S1 E20: Getting to the Root Cause of Acne with Robyn Johnson, RD


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Amanda: Hey, this is Amanda, women’s health dietitian.
Emily: And I’m Emily, nutritional therapy practitioner.
Amanda: And this is the Are You Menstrual? podcast where we help you navigate the confusing world of women’s hormones and teach you how to have healthy periods.
Emily: Each week we will be diving into a different topic on women’s health and sharing our perspective using nutrition, female physiology, and metabolic health.
Amanda: Our goal is to help you wade through conflicting health information and empower you on your healing journey.
Emily: We hope you enjoy it.

Amanda: In this episode, we’re discussing a topic I think most women can relate to, and that’s acne. I’m here with my friend and colleague Robyn Johnson, aka @nutritionbyrobyn on Instagram. Robyn is a Functional Medicine Dietitian Nutritionist. Her passion of using food and lifestyle as medicine found her after a personal battle and triumph with psoriasis. She specializes in helping women optimize their hormones, gut, and skin by finding the root cause to their symptoms. Robyn runs a virtual private practice and is the creator of the Clear Skin Lab. Robyn believes healthcare should be individualized and that starts with each person understanding how their bodies work and what their body truly needs to thrive. So thank you for being here, Robyn, I’m really excited to interview you.

Robyn: I am excited to dig into this.

Amanda: Robyn and I have actually known each other for a little while now. I feel like, what like a year online maybe? 

Robyn: Yeah, I think we really bonded over vitamin A.

Amanda: Yeah, we both went through the Root Cause Protocol, so we’re both big mineral nerds and pro retinol. Robyn has been inside my membership. She’s taught the women in there about acne. You have a great Instagram, @clearskinlab or the actual course that you have. But I’ve learned a lot. I’ve learned a lot about acne from Robyn and I know if any of you have been listening to the podcast for a little bit, you know I struggle with acne a lot. That was a huge part of the reason why I even took the birth control pill in the first place. And something that I feel like still goes in waves. Like, I went through your course, Robyn, and it helped me, I don’t know if you can tell with my skin, but it really did help like using different topicals.

Robyn: Yeah, I DMed you and was like, okay, your skin looks really good right now.

Amanda: I’m like, well, it’s because of the recommendations in your course. There’s always more that you can learn. And like sometimes, you know, I’m obviously, like, my whole world is minerals. And it’s like, you can only get so deep into a topic and then you’re like, I’m just gonna refer out. That’s kind of how I feel with acne and how deep it can get, especially when people have tried a lot of different things. And so today, I’m excited because we’re going to dig into the different types of acne, maybe like a little bit on face mapping, which I think will be interesting, possible root causes of acne, and how that is going to change how you’re going to treat that. And then things like Accutane, spironolactone, things that we see women using all the time to treat that. So let’s dig into the types of acne first and I feel like that goes right along with their root causes.

Robyn: Absolutely and that’s kind of why they’re named the way they are. So I kind of separate acne causes or types into five main categories. So we have hormonal—meaning some sort of hormone mechanism is driving the reason for the acne lesion—inflammation, infection, irritation, and stress. And the hardest part is you can have more than one at the same time. And in fact, I would say more severe acne cases typically are a combination of like hormonal and inflammation and maybe even infection. So while I think understanding the acne type and your root cause is important, and it can empower you on what to focus on more, every type still needs the same foundation, which is what you teach, right? I mean, it’s getting your minerals optimized, it’s looking at blood sugar, and balanced nutrition and adequate nutrients and vitamins and managing stress. So I think those acne types can be helpful when it comes to details. But it’s not where I would have someone start, like meaning I wouldn’t say take DIM to target estrogen or some sort of hormone, I would really encourage people to start building their foundation first.

Amanda: And I think that makes sense. And we were kind of chatting before we hit record about how, you know, everyone, whether it’s an acne issue or hormone issue, we tend to think that ours is different, right? We’re like, nope, but my acne is different because it shows up on this part of my face, or it looks like this, or it only happens after this. And while I do think it’s, I mean, no one knows your body like you do, obviously, I feel like that’s true for everyone. But when I think of acne, it’s, it’s one of those things that it’s so heavily marketed towards women to where we’re, like, okay, if this is happening to you then try this product or remove this food or do this specific protocol. Whereas, I mean, I look at it acne as more of a symptom and it’s your body, you know, communicating with you and telling you something is off. So it’s, it’s difficult and while we might want to be like, okay, for hormonal acne, do XY and Z, it’s, like, there’s an imbalance and it’s usually coming from a much deeper place.

Robyn: Yeah, you’re right. And I mean, like you said, that foundation still needs to be built, but it is still helpful to know what your root cause is. For example, if someone has acne let’s say on their forehead and on their back, and they’re doing all the things that are hormonal acne…they might not see much of a change, because that might mean the type or the location tends to be more gut-related and infection-related. So it’s examples like that where your type of acne and your root cause it will impact maybe the details of what you need to do, but that doesn’t ever mean skip the minerals, skip the blood sugar balancing nutrition, skip the stress support, you never…you always start with that. And then you can fine tune with the details of your acne type.

Amanda: Do you want to give, and that was a really helpful example I feel like. Do you want to give an example for each of the types?

Robyn: Yeah, in terms of how to maybe think through that? 

Amanda: Like how it might appear?

Robyn: Yeah. So first of all, we do have a free acne quiz that takes people through this, so it will guide you to your most dominant type. And I emphasize that because you might have more than one, which is I know so frustrating. For hormonal acne, I would typically say mostly chin and jawline, it might be cystic, you might notice it after certain foods, like high amounts of, depending… high amounts of dairy, cow’s dairy, high amounts of sugar. Now, there are ways you can fix that. So I don’t want people to run away from those foods. But those are some initial thoughts. Infection acne I typically see it more along the forehead, potentially back chest shoulders, it can still be on the cheeks, you might or might not have some gut issues. Infection acne will often either improve or worsen with topical or oral antibiotics. Stress acne is typically identified after stressful events, or it’s kind of like you’ve ruled out the other things. And you can tell it’s when stress pops up in your life—everyone pretty much experiences that in their life. Irritation is usually more topical related, so it’s like an allergy to a product or an ingredient or your pillowcase or your laundry detergent. Or you’re wearing hats and it’s sweating along the hairline, stuff like that. Usually people have identified that before they end up getting to me. And then inflammatory acne is usually involved, period. I mean, unless you’re just having like little pustules, or white heads, usually inflammation is irritated skin, red or purple, usually cheek, jawline, forehead, it can be anywhere. So that one most, most of the time people also have an inflammation level to some extent.

Amanda: Yeah, especially if it’s probably more like red and everything, that makes sense. And I feel like some of those could be even, it just shows you how different they can be. But it’s like a lot of them can appear in the same spot. So the next thing I wanted to go into is that face mapping post that you did on Instagram that everyone loved. I know I shared it in my stories, because it’s a question that I get a lot when it comes to acne is, well, if it’s here or here on my face, does it, this face map says it means this. So should I only focus on that? So do you kind of want to, and I’m gonna link the face map and other posts that Robyn did in the show notes. But do you want to kind of walk us through face mapping? Is it helpful? Is it accurate? How do you, or do you use it? Or do you not recommend using it with clients?

Robyn: Yeah, I feel like we have to touch on this even though it’s a topic I did not want to make a post about, but it’s our most, one of our most asked questions, open email, that people want to know about the face mapping. And so the reason I don’t love talking about it, because I don’t want to over simplify how complex acne really is. And like you said, it’s really a symptom of something else. And so I think a lot of those face mapping maps make it seem so simple, like, oh, if I have a pimple between my eyes, I need to do a liver cleanse or I need to take a liver supplement, and it just skips the big picture. However, that being said, I still think paying attention to the location of your lesions can guide you to maybe what to consider more of or what to give more attention to or even just what to experiment with in some ways, but never skipping the foundational work. And so for example, I’ve mentioned this earlier, but if you what I want one of the most common ones and I’m sure your audience sees this is chin acne, jawline acne, especially pre-period might be cystic or like nodules, mainly like deep and painful. Those are all pretty hormonal type scenarios. And in that case, I wouldn’t say you need to go directly take DIM or directly take some hormone balancing supplement, but rather, yes, it may be coming from a hormonal signal. Yes, it clearly is linked to your cycle if it’s every cycle pre-period.

So what, what do you do? You start with a foundation. So you start with everything you’ve talked about on all your podcasts. You start with minerals which help make and signal hormones. You start with repleting nutrients, like vitamin D, vitamin A. You start with balancing your blood sugar. And we’ll talk about time expectations later in this podcast, but give that time, and the hormonal mechanisms that are often triggering those hormones, that are triggering acne will typically regulate and resolve the acne. 

Amanda: I think, too, it can be confusing when you look at one of those face maps, because, say you do have that hormonal area, like the chin and the jawline. But it might, like, yeah, it could be hormonal, but what if that person has a ton of gut issues that are driving up estrogen, you know, it’s or stress hormones. So it’s like, I think this is why it is so difficult to just say like, oh, it’s just hormonal, because that person could work just on DIM, just on like taking things that are going to reduce that, but it might not work long term. Or they’re taking those supplements forever, because the issue is really in their gut and like poor digestion. So I think that’s like, you know, that’s why the face mapping can be really confusing for people. I always see them and they’re always a little bit different. I really like yours, because it doesn’t just say like, like, it’s like, you know, back and chest, gut infections, inflammation, sweat, like it’s not just like, liver, gallbladder, like large intestine, small intestine… I feel like that can be it’s kind of like, well, what do you do from there? What do you think? Like, what’s the most common type of acne that you see in practice?

Robyn: It’s definitely, it’s actually probably a tie between inflammation and infection. And even our quiz results. Those are like the top two.

Amanda: Really? I feel like people wouldn’t always think of infection.

Robyn: Wait, did I say…? I meant to say hormonal and infection. Yeah, hormonal, hormonal, and infection are like the top two.

Amanda: So talk about the infection a little bit, because I don’t know if everyone’s really going to know what that means. What’s going to be the main driver, like an actual infection on top of their skin?

Robyn: It can be that, or it can be like a gut infection or even a systemic infection. But topically there can, I mean, the skin has such a big microbiota, just like the gut, and the gut really sets the stage for what’s happening on the skin. So I mean, this is why like dermatologists will often give topical antibiotics but they also give oral antibiotics, and both can clear people’s skin, but it’s because it’s, you know, suppressing the infection. Topically though, there can be bacterial infections, there can also be fungal infections, both can which irritate the skin. And if you have a systemic gut infection, bacteria-wise like staph, or you’ve got something like H. Pylori, something that’s essentially keeping your gut microbiome out of whack, that can show up on the skin. And like I said, that’s because the gut is really setting the stage for the microbiota on other areas of the body.

Amanda: And what would, like, fungal type, like, a fungally-driven acne look like?

Robyn: Yeah, that one is, first of all, super hard to actually diagnose because even the topical testing is not super accurate. So the best way to really know is to trial some things topically and see what happens. But from what I see, topically, it’s not, it’s usually more like little small bumps. And sometimes it’s even just texture. People don’t necessarily see it as much as they feel their skin have those little bumps, and it can show up anywhere. It doesn’t have to just be the forehead, it, those topical infections can be anywhere on the skin.

Amanda: Yeah, I tend to see a lot of that happen as women start working on mineral balance and protocols and stuff. It’s like, it’s almost like their body’s trying to like purge it.

Robyn: For sure, and this is why and you heard me emphasize this inside the course—acne really needs a two-pronged approach. The inside out is so huge, which is what we talk about all the time with clients, but the topical lens needs attention too. And I think in the conventional world we only pay attention to it topically, and then sometimes in like holistic world, we only pay attention to it internally. But it, it truly needs both. And as you’ve noticed with your skin, like, once you added different topicals it kind of leveled it up even more.

Amanda: Yeah, and because it’s, I mean, realistically, like we’re always going to be going through some season. Like, my skin is definitely very stress-related acne at this point. For myself it was definitely hormonally and infection-driven before, because antibiotics did work for my skin and topical antibiotics, for the most part. And so it’s, it’s like one of those things where I’m stressed, didn’t get enough sleep, anything like that. Not eating enough, you know, you’ll immediate, that’s immediately where I see it. That’s how I first know that I’m like, okay, gotta slow down, gotta chill out. But using some of the mandelic acid, don’t even know what it is, so I’m just, like, Robyn told me to take it so I’m putting on my skin. Even just using that and adding that in, like I did have a purging at first which I was like, oh, this sucks, but it’s, you know, just reminding yourself that it’s gonna be worth it. And now it’s like very consistent and I don’t really have to worry about it, which is really cool. But it’s like, I did need a little bit more support than what I was currently giving my skin. 

Robyn: Well and even if, so if you keep up with things like that, like mandelic acid is an active and that can help with exfoliation. And if you incorporate that into your routine on a regular basis, you’re preventing that pore, that follicle from being congested with sebum and then showing up as acne. But if you in a way just kind of keep that flowing, it is reducing the likelihood of that building up and turning into a zit.

Amanda: Yeah, so I think like me and a few other women that were on the call when you taught that class for my membership, we all had kind of similar, like, just like small whiteheads, like, nothing super crazy. And you’re like, if you probably just use something topically as like an exfoliator, I believe you referred to it as, and like that would get rid of it. And it was just, it’s just crazy because you think that you do all these things to take care of your skin, that you’ve tried everything, and then it’s something as—I would say simple because it’s, I mean, it’s two ingredients in the product, it’s nothing crazy—as simple as that. I’m like, okay, so I, my skin literally just needed exfoliation.

Robyn: And I think highlighting the fact that you went through a purge is important, because that’s so normal. And we, we actually have like entire lessons in our course on purging because it’s just part of it. It’s almost like, let’s celebrate it because it means you’re pushing gunk out. But I think a lot of people freak out and think that whatever they’re doing is not working for them or they’re reacting to it. And there are certainly cases where you might not tolerate a product. But pushing through that purge is important. And then keeping those, that sebum, or that follicle open, so that sebum doesn’t build up is just going to help you maintain the clear skin.

Amanda: And it’s the same thing that happens with hormones. Like I think about even, I’ve even had people message me that then, they haven’t gone through my course, we’ve never worked together, they just follow the recommendations that I give on this podcast and on Instagram… And I’m sure you’ve gotten a million from your mineral mocktail guide that you have. But people are like, oh, I’ve been adding adrenal cocktails, I’ve been eating regularly, all this stuff and like, my skin’s freaking out, my periods are crazy. And it’s, they’re going through that like estrogen kind of wave. I call them estrogen waves of like, you know, estrogen is up and then it’s down. But I know that that happens with skin too. So can you talk a little bit about like, why this starts happening, especially when you’re doing the internal and external approach to this whole like purge. Like, it’s like an internal and external purge. It’s kind of crazy. Why does it happen? And like, what, what can women do to help it? 

Robyn: Yeah, so I would say topically, it’s because you’re open…well, depending on what products you’re using, whether it’s adding oils for the first time, which purging is very common with being new to oils, or adding actives, like, maybe that’s a retinoid or a quality vitamin C or an acid, mandelic acid, salicylic acid…you are probably going to pull up sebum that’s been in the follicle for a long time. Acne starts building deep in the hair follicle before it ever actually shows up as a zit. And so typically adding some of those products is pulling up sebum that’s been in there, going to show up as acne, you’re pulling that out, and that’s what we consider a purge. And that can last weeks, I mean, that can last like six weeks for people. So that’s kind of what’s happening on a topical lens.

And then internally, when we start adding minerals and we start adding nutrients like vitamin A and vitamin E, which are big ones we talk about in the program, you’re pulling things from the tissues like estrogen and iron. And when you start moving hormones and iron around the body, you may temporarily feel worse, not just in skin. but I mean, you’ve talked about period symptoms, pain, lots of things. But because, as I mentioned earlier, hormones can be one of the big triggers, one of the mechanisms that triggers the acne, when you start moving that stuff and you’re getting estrogen in your blood, I mean, that that can trigger temporarily worsened acne. 

Amanda: And I think that it’s, with the skin stuff, especially. I mean, if you struggle with your skin, it’s so hard when it gets worse. You want to freak out because you’re, you’re probably, you’ve probably, you’re doing everything, I’ve tried everything or feel like you have to in order to improve it. Same thing with your cycles. Like if you already deal with period pain, it really sucks when you’re making all these changes and you see some improvements in other areas, but your periods are still painful. And I do think sometimes it’s something deeper, you know, even with mineral stuff. It’s like, maybe there is a deeper digestive issue that we need to deal with. And I’m sure that obviously with infection being one of your most common types of acne, I’m sure that’s very, very common, but it just shows you how powerful those changes can be. That yeah, that’s, I’m not, I’m not surprised. So my skin was I think it was almost two months that I purged for but it was like baby purge. And then all of a sudden, I was like, I think I’m purging and then it was like, oh, no, you’re definitely purging. But now it’s like very consistent, which is nice. 

Robyn: I’m glad you had some tools to get you through that. And some, sometimes the purging is worse than others. And I really think that depends on the stage of someone’s just total health, but also where their, where their skin is at, because sometimes it’s it can be an actually pretty severe purge where they’re getting more cystic more painful stuff. And so much of the hormonal acne triggers are related to the, the ratios I would say or the, the levels between different hormones. So for example, if you have low progesterone compared to testosterone, you might not even have high testosterone, but simply having low progesterone in, in ratio to that can trigger acne because most of hormonal acne is driven by androgens, it’s driven by testosterone. It can come from too low or too high progesterone. And with estrogen, it’s typically the ratio between progesterone or testosterone. So that’s where it gets so tricky, because you can’t just like test one level and, and know where it’s coming from. It’s really understanding how these hormones work together, because they really do communicate.

Mid-Episode Ad 20:18 
Hey, Amanda here, just giving you a quick break, hopefully a break for your brain in the middle of this podcast episode to remind you that if you haven’t gone through our free training, Optimizing Hormone Health Through Mineral Balance, we really do recommend starting there. And the main reason for that is because you’re going to hear us say things like mineral foundation, having a solid foundation, are you putting the foundations in place, especially as we get deeper and deeper into different hormonal topics and specific imbalances in the body. The mineral foundation is always going to be so essential. So if you haven’t watched the free training, you can find it in our show notes or you can go to hormonehealingrd.com and it’s going to be right on that front page there. But we really recommend starting there so that you can understand how is your current mineral status, how do you assess this, and how to get started with all that just so you can get as much as you possibly can out of the rest of the podcast episodes. But that’s it. I hope you enjoy the rest of this episode.

Amanda: And nothing happens in isolation in the body. So I guarantee you that someone that thinks they’re struggling with hormonal acne, it’s like, okay, well, how are your bowel movements? How’s your digestion? Are you bloated? Like, how’s your sleep, energy, all that kind of stuff. I feel like if you really sit down and think about it, I’m sure that there’s other things going on. But it’s, it’s just easy when it’s like, oh, I have acne on my chin, it’s hormonal, you know, that, then you tend to want to focus on it. But even, I just think of like, you know, if someone’s got a lot of excess iron going on, or say maybe they add in like adrenal cocktails, and they’re using like beef liver, eating it or taking a supplement, and they start to notice, like, they’re starting to get rid of some of that excess iron. I mean, yes, it’s iron, but it’s still, it can still trigger hormonal-looking acne for sure. How long does it typically take? I know, we kinda talked about this, but do you want to outline… You have a really good post on this on Instagram, too. It’s like a visual post. But how long does it take to see improvements in skin? Or like, what is that, like, you know, kind of purging and then getting better phase look like? 

Robyn: The short answer is, it’s never fast enough. Because with skin, I mean, I personally have been through major psoriasis. So I know, like the desperation of just like, please just make it go away faster. And it’s conflicting when someone wants to take a natural approach, but they also want their skin cleared yesterday. So we I’m really big on proper expectations. And so typically, what I say is, what, in the first one to four weeks of making changes, most of what you’re going to see is probably texture related, like topically. Especially if you’re new to properly hydrating your skin and moisturizing your skin and cleansing and all those things. So usually, there’s not like massive changes within the first month. Now, depending on what your diet looks like, or inflammation levels that might be unique, you might see things calm down faster. Five to eight weeks is typically where I expect people to see reduction in new lesions, more hydrated skin, and reduction of visible inflammation. And then 9-12 weeks is typically when we would say expect the longer-term stuff.

And I’ll even tell you some of my one-on-one clients took seven months to see their skin turn a corner. And this is where it can be so hard. Because you’re doing the things, your skin got worse from purging, you’re still taking action, and it’s not really doing much. But skin takes time. It’s like one of the last things to respond. You might have better energy, your periods might be improving, your digestion might be improving, but skin might be the last to change or turn a corner. And it’s so frustrating when that’s the only thing you want to change and it’s the last one. But that’s just honestly how it is. And we give a lot of tools to help speed that up as much as you can. But I also don’t want to give false hope—it really just will take time.

Amanda: Yeah, and it’s, I just, think about it, like, if you’ve dealt with skin issues your whole life, if it takes you a year to fix it and then have consistency, and not even to have better skin but to know what to do… I think that’s one of the coolest things about the Clear Skin Lab, that program that you have, is because, and I’m sure obviously clients are going to get this working one-on-one as well. But it’s like, you know, if something comes up, like if you think, oh, I think this is infection-related. You can go look under like the fungal or the bacterial sections and look at here’s, I’m gonna try these and see if my skin responds to this. Or if you have that history of maybe yours was like infection, hormonal, and then you know what fixed it and then maybe it starts to pop up in the future. It’s not like you don’t know what to do. You’re not back at square one. And I think it’s the same thing with hormones and everything and like digestive gut health, too. So you have to just understand how those systems of the body work at least a little bit foundationally. And then you can really get like, okay, so this is what I think might be going wrong, I’m actually going to pay attention to my body instead of just freaking out about this symptom, and then you can kind of move forward. So it’s like, it could be a year, seven months, but it’s like, then you don’t really, you don’t really have to worry about it after that.

Robyn: And I would say, if someone feels like they’re doing all the things, testing can really help. Because in my experience with one-on-one clients, the ones that have taken the longest typically either have a pretty big gut imbalance, infection, or something going on in the gut, or the clients that I’ve seen take a long time have really high calcium levels in tissue, hair tissue, mineral tests, so stuffs’ going on with thyroid at the cellular level. Or super low ceruloplasmin levels, which we can get into some discussions about that and acne. But I do think it helps. It helps me help the client set an expectation if I can see kind of how off certain levels are, and know what we might expect in terms of time.

Amanda: Yeah, I think it’s, that’s like the beauty of testing if you can do it. And if you’re, and a lot of people are like, but I’ve already spent so much money on my skin, it’s like, but it’s, you know, everyone thinks their skin is unique to them. Like, it is, so then like, if you get, if you do some sort of testing, then you’ll be able to see what’s actually going on. So what, what would you say as far as, because I know we talked about like foundations, right, setting a solid foundation so that you can eventually see those changes in your skin. What micronutrients do you think are the most important for skin?

Robyn: Yeah, I mean, honestly, there’s so many we could go down rabbit holes on. I would say…I think I’ll answer it in terms of what micronutrients do I think don’t get enough attention. Because I, you know, we do know zinc, magnesium, there’s a ton that are pretty popular for acne, you can like, you know, you do the average Google and that type of stuff shows up. But I think there are a lot that are dismissed. One of the big ones being vitamin A. And so, I mean, there’s some really interesting and really high-dose studies with vitamin A. And this actually kind of connects to Accutane too, but we need vitamin A for proper thyroid function, for proper utilization and recycling of i

Amanda Montalvo

Amanda Montalvo is a women's health dietitian who helps women find the root cause of hormone imbalances and regain healthy menstrual cycles.

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