Nandrolone Decanoate and the Skin: Acne and Oiliness

Nandrolone decanoate is often called a «mild» steroid with respect to the skin, because it is converted into potent androgens in skin tissues to a lesser degree. Yet dermatologists regularly see acne and increased skin oiliness in people who use it. Our editorial team has examined where this contradiction comes from and what the research says.

The skin as an androgen-dependent organ

The skin contains a large number of androgen receptors, especially in the sebaceous glands and hair follicles. Androgens stimulate the growth of the sebaceous glands and the production of sebum. That is why acne first appears during puberty, when androgen levels rise sharply.

Sebum in itself is beneficial: it protects the skin from drying out and from microbes. The problem arises when there is too much of it and the ducts of the sebaceous glands become clogged due to excessive keratinization of cells. In a clogged duct, Cutibacterium acnes bacteria multiply, which triggers inflammation.

In the skin there are active enzymes that alter androgens on site: 5-alpha-reductase converts testosterone into dihydrotestosterone, the most active androgen for the sebaceous glands. The skin is also able to synthesize androgens itself from precursors, meaning it is not only a target but also a participant in hormonal metabolism.

These features explain why supraphysiological doses of any androgens almost inevitably affect the skin. The only question is the intensity, and that depends on the specific molecule, the dose, the duration and individual sensitivity.

How nandrolone differs from testosterone

The key difference of nandrolone is related to 5-alpha-reductase. Whereas testosterone under the action of this enzyme is converted into the stronger dihydrotestosterone, nandrolone is converted into 5-alpha-dihydronandrolone, which binds to the androgen receptor more weakly than nandrolone itself. This was shown, in particular, by the studies of Bergink and colleagues (1985).

In tissues with high 5-alpha-reductase activity, the prostate, skin, hair follicles, the androgen signal from nandrolone is therefore weakened rather than strengthened. It is precisely on this that the notion of nandrolone's lower «androgenicity» compared with testosterone is based.

However, «lower androgenicity» is a relative concept. Nandrolone itself remains a potent agonist of androgen receptors and, at supraphysiological concentrations, is capable of stimulating the sebaceous glands directly, without conversion.

In addition, in real practice nandrolone is rarely used in isolation. Combining it with testosterone or other androgens negates any «skin advantage», and the dermatologist sees the consequences of the total androgen load.

Acne with steroid use

Melnik, Jansen and Grabbe (2007), in a review devoted to so-called «bodybuilder acne», described that acne is one of the most common visible signs of anabolic steroid use. The rash usually appears on the back, shoulders, chest and face, in the zones with the highest density of sebaceous glands.

The mildest form is increased skin oiliness and the appearance of comedones and small inflammatory elements. More severe forms include deep painful nodules and cysts that heal with scars. Cases of acne fulminans have also been described, a rare severe form with skin ulcers and general symptoms: fever and joint pain.

A predisposition to «steroid acne» is higher in people who had acne in adolescence and with a family predisposition. An important role is also played by the diet typical of mass gain: a high glycemic load and large volumes of dairy proteins, which, according to Melnik's hypothesis, additionally activate signaling pathways related to sebaceous gland growth.

Acne in adulthood that suddenly appeared or sharply worsened against the background of intense training is regarded by dermatologists as a possible marker of androgen use. It is not a diagnosis but a reason to raise the question and, if necessary, undergo further examination.

Other skin changes

Besides acne, an excess of androgens can cause seborrheic dermatitis, flaking and redness of the skin on the face, in the area of the eyebrows, the wings of the nose and the scalp. This condition is related to changes in the amount and composition of sebum.

Striae, stretch marks on the skin, often appear in people who rapidly gain muscle mass, especially on the shoulders, chest and armpit areas. Their appearance is explained by a combination of mechanical stretching and changes in connective tissue. Striae are persistent and only partly amenable to cosmetic correction.

Injecting oil solutions is associated with local complications: pain, indurations, and, when sterility is violated, abscesses. Oil granulomas and scars at the sites of repeated injections have been described in clinical observations.

In women, nandrolone can cause hirsutism, excessive male-pattern hair growth on the face and body, as well as increased skin oiliness and acne. Some manifestations of virilization, for example a change of voice, may be irreversible.

• acne on the back, chest, shoulders and face;
• increased oiliness of the skin and hair;
• seborrheic dermatitis;
• striae with rapid mass gain;
• local reactions and abscesses at injection sites;
• in women, hirsutism and other signs of virilization.

What to do and when to see a doctor

The most important factor determining the course of acne is eliminating its cause. If acne is provoked by an excess of androgens, topical agents can only partly reduce the rash. Doctors emphasize that without removing the cause, treatment of severe forms is ineffective.

Mild forms of acne are usually treated with agents for external use: preparations with benzoyl peroxide, retinoids, azelaic acid. Basic care involves gentle cleansing of the skin, changing sweat-soaked clothing after training and refraining from squeezing the elements.

Moderate and severe forms require treatment by a dermatologist. He may prescribe systemic antibiotics or isotretinoin. The latter has serious side effects and requires laboratory monitoring, so self-administration is unacceptable.

You should see a doctor immediately if the rash is accompanied by fever, joint pain, skin ulcers, as well as with redness, swelling and pain at the injection site. Such symptoms may indicate severe forms of inflammation or an infection.

Being open with a dermatologist about drug use is important: it helps the doctor correctly assess the cause, choose therapy and take into account possible interactions, in particular the effect of isotretinoin on lipids and the liver, which may already be altered under the action of steroids.

Editorial conclusions

Nandrolone decanoate does indeed affect the skin less than testosterone, because of the peculiarities of its metabolism by 5-alpha-reductase. But at supraphysiological doses it remains a potent androgen capable of stimulating the sebaceous glands.

Acne, skin oiliness, seborrheic dermatitis and striae are typical skin consequences of steroid use. In rare cases severe forms develop that require urgent care.

Effective treatment is possible only by taking the cause into account and under the supervision of a dermatologist.

We also recommend reviewing our articles on nandrolone decanoate and the risk of androgenic baldness, on its effect on the prostate, and on how to recognize a counterfeit of this drug.

References

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3. Kicman AT. Pharmacology of anabolic steroids. Br J Pharmacol. 2008;154(3):502–521.
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5. 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.
6. Kanayama G, Pope HG Jr. History and epidemiology of anabolic androgens in athletes and non-athletes. Mol Cell Endocrinol. 2018;464:4–13.