Hormonal acne in women: causes and treatment options

What is hormonal acne?

Hormonal acne is an everyday term. Doctors usually call it adult female acne, meaning acne in women over 25, whether it has carried on from the teenage years or started in adulthood.

It classically affects the jawline, the chin, the skin around the mouth and the front of the neck, mostly as red bumps and pus-filled spots. The pattern varies, though. In one study, most women had spots across several areas of the face, and nearly half had some on the chest or back.

Androgens, such as testosterone, stimulate the skin's oil glands. In adult female acne the oil glands seem more sensitive to these hormones, and the skin can turn weaker hormones into stronger ones locally. Most women with it show no signs of raised androgens on examination or blood tests.

Many women notice a flare in the days before a period. One review puts this at 60 to 70% of women with adult acne.

What causes hormonal acne?

Acne comes from a mix of excess oil, blocked pores, bacteria and inflammation, and hormones act mainly on the oil. These triggers are linked to flares in adult women:

• Your menstrual cycle, with spots building in the days before a period.
• Changes in contraception. Acne can appear after stopping a combined pill, and progestogen-only methods such as the hormonal implant or hormonal IUD can make acne worse in some women.
• Polycystic ovary syndrome (PCOS), now also called polyendocrine metabolic ovarian syndrome (PMOS), which is covered below.
• Some medicines, including steroid tablets, anabolic steroids and lithium. Don't stop a prescribed medicine without advice from your doctor.
• Stress. In a small study of 22 university students, acne got worse during exams in step with how stressed they felt, though research on stress and acne is limited.

How is hormonal acne treated?

Treatment depends on how severe your acne is, whether it is scarring, and whether you might become pregnant. Even when hormones seem to be behind it, guidelines usually start with treatments applied to the skin, then add tablets such as antibiotics or hormonal treatments if needed.

Does the pill help hormonal acne?

Yes, for many women. The combined pill contains an oestrogen and a progestogen and lowers the level of active androgens in the blood. A Cochrane review of 31 trials found that the combined pills tested against a dummy pill all reduced acne, with few consistent differences between types.

The pill works more slowly than antibiotic tablets. A review of 32 trials found antibiotics did better at three months, but by six months the pill had caught up, so give it three to six months before judging it.

If you have PCOS (PMOS), the international PCOS guideline recommends the combined pill as the first medicine for irregular periods and excess hair. For acne with PCOS, NICE advises adding a combined pill if standard acne treatment hasn't worked well enough.

The pill isn't safe for everyone. It is usually avoided if you get migraine with aura, have had a blood clot or have a clotting disorder, have high blood pressure, or are 35 or older and smoke.

One serious risk is a blood clot in a leg or lung. Another Cochrane review found that about 2 to 4 in 10,000 women a year who don't take the pill get a clot, and that the pill raises this risk about three and a half times. Pills containing cyproterone acetate, drospirenone, desogestrel or gestodene carried more risk than those containing levonorgestrel, and your doctor will weigh this up when choosing one.

Does spironolactone help hormonal acne?

Spironolactone is a water tablet widely used for high blood pressure. It also blocks androgens, and doctors prescribe it for acne in women off-label, meaning outside the uses it was originally licensed for.

A 2023 trial called SAFA, the largest of its kind at the time, included 410 women with persistent acne in England and Wales, who could keep using their skin treatments. After 24 weeks, 82% of women taking spironolactone said their acne had improved, compared with 63% taking a dummy tablet, and the gap was bigger at 24 weeks than at 12. The researchers concluded it is a useful alternative to antibiotic tablets.

The American Academy of Dermatology gives it a weaker, conditional recommendation. In SAFA, most side effects were mild, and headaches were more common, affecting 20% of women compared with 12% on the dummy tablet. Other studies report irregular bleeding as a common side effect, possibly more so at higher doses.

Spironolactone isn't used in pregnancy because it can affect the development of a male baby's genitals, so reliable contraception is advised while you take it. It may not suit you if you have kidney problems or take certain blood pressure medicines, and your doctor may check your kidney function and potassium level before you start.

Can I treat acne if I'm pregnant, trying to conceive or breastfeeding?

Yes, but your options narrow. Isotretinoin, topical retinoids and tetracycline antibiotic tablets should be avoided in pregnancy and while planning one, and spironolactone isn't used in pregnancy either.

Azelaic acid is generally considered safe during pregnancy and breastfeeding, and NICE lists a benzoyl peroxide combination that can be used with caution in both. If you're trying to conceive, speak to your doctor before you start trying, because several acne medicines need to be stopped first.

If you're breastfeeding, tell your doctor. The advice for some treatments differs between pregnancy and breastfeeding.

How long does hormonal acne treatment take?

Expect slow change. NICE advises reviewing a skin treatment after about 12 weeks, and hormonal treatments need three to six months before you can judge them, so a slow start doesn't mean a treatment has failed.

Adult acne also tends to come back. Many women keep using a skin treatment after their skin clears to hold on to the improvement, sometimes for years.

A doctor can help you choose treatment that suits your skin, your health and any plans for pregnancy. If you'd like a doctor to look at your skin, you can start an online assessment.

Common questions