blood but also on the individual sensitivity of the receptors and the activity of 5-alpha-reductase. This explains why in some people breakouts appear already with a moderate increase in testosterone, while in others — almost never.

Steroid Acne: What It Looks Like

Classic steroid acne differs from teenage acne in its localization and severity. Most often the breakouts appear on the back, shoulders, chest and neck, not only on the face. The skin becomes noticeably oily, the pores widen, and papules and pustules appear.

In severe cases, nodular and cystic elements develop that leave scars. Dermatological reviews describe in users of anabolics even rare forms — acne conglobata and acne fulminans, which are accompanied by general malaise and require systemic treatment.

Melnik and colleagues (2007) called bodybuilders' acne an "underestimated health problem," pointing out that some patients do not tell the doctor about their use of androgens. Because of this, the dermatologist may prescribe standard therapy that does not work, because the main cause remains.

• Oily sheen of the skin, enlarged pores on the face and back.
• Breakouts on the back, shoulders, chest — the typical "steroid" localization.
• Deep painful nodules, cysts, a tendency to scarring.
• Folliculitis and boils, sometimes with an added staphylococcal infection.

Besides acne, skin manifestations of an excess of androgens include seborrheic dermatitis, stretch marks due to rapid muscle growth, increased body hair growth and, in women, hirsutism.

What Its Severity Depends On

The key factor is dose. In clinical studies of replacement therapy, acne occurs but usually in a mild form. At supraphysiological levels of androgens, the risk and severity of breakouts increase substantially. The fluctuations in hormone levels characteristic of injectable esters may also matter.

The second factor is genetics and history. People who had pronounced acne in adolescence more often repeat this experience while on androgens. A family predisposition to cystic forms is an especially alarming sign.

The third is accompanying substances. Drugs derived from dihydrotestosterone or nortestosterone, as well as oral anabolics, are, according to reviews, often associated with more pronounced acne. A high-glycemic diet and dairy protein products are associated in some studies with worsening of breakouts, although the evidence here is ambiguous.

Finally, hygienic conditions matter: prolonged time in sweaty clothing, tight sportswear, contact of the skin with equipment in the gym. Friction and moisture promote folliculitis.

What a Dermatologist Can Offer

Treatment of steroid acne is based on the same principles as ordinary acne: reducing the formation of comedones, controlling bacteria and inflammation. However, effectiveness is significantly lower if an excess of androgens persists.

Isotretinoin is considered the most effective agent for severe acne, but it has its own risk profile, in particular an increase in liver enzymes and lipids. Combining it with androgens, which already change the lipid profile, requires especially careful monitoring of test results.

Independent attempts to "dry out" the skin with aggressive agents or to squeeze cystic elements often end in scars and secondary infection. Therefore deep and painful breakouts are an indication for consulting a doctor.

The Skin After Discontinuation and the Consequences

After the level of androgens normalizes, the work of the sebaceous glands gradually decreases, and in most cases the acne subsides over several months. However, scars after nodular and cystic forms may remain forever and require dermatocosmetological correction.

Stretch marks that arose against the background of rapid mass gain fade over time, but do not disappear completely. Hyperpigmentation after inflammation in people with dark skin may persist for months.

It should be remembered that the sudden appearance of pronounced acne in adulthood without an obvious cause may be a sign of a hormonal disorder, in particular an androgen-secreting tumor or congenital adrenal hyperplasia in women. Such a situation requires examination by an endocrinologist.

For a dermatologist, information about the use of androgens is not grounds for condemnation but a key to the correct approach. Concealing this fact only prolongs treatment.

Editorial Conclusions

Oily skin and acne on testosterone enanthate are a direct consequence of the effect of androgens and DHT on the sebaceous glands. The risk depends on the dose, genetics and accompanying drugs.

Steroid acne more often affects the back and chest, can be nodular and leaves scars. Standard therapy works worse as long as an excess of hormones persists.

We also recommend familiarizing yourself with our materials about testosterone and hair, about the effect of enanthate on the liver and lipids, and about tests during hormonal therapy.

References

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