Case Study: Hormonal Acne, Gut Dysbiosis, and Nutrient Deficiencies

Patient Overview

M.Z. is a 32-year-old female who presented with persistent cystic acne along her jawline, significant premenstrual syndrome (PMS), mood instability, and occasional episodes of binge eating related to extreme hunger. She also reported intermittent diarrhea, low libido, fatigue, and episodes of brain fog.

Her medical history included five years of oral contraceptive use (now discontinued for one year), prior Accutane therapy, and no diagnosis of PCOS despite ultrasound evaluation. She follows a strict Paleo diet and runs 30–40 miles weekly as an endurance athlete.

Clinical Findings and Laboratory Assessment

Basic Labs:

• Fasting insulin: 10 μIU/mL (elevated)
• Fasting glucose and A1c: normal
• Total cholesterol: 132 mg/dL (low)
• White blood cell count: 9.8 x10³/μL (mildly elevated)
• Vitamin B12: 384 pg/mL (low-optimal)
• Homocysteine: 13 (high) umol/L
• Homozygous MTHFR C677T polymorphism
• Zinc: 62 ug/dl (low)

Hormone Panel (DUTCH Plus Test):

• Elevated free and total cortisol (especially AM) 
• low estradiol with poor estrogen detox
• Normal testosterone
• Elevated progesterone

Comprehensive Stool Test:

• Evidence of intestinal dysbiosis with low diversity of commensal bacteria
• Elevated markers of fungal overgrowth (Candida spp.)
• Mild elevation in fecal zonulin (suggestive of intestinal permeability)
• Slightly reduced secretory IgA, indicating compromised mucosal immunity

Functional Interpretation

Despite an outwardly “clean” Paleo diet, M.Z. showed evidence of micronutrient deficiencies, gut dysfunction, and hormonal dysregulation — all contributing to her acne, PMS, and fatigue.

Likely contributing nutrient deficiencies:

• Vitamin A: Essential for epithelial differentiation and sebum regulation; deficiency linked with hyperkeratinization and acne.
• Zinc: Crucial for skin healing, immune regulation, and vitamin A metabolism; endurance training may increase losses.
• Vitamin B12 and Folate: Suboptimal due to MTHFR variant and possible malabsorption from gut dysbiosis.
• Vitamin K2: Low intake due to limited grass-fed dairy and fermented foods; impacts skin elasticity and synergy with vitamins A and D.
• Sulfur-containing amino acids (methionine, cysteine): Likely low due to inadequate protein variety; affects collagen and glutathione production.
• Vitamin E and Selenium: Antioxidant nutrients depleted by oxidative stress and poor absorption; important for immune and skin defense.
• Omega-3 fatty acids: Likely suboptimal ratio given high training load and Paleo restrictions; contributes to systemic inflammation.
  

Assessment Summary

Key Imbalances Identified:

• Hormonal: Low estrogen, elevated cortisol, PMS symptoms
• Gastrointestinal: Dysbiosis with fungal overgrowth, intestinal permeability
• Metabolic: Relative under-fueling and overtraining contributing to elevated cortisol and dysregulated insulin
• Nutritional: Multiple mild-to-moderate micronutrient deficiencies impacting skin and hormone metabolism

Treatment Plan

1. Nutrient Repletion & Dietary Optimization

• Caloric Support: Increased total caloric intake from ~1,800 → 2,500–2,800 kcal/day to meet energy demands
• Carbohydrate Repletion: Raised intake from 120–150 g → 280–300 g daily to improve cortisol regulation and hormonal balance
• Protein & Fat Balance: Emphasized diverse protein sources (grass-fed beef, eggs, fish) and inclusion of nutrient-dense fats

Specific Nutrient Repletion Strategy:

2. Gut Restoration Protocol

Phase 1: Antimicrobial + Yeast Protocol (8 weeks)

1. Botanical antifungal: Caprylic acid, oregano oil, and berberine blend
2. Biofilm disruptor: Biofilm defense
3. Digestive support: Betaine HCl + enzymes with meals

Phase 2: Rebuild & Re-inoculate (8 weeks)

• Probiotic: Soil-based organism (e.g., MegaSporeBiotic)
• Prebiotic support: Jerusalem artichoke, leeks, garlic, cooked/cooled starches, PHGG supplementation to start with a slow introduction)
• Mucosal repair: L-glutamine (5–10 g/day), zinc carnosine, and aloe vera extract

3. Hormone & Stress Support

• Adaptogens: HPA Balance (Ashwagandha, Rhodiola, etc.) for cortisol modulation
• Hormone support: FemGuard Balance (vitex, DIM, calcium d-glucarate) for estrogen metabolism
  Lifestyle: Daily meditation (10 min), HRV-based training adjustments to reduce overtraining stress

4. Skin-Focused Lifestyle Additions

• Hydration: ≥2.5 L/day, trace mineral drops for silica support
• Sleep hygiene: 8–9 hours, consistent bedtime
• Environmental toxin reduction: Avoid seed oils and endocrine-disrupting chemicals in skincare. Start small and create ONE goal a month to make this attainable.

Outcomes (After 3 Months)

• Acne: >90% resolution of cystic lesions, reduced inflammation, minimal residual scarring
• Energy & Recovery: Improved stamina, reduced post-run fatigue, still has afternoon fatigue but continues to work on arranging food intake and workouts to support energy levels. 
• GI Health: Normal bowel movements, resolution of bloating and diarrhea
• Hormones: PMS symptoms significantly reduced; mood stability improved
• Lab Improvements:
  • B12 increased to 956 pg/mL
  • Homocysteine improved to 8.2 umol/L
  • Zinc improved to 98 ug/dl 
  • WBC normalized to 5.4
  • Insulin decreased to 4.8 μIU/mL
  • Cholesterol normalized to 168 mg/dL

Overall: M.Z. reported clear skin, improved cognition, stable energy, and better overall hormonal resilience. Still had some acne during end of luteal phase of cycle that we will continue to work on. 

Clinical Lessons

This case underscores the importance of evaluating gut function and nutrient sufficiency in hormonally driven skin conditions. Acne in this context was not purely dermatologic, it reflected a systemic imbalance rooted in nutrient depletion, dysbiosis, and chronic stress physiology.

Functional restoration through targeted nutrition, gut repair, and cortisol modulation can yield transformative outcomes without pharmaceutical intervention.