Everything about hormonal acne: causes, diagnosis and treatment

Many women consult because they present persistent pimples since adolescence or because acne appears for the first time in adulthood.

They frequently hear phrases such as:

• "The tests are normal."
• "The hormones are fine."
• "It will pass."

However, the reality is more complex.

Hormonal acne can exist even when the hormonal tests are apparently normal.

Understanding how hormones act on the skin makes it possible to understand why it occurs and how it can be treated.

Hormonal acne is a form of acne in which hormones, especially androgens, play an important role in the development of the disease.

These androgens stimulate the sebaceous gland, increasing the production of sebum and favouring the obstruction of the hair follicle.

Subsequently inflammation, bacteria of the skin itself and acne lesions appear.

No.

It can also appear in men.

However, it is especially frequent in adult women, between 20 and 45 years of age.

The most important are the androgens, among them:

• Testosterone.
• Free testosterone.
• DHEA-S.
• Androstenedione.

Nevertheless, other hormones can also influence indirectly:

• Insulin.
• IGF-1.
• Cortisol.
• Thyroid hormones.
• Prolactin.

The hormonal balance is complex and does not depend on a single hormone.

Yes.

This is one of the most important concepts.

A "normal" test does not rule out hormonal acne.

There are several reasons:

• Some women present a greater sensitivity of the skin receptors to androgens.
• The values may be within the reference range, but relatively high for that patient.
• Not all hormonal alterations appear reflected in a routine test.

Therefore, the diagnosis must not be based only on a blood test, but on the clinical history, the examination and the pattern of the acne.

It frequently appears on:

• The jaw.
• The chin.
• The jawline.
• The neck.

The lesions are usually:

• Inflammatory.
• Painful.
• Deep.
• Persistent.
• Recurrent.

Many patients report a worsening before menstruation.

In some cases it is advisable to rule out diseases such as:

• Polycystic ovary syndrome (PCOS).
• Non-classical adrenal hyperplasia.
• Thyroid alterations.
• Hyperprolactinaemia.

Most women with hormonal acne do not necessarily present an important endocrine disease, but it is fundamental to identify those patients who do require a specific study.

Not all patients need a test.

It is usually indicated when there are signs suggestive of hyperandrogenism, such as:

• Menstrual irregularity.
• An important increase in body hair.
• Androgenetic alopecia.
• A sudden onset of acne in adulthood.
• Very resistant acne.
• Suspicion of polycystic ovary syndrome.

The interpretation of these studies must always be carried out in the clinical context.

In some people, yes.

The following can especially influence:

• Diets with a high glycaemic load.
• An excess of refined sugars.
• Some dairy products, especially skimmed milk.

There is no universal diet for all patients, but a balanced diet can be part of the treatment.

It depends on each patient. It may include:

Topical treatments:

• Retinoids.
• Azelaic acid.
• Benzoyl peroxide.
• Topical antibiotics in specific situations.

Oral treatments. When the hormonal component is important, the following may be considered, among others:

• Selected hormonal treatments.
• Contraceptives suitable for certain patients.
• Spironolactone in correctly selected women and under medical supervision.
• Isotretinoin when it is indicated.

The treatment must be individualised and take into account the age, the medical history, the desire for pregnancy and the possible side effects.

Spironolactone is a medication used for years which, in addition to other medical indications, can be very useful in certain women with hormonal acne.

It acts by reducing the effect of androgens on the sebaceous gland.

It is not indicated for all patients and must always be prescribed and controlled by a doctor, assessing possible contraindications, interactions and the need for clinical follow-up.

In well-selected patients it can offer a very significant improvement.

In many cases it can be excellently controlled.

Some women need treatments for several months and others require maintenance strategies to avoid relapses.

The objective is not only to eliminate the current pimples, but to prevent new lesions and to avoid scars.

• Thinking that hormonal acne only affects adolescents.
• Believing that "normal" hormones rule out this form of acne.
• Constantly changing cosmetics.
• Delaying the medical consultation.
• Manipulating the lesions.
• Stopping the treatment too early.

• Myth: If my hormones are normal, my acne cannot be hormonal. Fact: This is not true. Many women present hormonal acne with tests within the reference ranges.
• Myth: Hormonal acne disappears on its own. Fact: In some patients it persists for years if it is not treated.
• Myth: It only affects adolescents. Fact: It is very frequent in adult women.
• Myth: Washing the face a lot eliminates hormonal acne. Fact: Excessive cleansing can irritate the skin and worsen the barrier function.
• Myth: Hormonal treatment works for all patients. Fact: It must be individualised after a complete medical assessment.

• Hormonal acne is very frequent, especially in adult women.
• A normal hormonal test does not exclude this diagnosis.
• The clinical pattern and the examination are as important as the laboratory tests.
• There are very effective treatments, including some aimed at modulating the effect of androgens in selected patients.
• An early treatment reduces the risk of scars and improves the quality of life.
• The individualised medical assessment is fundamental to choose the most appropriate strategy.