How are hormones related to acne?

How do hormones turn into spots?

Androgens are a group of hormones that includes testosterone. During puberty, androgens enlarge the skin's oil glands and increase oil production. That oil, called sebum, can combine with dead skin cells to block hair follicles, the small openings where hair grows. Bacteria in blocked follicles can contribute to inflammation and pus.23

Skin also processes hormones locally. An enzyme in the skin converts testosterone into dihydrotestosterone, or DHT, a more potent androgen that acts on oil glands. The glands respond through androgen receptors, which are proteins that receive hormonal signals. How strongly those receptors respond is part of the relationship between hormones and acne, alongside how much oil the glands produce.4

Acne also involves changes in how skin cells build up inside follicles, inflammation and bacterial activity. Both the amount and composition of sebum can matter, including how sebum affects bacteria living in the follicle. The exact order of these events is not fully understood. Hormones are a major contributor to acne, not a solo act, despite getting most of the billing.5

Is testosterone the only hormone involved?

No. Insulin like growth factor 1, usually shortened to IGF 1, rises during puberty and influences oil glands as well as androgen activity. It can increase the conversion of testosterone to DHT and make oil glands more sensitive to androgen signals. Estrogens act in the opposite direction by suppressing oil gland function. Stress linked hormones, including cortisol, also influence these glands.4

Stress can worsen acne that already exists, rather than causing acne by itself. Genetics also matters: a close relative's history of deep, painful acne increases your risk of that type of acne. Too little sleep and oily skin or hair products can worsen breakouts too. A flare therefore does not point to one hormonal cause on its own.3

Why does acne continue after puberty?

Acne can occur at almost any age. In women, adult acne can be teenage acne that never cleared, acne that returns after years without breakouts, or acne that starts for the first time in adulthood. About 20% to 40% of women with adult acne first develop it as adults. Acne can persist beyond the teenage years, which is poor respect for an otherwise perfectly good milestone.3

Does acne mean you need hormone tests?

Most people with acne do not need tests. Hormonal testing can be considered in women when the features are unusual, rather than being a routine requirement for every breakout. Polycystic ovarian disease can provoke acne flares, as can medicines including steroids and hormones. A clinician can assess whether your acne needs investigation as well as treatment.6

Can food affect the hormonal pathways?

Insulin and IGF 1 help regulate oil gland cells, which is one possible link between diet and acne. A diet with a high glycemic load, meaning a stronger effect on blood sugar, may contribute through increased insulin activity. A lower glycemic load diet appears to reduce both inflamed spots and blackheads or whiteheads. This is an additional way to help manage acne, not a replacement for treatment.5

Milk can also stimulate pathways involving insulin and IGF 1. Some amino acids in milk proteins stimulate insulin release or support IGF 1 production. Dairy rich diets are among the factors that can provoke acne flares. These pathways help explain why food can influence acne; they do not make every breakout a direct response to one meal.56

How is acne with a hormonal component treated?

Treatment can target the skin, hormonal activity or both. Mild acne options include benzoyl peroxide, azelaic acid and topical retinoids such as adapalene or tretinoin. Salicylic acid washes are another option. More persistent or severe acne can require prescription treatment, including oral antibiotics or isotretinoin. The choice depends on severity and response to previous treatment, not just whether hormones are involved.6

The combined contraceptive pill can manage hormone levels that contribute to acne. Spironolactone, which reduces androgen signaling, is another treatment a clinician can consider for women, particularly when acne has not responded to a combined pill or polycystic ovaries are involved. These are prescription decisions, not a reason to change hormone medicines yourself.467

What can you do alongside treatment?

• Wash with a gentle cleanser twice a day and remove makeup at the end of the day.
• Choose skincare and makeup labelled noncomedogenic, meaning formulated not to clog pores.
• Avoid scrubbing, picking and squeezing spots.
• Wear loose, breathable clothing if you have body acne, especially during exercise or sweating.

Pore clogging skincare can contribute to acne, even when the bottle has ambitions of solving the entire problem.1

What if acne starts during testosterone therapy?

Testosterone therapy increases the likelihood of acne, but not everyone develops it. Breakouts can appear within months or within the first two years, often on the lower third of the face, chest, upper arms and back. Increased testosterone can raise sebum production and inflammation, and acne can remain persistent rather than gradually disappearing.1

You can treat acne while continuing gender affirming testosterone therapy. Reducing the dose does not necessarily clear acne, and changes to testosterone should be discussed with the prescribing clinician. A dermatologist can start with treatments such as adapalene, benzoyl peroxide or salicylic acid for mild acne and adjust the plan if widespread breakouts or deep lumps develop.1

Moderate or severe acne during testosterone therapy can need prescription medication such as isotretinoin. Treatment sometimes needs to continue longer because the acne is persistent. Tell your dermatologist about planned gender affirming surgery, which can affect the treatment plan. Skincare also matters: scrubbing can aggravate acne even while medication is treating it.1

When should you get medical help?

See a doctor if treatment you have tried is not helping, spots are deep or painful, acne is causing scars, or it is affecting your mental health. Hot, swollen or red skin also needs assessment for infection. Seek urgent medical assessment if severe acne comes with fever, joint or bone pain, or ulcerated skin lesions.67