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When It's More Than Acne

If your acne is more than an occasional problem, it could be linked to a hormonal condition. How to tackle acne when it's more than just skin deep.

All cases of acne have their roots in hormone production, but some acne is a symptom of an underlying hormonal condition that can cause far more than facial blemishes. If troublesome blemishes are plaguing you long after your teen years are over, it’s possible that they’re telling you to look beyond your skin for the problem.

“Acne is caused by an excess of oil production, which in turn is caused by the action of testosterone,” says Geoffrey Redmond, MD, a New York endocrinologist specializing in female hormone problems. “The oil glands are the most testosterone-sensitive tissue in the human body.”

Typical adolescent acne starts when testosterone levels start to increase during puberty (in both boys and girls), but certain diseases and conditions can also send testosterone and estrogen levels up. These are particularly common in girls and women, and the most common is polycystic ovarian syndrome (PCOS).

PCOS

The most common female endocrine disorder, PCOS affects between 5%-10% of all women. It involves multiple organ systems, and although it’s not fully understood, doctors believe that it is caused by insensitivity to the hormone insulin. In addition to irregular menstrual cycles and ovulation, weight gain, and thinning hair, one of the most notable symptoms of PCOS is acne.  

“Any female patient who presents to me with either persistent acne -- they had it in their teens and it’s continued past the age of 25 -- or acne starting after age 25, I’ll evaluate for PCOS,” says Bethanee Schlosser, MD, assistant professor and director of the women’s skin health program in the department of dermatology at Northwestern University’s Feinberg School of Medicine.

PCOS-related acne tends to flare in areas that are usually considered “hormonally sensitive," especially the lower third of the face. This includes:

  • Cheeks
  • Jawline
  • Chin
  • Upper neck, especially at the angles of the jaw

“Patients with PCOS tend to get acne that involves more tender knots under the skin, rather than fine surface bumps, and will sometimes report that lesions in that area tend to flare before their menstrual period,” says Schlosser. “They take time to go away.”

So if you tend to get acne in the places Schlosser describes and have noticed irregular periods, it’s a good idea to ask your dermatologist to refer you for PCOS testing.

Diabetes

Many women with PCOS also have diabetes, which isn’t surprising, given that both conditions appear to be related to how the body reacts to insulin. Could that mean that diabetes causes acne, or that your acne might be a symptom of diabetes?

If you look online, you may see a lot of speculation about diabetes causing acne, but Redmond says that’s false. “Acne is not a symptom of diabetes. Obviously, people with diabetes can develop acne, but the presence of acne by itself does not indicate a need to test for diabetes.”

Other Conditions

There are some other hormonal disorders whose symptoms can include acne, but these are much more unusual. For example, people affected by a group of inherited disorders known collectively as congenital adrenal hyperplasia often produce either too much or too little of certain sex hormones, including testosterone. “People with these disorders have a problem with the adrenal glands, which produce and metabolize hormones,” explains Schlosser.

Treating Hormonal Acne

Most women who have acne related to a hormonal condition like PCOS have probably found that more “standard” topical acne therapies, such as retinoid gels and creams, don’t meet their needs. “These people do best with hormonal therapy,” says Schlosser.

There are two primary options for hormonal management of acne:

  • Birth control pills (only certain formulations)
  • Spironolactone, a diuretic which also blocks the binding of androgen receptors, blunting the hormonal fluctuations that cause acne

Schlosser usually starts patients with acne related to a hormonal condition like PCOS on an oral contraceptive pill containing both estrogen and progesterone; Estrostep, Ortho Tri-Cyclen, and Yaz are the three brands approved by the FDA for acne treatment.

It’s not an overnight process. “You have to give this approach at least three months of use before you can judge its impact,” she says. “That’s the point at which studies found a notable difference between placebos and oral contraceptives. Many patients saw further improvement around the six-month mark.”

If oral contraceptives are not working, or only giving partial relief from your acne, your dermatologist may recommend spironolactone. It may also be the first treatment of choice for hormone-related acne if you smoke or have other risk factors that make hormonal contraceptives undesirable. “Many of my patients get significant added improvement with this drug,” says Schlosser. 

Redmond usually starts his patients on 100 to 200 mg of spironolactone per day. “Most people tolerate it fairly well. Since it is a diuretic [meaning that it causes you to urinate more often], you’ll need to keep up your water intake, but as long as you do that, you shouldn’t have too many problems.”

“For women, spironolactone works in a very high percentage of cases,” Redmond says. “For men, it’s not optimal because it blocks testosterone.”

So how long will you need to take these medications? That’s hard to say. “Eventually, the tendency to have acne goes away for most people, but it’s hard to know when,” says Redmond. “The medications are often necessary for a few years. It’s mostly luck in how long it persists.”

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