Acne in Athletes: Causes and the Link with Performance Drugs

Spots on the back, shoulders and chest are so common in gyms that many people regard them as part of the territory. Some of this acne is ordinary and mechanical; some, however, is a visible sign of hormonal disruption caused by performance-enhancing drugs. Telling the two apart matters, because the second type can be severe, scarring and a marker of wider health risks. Our editorial team explains the causes and the sensible routes to treatment.

How acne develops

Acne vulgaris is a disorder of the pilosebaceous unit — the hair follicle with its attached oil gland. Four processes interact: increased sebum production, blockage of the follicle opening by skin cells, colonisation by the bacterium Cutibacterium acnes, and inflammation. The result ranges from blackheads and whiteheads to inflamed papules, pustules, nodules and cysts.

Sebaceous glands are highly sensitive to androgens. Testosterone is converted within the skin to dihydrotestosterone (DHT), which stimulates the glands to grow and produce more oil. This is why acne peaks in adolescence and why any substance that raises androgen activity can provoke it.

Genetics also plays a part. People with a family history of severe acne are more likely to develop it themselves, and they tend to react more strongly to hormonal triggers.

In athletes, the trunk is often affected as much as the face. The back, shoulders and upper chest have a high density of sebaceous glands and are exposed to sweat, tight clothing and equipment.

Everyday causes not linked to drugs

Not every athlete with spots is using anything. "Acne mechanica" is caused by pressure, friction and heat — think shoulder pads, helmet straps, rucksacks and tight synthetic kit. Sweat trapped under clothing softens the skin and encourages follicular blockage.

Other non-pharmacological contributors include:

• delaying showers after training and leaving sweaty kit on;
• heavy, occlusive skincare or sun creams;
• high-glycaemic diets, which some studies associate with worse acne;
• whey protein supplements, linked in case series and small studies to acne flare-ups in susceptible individuals;
• stress, poor sleep and, in women, polycystic ovary syndrome.

Pityrosporum (Malassezia) folliculitis is a frequent mimic. It produces itchy, uniform small bumps on the chest and back, is caused by yeast rather than bacteria, and responds to antifungal treatment rather than standard acne therapy.

These causes usually produce mild to moderate acne. They improve with simple hygiene changes, a review of supplements and over-the-counter treatments such as benzoyl peroxide.

Acne and performance-enhancing drugs

Anabolic-androgenic steroids (AAS) are the best-documented pharmacological cause of acne in sport. Surveys of users consistently list acne among the most common side effects, and dermatologists describe a distinctive pattern: sudden onset or dramatic worsening in an adult, concentrated on the back and chest, sometimes with large painful nodules.

The most severe form is acne fulminans, an explosive, ulcerating acne that can be accompanied by fever, joint pain and raised inflammatory markers. Case reports have linked it repeatedly to testosterone and other androgens. It is a medical emergency for the skin and requires specialist care.

Because acne is so visible, it is sometimes the first sign that prompts a doctor to ask about AAS use. Other clues include stretch marks over the shoulders, gynaecomastia, testicular shrinkage and abnormal blood tests such as high haematocrit or low HDL cholesterol.

All AAS are Class C controlled drugs in the UK and prohibited at all times under the World Anti-Doping Code. Possession for personal use is not currently an offence, but supply and importation are.

Treatment options in the UK

NICE guidance (NG198) recommends a stepwise approach. For mild to moderate acne, first-line options are 12-week courses of topical combinations such as adapalene with benzoyl peroxide, or tretinoin with clindamycin. For moderate to severe acne, an oral antibiotic such as lymecycline or doxycycline may be added to topical treatment for a limited period.

Severe, nodular, scarring or treatment-resistant acne should be referred to a consultant dermatologist, who may prescribe oral isotretinoin. This is highly effective but requires careful monitoring, and in the UK it is prescribed only by specialists under strengthened safety measures introduced by the MHRA.

If acne is driven by AAS, treatment works far less well while the drugs continue. Stopping them is the single most important step, and doing so under medical supervision allows the doctor to check hormones, blood count and heart health at the same time.

Scarring is permanent, so early treatment is always preferable to waiting. Squeezing or picking deep lesions increases the risk of both scars and dark marks.

Prevention for people who train

Simple measures reduce mechanical and sweat-related acne considerably. Shower as soon as possible after training, change out of damp kit, and wash training clothes and headbands frequently. Breathable, moisture-wicking fabrics help on the trunk.

A gentle cleanser with benzoyl peroxide or salicylic acid on the back and chest is inexpensive and effective. Choose non-comedogenic sun cream for outdoor sports and avoid heavy oils on acne-prone areas.

If acne began or worsened after starting a new supplement, a trial without it for six to eight weeks is a reasonable experiment. Whey, high-dose B vitamins and products of uncertain composition are common suspects; the latter may contain undeclared steroids.

Finally, see a GP if acne is painful, leaving marks or affecting your mood. Acne has a well-documented impact on self-esteem and mental health, and effective treatment is available.

Editorial team's conclusions

Acne in athletes has many causes, from sweaty kit and friction to diet and supplements. Most of these are manageable with good hygiene and standard topical therapy. Sudden, severe trunk acne in an adult, however, should raise the possibility of androgen use, which brings risks well beyond the skin. Honest discussion with a GP opens the door to effective treatment and to checking the rest of the body as well.

You may also want to read who should not take isotretinoin, how anabolic steroids affect the liver and lipid profile, and whether whey protein really worsens skin.

References

1. Zaenglein AL, Pathy AL, Schlosser BJ, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2016;74(5):945–973.
2. National Institute for Health and Care Excellence. Acne vulgaris: management (NICE guideline NG198). London: NICE; 2021.
3. Melnik B, Jansen T, Grabbe S. Abuse of anabolic-androgenic steroids and bodybuilding acne: an underestimated health problem. J Dtsch Dermatol Ges. 2007;5(2):110–117.
4. Pope HG Jr, Wood RI, Rogol A, et al. Adverse health consequences of performance-enhancing drugs: an Endocrine Society scientific statement. Endocr Rev. 2014;35(3):341–375.
5. Williams HC, Dellavalle RP, Garner S. Acne vulgaris. Lancet. 2012;379(9813):361–372.
6. https://steroidelegalkaufen.com/produkt/anapolon-abdi-ibrahim-trkei-40-tabletten-x-50-mg/