Hormonal acne in adults is a chronic skin problem whose main causes are hormonal imbalances and lifestyle-related factors. Learn how to recognize, treat and effectively prevent hormonally driven lesions and when it is worth performing in-depth diagnostics.
Table of contents
- What is hormonal acne in adults?
- Most common causes of hormonal acne
- Symptoms and types of skin lesions
- How to diagnose hormonal acne?
- Methods of treating hormonal acne
- Diet and lifestyle in prevention of skin lesions
What is hormonal acne in adults?
Hormonal acne in adults is a specific type of acne whose main cause is fluctuations and disorders in the hormonal system, and not—as is often believed—solely “poor skincare” or lack of hygiene. It most commonly appears after the age of 25, in both women and men, although women seek dermatological help for this problem much more often. It is characteristic that skin lesions may occur even in people who practically had no acne during adolescence, or had it in a very mild form. In hormonal acne, androgenic hormones (including testosterone and dihydrotestosterone – DHT), estrogens, progesterone, insulin-like growth factor IGF-1 as well as thyroid and adrenal hormones play a key role. Their excess, deficiency or disturbed proportions affect sebaceous glands, causing excessive sebum production, accelerated keratinization of follicular openings and inflammation. This, in turn, leads to the formation of comedones, papules, pustules, painful nodules, and even cysts that heal slowly and may leave scars and post-inflammatory hyperpigmentation. Unlike typical adolescent acne, hormonal acne in adults usually has a more chronic, recurrent course—periods of improvement alternate with flare-ups, often related to the menstrual cycle, stress, lifestyle changes, diet or the introduction or discontinuation of hormonal contraception. Lesions very often localize in the so-called “hormonal zone”—the lower part of the face: on the chin, around the jawline, near the mouth and on the neck, sometimes also on the back, chest and shoulders. They may take the form of deep, painful subcutaneous nodules that are hard to squeeze and persist for a long time, even if classic “white” pustules are not visible on the skin surface. This type of acne often coexists with other symptoms of hormonal disorders—women may experience irregular periods, excessive hair growth (hirsutism), hair loss, problems maintaining normal body weight or difficulties conceiving, while men may notice hair thinning, seborrhea or mood decline. Importantly, hormonal acne is not a “whim” nor solely a cosmetic issue: it can significantly affect self-esteem, social and professional life, and in extreme cases increase the risk of anxiety disorders and depressive conditions. Therefore it is treated as a chronic skin disease that requires in-depth diagnostics and a comprehensive approach—not only using ointments or creams, but also understanding what is happening “inside” the body. The etiology of hormonal acne is multifactorial: besides hormones themselves, genetic predispositions, chronic stress (which stimulates the hypothalamic–pituitary–adrenal axis and increases cortisol production, indirectly affecting androgens), a diet rich in simple sugars and highly processed products (which increases insulin and IGF-1 secretion), sleep deficiency, and even some medications are important. For this reason two adult patients with seemingly similar skin lesions may have completely different causes—the key factor in one person might be polycystic ovary syndrome (PCOS), while in another hypothyroidism, hyperprolactinemia or chronic occupational stress. Hormonal acne can also present various clinical pictures: in some patients diffuse subcutaneous inflammatory infiltrates dominate, in others numerous closed and open comedones predominate, periodically accompanied by flare-ups with pustules and papules. It happens that the skin is at the same time greasy to the touch yet irritated, reddened and hypersensitive—especially when a desperate patient reaches for excessively strong drying and exfoliating agents, which paradoxically can increase sebum production and inflammation. Hormonal acne in adults also needs to be differentiated from other dermatoses such as rosacea, perioral dermatitis, contact dermatitis or steroid-induced changes (so-called post-steroid acne). Therefore, in clinical practice not only a thorough skin examination but also a detailed history is critical—questions about the menstrual cycle, contraceptives, thyroid and adrenal diseases, medications, lifestyle, symptom worsening before periods or during heightened stress. Based on this, the dermatologist may suspect that acne has mainly a hormonal background and order further diagnostics with a gynecologist-endocrinologist or endocrinologist. Ultimately, awareness that one is dealing with hormonal acne rather than “ordinary” adult acne is crucial for selecting effective treatment, which often must combine topical therapy with appropriately chosen systemic therapy and lifestyle modification.
Most common causes of hormonal acne
Hormonal acne in adults most often develops on the basis of complex, multifactorial hormonal disorders that directly affect the function of sebaceous glands, the keratinization process of the epidermis and inflammatory responses in the skin. Androgenic hormones (testosterone and its derivative dihydrotestosterone – DHT) play a central role: their excess or increased sensitivity of skin receptors leads to sebum overproduction. Sebum with altered composition becomes thicker, more readily clogs follicular openings and favors the formation of microcomedones. Over time, this state can be exploited by Cutibacterium acnes bacteria (formerly Propionibacterium acnes), resulting in the development of inflammatory lesions—pustules, papules and even painful cysts. Hormonal acne is also aggravated by fluctuations in estrogen and progesterone levels, which physiologically occur in women during the menstrual cycle, pregnancy, postpartum, breastfeeding and before and during menopause. A drop in estrogen levels in the luteal phase, together with a relative rise in androgens, favors exacerbation of lesions; therefore many women observe a “flare” a few days before menstruation or during it. In some patients disturbances of the hypothalamic–pituitary–ovarian axis play a significant role, which may be associated, among other things, with polycystic ovary syndrome (PCOS). In PCOS hyperandrogenism (high androgen levels), insulin resistance and irregular cycles are observed, which together create conditions favorable for chronic acne, most often in the form of deep, painful lesions in the lower face (jawline, chin, neck). In men, androgen overproduction can be caused by testicular or adrenal abnormalities, as well as the use of anabolic steroids to increase muscle mass—the so-called “steroid acne” is often very severe and involves not only the face but also the back, chest and shoulders.
A very important but often underestimated factor is insulin resistance and related carbohydrate metabolism disorders. High insulin levels and IGF‑1 (insulin-like growth factor) stimulate sebaceous gland activity and increase androgen production in the ovaries and adrenals, which directly translates into increased skin oiliness and greater susceptibility to inflammation. A diet rich in foods with a high glycemic index (sweets, white bread, sugary drinks, fast food), frequent snacking and excess dairy (especially cow’s milk) favor chronically elevated insulin, which can trigger or worsen hormonal acne even in people without obvious, diagnosed endocrine diseases. Similarly, chronic stress affects the skin via the hypothalamic–pituitary–adrenal axis: elevated cortisol levels disrupt tissue sensitivity to insulin, increase adrenal androgen levels and promote inflammation. Patients living under permanent stress often observe clear flare-ups after particularly difficult professional or emotional periods. The role of medications and hormonal preparations should not be overlooked—some forms of contraception (especially those with a progestin component with androgenic activity), as well as sudden discontinuation of contraceptive pills after long-term use, can exacerbate acne while the body needs time to “reset” its hormonal axis. A similar effect may occur with some antiepileptic or antidepressant drugs or testosterone-containing preparations in men. Often other endocrine disorders coexist in the background—thyroid diseases (both hypothyroidism and hyperthyroidism), hyperprolactinemia or adrenal diseases—that, through complex hormonal mechanisms, disturb skin balance. It’s also worth remembering that acne tendency has a strong genetic component: if parents or siblings experienced severe, chronic adult acne, there is a higher risk that similar problems will occur in other family members. Finally, it must be emphasized that skincare alone or a single “dietary mistake” rarely directly causes hormonal acne, but can become a triggering or aggravating factor in people with an existing hormonal predisposition—overly aggressive cleansing, use of comedogenic cosmetics, lack of sun protection or frequent touching of the face can decisively worsen the clinical picture of a disease that at its root is a hormonal disorder.
Symptoms and types of skin lesions
Hormonal acne in adults is characterized not only by the presence of eruptions but also by a specific type of lesions, their localization and a chronic, recurring course. For many people the first signal is single painful nodules appearing cyclically—most often one to two weeks before menstruation in women or during periods of increased stress. The so-called “hormonal zone”—the lower part of the face: jawline, chin, jawline, sometimes the neck, and also the lateral parts of the face along the ear line—is typical. However, lesions can also occur on the back (especially the upper back and shoulder blades), chest and shoulders. In many adult patients hormonal acne takes a mixed form—alongside individual inflammatory lesions, open (blackheads) and closed comedones (whiteheads), enlarged pores, excessive oiliness and visible redness appear. Unlike typical teenage acne, where numerous small pustules and papules are often scattered over the entire face, adults usually have fewer lesions, but they are larger, deeper and more painful. Patients describe them as “subcutaneous lumps” that mature slowly, are difficult to heal and often leave traces. Chronicity of the problem is also characteristic—the symptoms persist for years, recur after periods of apparent improvement, and the skin is rarely completely “clear” for a long time. A typical accompanying symptom is seborrhea, i.e. excessive sebum secretion: the complexion quickly becomes shiny, makeup “melts” during the day, and pores are noticeably enlarged, especially in the T-zone and on the chin. Skin lesions may also vary in intensity during the month—many women notice that their skin condition noticeably worsens before the period and then calms down slightly after menstruation. When a hormonal background is suspected, it is also important to pay attention to systemic symptoms: irregular periods, pronounced premenstrual syndrome, ovarian pain, increased hair growth (on the chin, upper lip, chest, abdomen), hair loss on the scalp, weight gain or difficulty maintaining body weight. Their coexistence with acne may indicate, for example, hormonal disorders. In men, a symptom indirectly related to hormonal acne may also be changes in body hair, excessive oiliness of the scalp or sudden worsening of eruptions after starting supplements aimed at increasing muscle mass. It is also important to distinguish hormonal acne from other dermatoses that can resemble it, such as rosacea (erythema, telangiectasia, burning of the skin), perioral dermatitis or allergic lesions; therefore the appearance of the skin alone is not always sufficient for self-diagnosis and usually requires dermatological consultation.
In the course of hormonal acne several types of skin lesions can be distinguished, which often coexist, creating a complex clinical picture. The most characteristic are deep inflammatory lesions: inflammatory papules and nodules and acne cysts. Papules are raised, red, painful “bumps” without a visible purulent opening, which may persist for many days. Nodules reach deeper into the skin, are larger, firm, very painful to touch and tend to merge into larger inflammatory foci. Acne cysts are even deeper lesions, often with pus accumulation and a high risk of scarring; in adults with hormonal acne they occur especially on the jawline and back. Alongside them classic pustules appear—lesions with a visible purulent tip, often developing on the basis of earlier papules. The second group are non-inflammatory lesions, i.e. open and closed comedones. Open comedones are visible as dark dots, particularly on the nose, chin and central face; their dark color results from oxidation of sebum-keratin masses, not “dirt”. Closed comedones look like small, white or skin-colored bumps under the skin, often palpable under the fingers. Adults with hormonal acne often also have so-called microcomedonal changes—the skin appears uneven, rough, “curdled”, although not every change is always clearly visible to the naked eye. Long-lasting, recurrent inflammation promotes the formation of post-inflammatory hyperpigmentation (darker spots after healed lesions) and acne scarring. Hyperpigmentation is particularly troublesome in people with darker skin phototypes and can persist for months, even though the active inflammation has subsided. Scars take various forms: atrophic (depressions, “pits” in the skin), hypertrophic, less often keloids (scar tissue), especially on the back and chest. Characteristic of hormonal acne in adults is also that even a small number of active lesions can cause significant aesthetic discomfort due to their location (central parts of the face, chin) and tendency to leave permanent marks. A common symptom “invisible” to others but very burdensome to the patient is the pain of deep lesions, a feeling of skin tightness, burning and a tendency to manipulate eruptions (squeezing, scratching), which only intensifies inflammation and the risk of scars. The clinical picture of skin lesions may also differ depending on age: in women after 30–35 years of age a so-called late “low-grade” acne is often observed, with fewer but persistent inflammatory lesions, intensified oiliness and perifollicular redness. It should be remembered that hormonal acne rarely limits itself to the skin alone—it is a manifestation of broader disorders in the body, and careful observation of the type and location of lesions allows the dermatologist to choose more targeted tests and treatments, including possible endocrinological diagnostics.
How to diagnose hormonal acne?
Diagnosing hormonal acne in adults begins with a thorough medical history and clinical skin assessment, and only later—if indicated—is supplemented with laboratory tests and consultations with other specialists. The dermatologist first pays attention to the patient’s age, the time of onset of lesions and their localization—typical for hormonal acne are eruptions in the lower part of the face (jawline, chin), on the neck, chest and back, often in the form of deep, painful nodules and cysts. It is also very important to determine whether acne appeared suddenly in a person who previously had no major skin problems, or whether it is a continuation of adolescent lesions that intensified after the age of 25. In the history the doctor asks, among other things, about the relation of acne flare-ups to the menstrual cycle (worsening a few days before the period), pregnancy, postpartum, discontinuation or initiation of hormonal contraception, as well as the occurrence of irregular periods, difficulty conceiving, sudden weight gain, increased male-type hair growth (on the chin, chest, abdomen), hair loss, mood drops or chronic fatigue symptoms. These elements allow a preliminary assessment of whether hormonal disorders such as PCOS, hyperandrogenism, thyroid or adrenal dysfunction may underlie the skin problems. At the same time the doctor analyzes previous skincare, used cosmetics (including heavy, comedogenic foundations and creams), prior dermatological treatment, taken medications (especially steroids, some psychiatric drugs, anabolic “mass” supplements) and lifestyle factors: stress level, eating habits, smoking, sleep quality. In the physical examination the dermatologist assesses the type and severity of lesions (comedones, papules, pustules, nodules, cysts), presence of scars and post-inflammatory hyperpigmentation, skin type and thickness, oiliness of the T-zone, and also presence of hair in “typically male” locations in women. On this basis one can preliminarily distinguish hormonal acne from acne mainly caused by cosmetics (acne cosmetica), mechanical acne (from helmets, masks, headbands) or rosacea, which more often affects the central face, is associated with erythema, telangiectasias and skin burning, but not deep nodules on the jawline. It is equally important to exclude other dermatoses, e.g. perioral dermatitis or seborrheic dermatitis, which may coexist with or mimic acne. If a deeper hormonal background is suspected the dermatologist refers the patient to a family doctor, endocrinologist or gynecologist-endocrinologist, and orders basic blood tests and a hormonal profile.
The range of laboratory tests in suspected hormonal acne is chosen individually, but usually includes measurement of androgen levels (total and free testosterone, DHEA-S, androstenedione), sex hormones (estradiol, progesterone, LH, FSH), thyroid hormones (TSH, FT3, FT4), and in some cases also prolactin and cortisol. In women being evaluated for PCOS a pelvic ultrasound is often additionally performed to assess ovarian appearance and follicle count, as well as carbohydrate metabolism tests—fasting glucose, insulin, sometimes an oral glucose tolerance test (OGTT) with insulin measurement, which helps detect insulin resistance closely linked to acne severity. Assessment of the lipid profile and general health status is also important, especially if systemic drugs such as oral retinoids or hormonal contraception are being considered. Importantly, a single “abnormal” hormone result does not always determine the cause of the problem—the interpretation must take into account the day of the menstrual cycle, medications taken, body weight and clinical symptoms. It happens that despite a typical clinical picture hormone levels are within laboratory norms, and acne still has a hormonal character, e.g. due to increased sensitivity of skin receptors to androgens. Therefore diagnosing hormonal acne is a process based on combining a thorough history, assessment of lesion appearance and localization, laboratory tests and—if necessary—consultations with a gynecologist, endocrinologist or diabetologist. In some cases it is also useful to assess acne severity scales (e.g. Leeds scale, GAGS), perform photographic documentation of the skin and monitor changes over time, especially when introducing a new treatment or modifying hormonal contraception. In clinical practice the diagnosis of hormonal acne is always multi-stage: it begins in the dermatology office but often requires involvement of several specialists and repeated tests that capture not only the skin lesions themselves but also their cause in the patient’s hormonal and metabolic system.
Methods of treating hormonal acne
Treating hormonal acne in adults always requires an individualized approach and patience, because a single preparation or a short course is rarely sufficient. The basis is an accurate diagnosis and determining whether lesions are solely due to sebaceous gland hypersensitivity to hormones or whether more serious endocrinological disorders such as PCOS, hyperandrogenism or insulin resistance coexist. In most cases the dermatologist combines topical treatment with systemic therapy, and also recommends lifestyle modifications and appropriate skincare to enhance therapy effects and limit relapses. Topical pharmacological treatment primarily includes retinoids (e.g. adapalene, tretinoin) that regulate epidermal keratinization, prevent comedone formation and indirectly reduce inflammation. Preparations with benzoyl peroxide and azelaic acid are also used for their anti-inflammatory, antibacterial and lightening effects on post-inflammatory hyperpigmentation, which is particularly important in adult patients who often struggle with post-acne marks. Topical antibiotics (e.g. clindamycin) are usually introduced short-term and only in combination with other substances to minimize the risk of bacterial resistance. For many people repair of the skin’s hydrolipid barrier is also key, so alongside medications the dermatologist recommends gentle dermocosmetic cleansers, non-comedogenic moisturizers and consciously avoiding aggressive mechanical peels, alcohol-containing drying tonics and heavy occlusive makeup. Regular use of sunscreen SPF 30–50 is also very important, because some medications (especially retinoids) increase sun sensitivity and UV radiation exacerbates hyperpigmentation and inflammatory processes.
In moderate and severe forms of hormonal acne, topical therapy alone is usually insufficient, so the doctor may recommend systemic treatment aimed at hormonal regulation and inflammatory processes occurring in the whole organism. In women oral hormonal contraception containing antiandrogenic components, e.g. drospirenone or dienogest, is very often used; these lower androgen activity in hair follicles and reduce sebum production. In selected cases the dermatologist or gynecologist-endocrinologist may additionally recommend antiandrogen drugs such as spironolactone, which block androgen receptors in the skin—however this requires strict monitoring, exclusion of pregnancy and regular checks of electrolytes and blood pressure. In patients with insulin resistance or coexisting metabolic syndrome, metformin is sometimes considered; by improving tissue sensitivity to insulin it indirectly reduces excessive androgen stimulation and may alleviate acne symptoms. In severe, treatment-resistant cases oral retinoids (isotretinoin) are considered. This is a very effective but demanding therapy with potential side effects that permanently decreases sebaceous gland activity, inhibits keratinization of follicular openings and reduces inflammation; during its use regular blood tests and strict contraception in women of reproductive age are required. In men treatment usually focuses on oral retinoids, systemic antibiotics (e.g. doxycycline, lymecycline—used as briefly as possible and always combined with topical therapy) and parallel diagnostics of possible testicular or adrenal disorders. Diet interventions are increasingly part of a comprehensive plan—reducing high-glycemic foods, limiting dairy (especially skimmed milk), ensuring adequate fiber, healthy fats and protein intake—which supports stabilization of insulin-androgen balance. Supportive supplements such as probiotics, omega-3 fatty acids or vitamin D can be introduced, but always as a complement, not a substitute for physician-prescribed therapy. For some patients dermatological aesthetic procedures are also helpful, such as chemical peels with mandelic, salicylic or pyroglutamic acid, retinol-based treatments, laser therapy or LED light therapy (blue and red light), which reduce the amount of Cutibacterium acnes, accelerate lesion healing and help even out skin texture. The key principle in treating hormonal acne is consistency and long-term commitment—improvement usually appears after several weeks, and stable effects after several months, so ongoing cooperation with a dermatologist, regular follow-up visits and readiness to modify the treatment regimen with changes in symptoms or hormonal situation (e.g. pregnancy, stopping contraception, menopause) are extremely important.
Diet and lifestyle in prevention of skin lesions
Diet and lifestyle play a key role in prevention and supporting the treatment of hormonal acne in adults, since they directly affect hormonal balance, insulin levels, systemic inflammation and sebaceous gland function. Increasing evidence indicates that high glycemic index foods (white bread, sweets, sugary drinks, highly processed snacks) increase insulin secretion, which in turn stimulates production of IGF‑1 and androgens that activate sebaceous glands. In practice this means frequent “sugar spikes” may translate into a larger number of eruptions, especially in people predisposed to insulin resistance and hormonal acne. Better choices are low and medium glycemic index foods: whole grains (oat flakes, buckwheat, quinoa, sourdough wholemeal bread), non-starchy vegetables (broccoli, zucchini, peppers, leafy greens) and legumes, which stabilize blood glucose and support hormonal balance. In prevention of hormonal acne it is also recommended to pay attention to dairy intake, particularly cow’s milk and sweetened yogurts, which can raise IGF‑1 levels and exacerbate lesions in some patients. This does not necessarily mean complete dairy elimination for everyone, but it is often worth testing reduced milk consumption and choosing fermented products (kefir, natural yogurt, buttermilk) or unsweetened plant alternatives while observing skin reaction. The quality of fats in the diet also matters—trans fats and excess saturated fats (fast food, pastries, fried dishes) promote inflammation, while omega‑3 fatty acids (fatty marine fish, flaxseed, chia seeds, walnuts) can reduce inflammation and improve skin condition. Ensure sufficient antioxidants from vegetables and fruits (berries, raspberries, tomatoes, peppers, kale, parsley) that protect skin cells from oxidative stress, and adequate intake of B vitamins, which support epidermal regeneration and hormonal function—their sources include pumpkin seeds, sunflower seeds, nuts, eggs, whole grains and good-quality meat. At the same time it is worth avoiding excessive alcohol, which increases dehydration, burdens the liver and can increase inflammation, and large doses of caffeine, especially if there is a tendency to sleep disturbances and chronic stress. Proper hydration (mainly water, unsweetened herbal teas) supports the skin’s hydrolipid barrier function and natural detoxification processes. For many patients adopting low-glycemic-style diet principles—rich in vegetables, fruits, olive oil, fish, with moderate red meat and sweets—helps reduce systemic inflammation.
Lifestyle is as important as diet because hormones react to chronic stress, lack of sleep, physical inactivity or stimulants, and each of these factors can worsen hormonal acne. Long-term stress raises cortisol levels, which affects glucose metabolism, may worsen insulin resistance and indirectly increase androgen activity, translating into more active sebaceous glands. Therefore in prevention it is recommended to regularly practice stress-reduction techniques: breathing exercises (e.g. simple 5–10 minute deep-breathing sessions), yoga, mindfulness meditation, walks in the fresh air and other activities that help the body “downregulate” stress responses. Physical activity itself improves insulin sensitivity and hormonal regulation—particularly beneficial is combining moderate aerobic exercise (brisk walking, swimming, cycling) with strength training (resistance training, bodyweight exercises). For the skin it is important to cleanse the face and body promptly after exercise to remove sweat and sebum using gentle cleansers, which reduces the risk of pore clogging. Another pillar of prevention is sleep—its deficiency disrupts the hypothalamic–pituitary–adrenal axis, raises cortisol levels and can increase inflammation. Aim for 7–9 hours of sleep per night, ideally at consistent times, and limit blue light exposure from screens 1–2 hours before bedtime. Hygiene of contact between skin and the environment is also important: regular changing of pillowcases, more frequent washing of towels, disinfecting phone screens and avoiding frequent touching of the face reduce the amount of bacteria and contaminants that can worsen skin condition. In the context of lifestyle, a cautious approach to supplements and performance enhancers is key—some products, such as whey-based protein powders or supplements with high doses of vitamins B6 and B12, may worsen acne in some individuals, so it is worth consulting their use with a doctor or dietitian. Reducing smoking (including e-cigarettes) supports skin microcirculation and reduces oxidative stress, which promotes better epidermal regeneration. It is also essential to introduce dietary and lifestyle changes gradually and observe the body’s and skin’s reactions—keeping a simple diary (noting food intake, stress level, menstrual cycle phase and skin condition) helps detect individual acne triggers and better tailor daily habits to the needs of skin prone to hormonal acne.
Summary
Hormonal acne in adults can have many causes, including hormonal disorders, diet and stress. Proper diagnosis and comprehensive diagnostics are key to effective treatment. Pharmacotherapy, appropriate skincare and modification of lifestyle and diet significantly increase the chances of lasting skin improvement. Remember that consultation with a dermatologist and support from a dietitian help select the optimal therapy, individually tailored to the needs of adult skin.
