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For most people, the onset of acne is synonymous with puberty. Some find they need a dermatologist to help their skin clear up, while others experience occasional pimples that go away with drugstore solutions and a little patience. Either way, many of us spend our teen years looking forward to the moment puberty ends, in hopes of being in the clear (literally and figuratively).
Unfortunately—and almost needless to say—this is often not the case. Adult-onset acne, frequently referred to as hormonal acne, is common and can lead to a whole new scramble for solutions. Keep reading to learn about the presentation and treatment of hormonal acne, so you can learn whether you might have it and how to clear it up.
Meet the Expert
Dr. Elyse Love, MD, is a board-certified dermatologist practicing medical and cosmetic dermatology at Gramercy Medical and Laser Dermatology.
What Is Hormonal Acne?
The term hormonal acne is typically used to describe adult-onset female acne, as there tends to be a strong hormonal component to this type. It tends to present in adulthood—usually in your 20s, 30s, or even 40s—and it affects both those who had cystic acne in their teen years and those who’ve hardly had any breakouts before.
Hormonal acne is almost always cystic and inflammatory in nature. It presents with painful red papules, pustules, and deep cysts on the lower face, and it can create long-term scarring (especially if you attempt to pop it). At its mildest form, hormonal acne presents with a breakout or two near menstruation, but for many, it can persist all month long.
The natural history of hormonal acne is variable by person. For some, it may last a few months before burning out, while for others, it may persist for years.
Where Do Hormonal Breakouts Usually Pop Up?
In general, face mapping for acne is not substantiated. The one exception is adult-onset female acne, or hormonal acne, which tends to occur most commonly on the lower face and the body. Typical areas of involvement include:
- Lower cheeks
- In between the brows.
Signs Acne is Hormonal
Your Acne (or This Type of Acne) First Presented in Adulthood
There are two classic stories for hormonal acne:
- A patient who has never had particularly acne-prone skin, who suddenly experiences painful cysts and inflammatory papules on the lower face in adulthood.
- A patient who had acne as a teenager that either resolved on its own or with isotretinoin therapy (best known as Accutane). Then in adulthood, they began to experience inflammatory acne on the lower face.
Of course, there are thousands of variations of this story, but most people fall into one of these broad categories. Hormonal acne presents during a phase of life that we typically think of as unexpected for acne, especially for painful, cystic breakouts like these.
Your Acne Is Cyclical
At its mildest, hormonal acne may only occur at certain points during your regular menstrual cycle. For many people, that is usually in the days preceding your period. For others, it may be near ovulation, which typically occurs 2 weeks prior. For still others, acne may happen throughout the month but worsen around menses or ovulation.
Your Acne Is Painful
Hormonal acne tends to present with deep cysts underneath the skin and red, painful papules and pustules on the lower face. Whiteheads and blackheads can occur, but they're usually not the main type of breakout for those with hormonal acne.
Your Back Is Breaking Out
Hormonal acne often affects the face and the body, but it can also occur mainly the body. If this is happening to you, you'll likely find inflammatory papules and cysts instead of the small pustules that can be seen in folliculitis.
Your Acne Didn't Respond to Isotretinoin
Isotretinoin (a common brand is Accutane) is one of my favorite medications because it has the potential to provide a long-term cure for acne. The one exception: hormonal acne. This form of acne is classically resistant to isotretinoin therapy: skin may improve during treatment, but the cystic breakouts may flare up again soon after stopping. Sometimes I still use this therapy for hormonal acne, but it is always with the understanding that we will likely still need additional treatment after the course.
You Stopped Taking Oral Contraception
A number of oral contraception options (birth control pills) are approved for the treatment of acne, and in general, most therapies that contain estrogen will help with breakouts. Many women start oral contraception in the teen years and continue into adulthood. For many women, their oral contraception is secretly preventing underlying hormonal acne, and they may only find out when they stop their oral contraception.
You Switched from Oral Contraception to an IUD
Long-acting, reversible contraception options such as IUDs are amazing for the purpose of birth control, but they do not provide the same acne-fighting benefits as the estrogen in their oral counterparts. Therefore, many women will notice a flare-up in their acne when they switch from an estrogen-containing birth control pill to a hormone-free or progesterone-only form of contraception.
You Have Excess Facial Hair and Inflammatory Acne
Increased testosterone levels can lead to inflammatory acne, excess facial hair, and early thinning of hair at the front of the scalp. Not everyone with hormonal acne has elevated testosterone, but having more than one of these symptoms makes this more likely.
You Have Polycystic Ovarian Syndrome (PCOS)
Polycystic ovarian syndrome (PCOS) is a clinical hormonal syndrome affecting an estimated 10 to 15% of people with uteruses, and may be associated with increased facial hair growth, early thinning of hair at the front of your scalp, weight gain, and elevated glucose levels. Perhaps unsurprisingly, inflammatory hormonal acne is a common occurrence for those who have PCOS.
Your Acne Flares with Stress
Our body is interconnected and stress causes abnormal fluctuations in hormone levels, which can trigger mild to severe inflammatory acne.
Treatment Options for Hormonal Acne
By far, the most specific treatment for hormonal acne is a form of hormone regulation, especially for cystic breakouts. Spironolactone helps to minimize the hormonal fluctuations that contribute to acne breakouts. It specifically works to lower and stabilize the levels of testosterone-related hormones.
Since it does not contain estrogen, it does not commonly have side effects like moodiness or bloating. In fact, the most common side effect is increased urination, and possibly irregular periods for those not on birth control. Otherwise, it is often well-tolerated, and can also treat things like excess facial hair, early hair loss, and polycystic ovarian syndrome.
Estrogen-containing Oral Contraception Pills
For those who are looking to start (or restart) oral birth control and are a good candidate, this can be an effective way to both treat acne and prevent pregnancy. Since there are more effective forms of birth control, I make sure my patients are aware of this option but I ultimately think it’s important to choose the best birth control for your lifestyle and not necessarily factor in hormonal acne, since there are other effective treatments if another form of birth control works better for you.
Topical antibiotics such as dapsone, minocycline, and clindamycin can make a significant difference in the number, intensity, and persistence of inflammatory lesions.
Benzoyl peroxide is one of my favorite acne-fighting ingredients. It's available as a prescription but also readily available over the counter. Benzoyl peroxide can sometimes be irritating, so my favorite over-the-counter formulation is CeraVe Acne Foaming Cream Cleanser, which is designed to be gentle on sensitive skin. You can use it up to twice a day, but I always recommend starting with a few times a week and slowly increasing the frequency as your skin builds a tolerance to the product.
Topical retinoids are my favorite skincare products, period. They help to exfoliate skin, even tone, fade post-inflammatory hyperpigmentation, prevent whiteheads and blackheads, and prevent inflammatory papules. I have a few favorite prescription products that I decide between based on my patient’s skin type and acne presentation. If you're interested in an over-the-counter retinoid, though, Differin is a widely accessible option. I recommend starting every third day and increasing to daily as tolerated.
A Healthy Diet
High glycemic index foods (sugary foods and/or processed breads), dairy (particularly skim milk), whey protein, biotin, B12 supplements, and iodine supplements have all been linked to worsening of inflammatory acne. Maintaining a healthy diet centered around whole, non-processed foods is helpful to supplement an acne routine. For those with mild acne, a healthy diet may be enough to control symptoms. For those with more moderate to severe breakouts, a balanced diet will minimize the amount of treatment needed. It's important to understand that what you eat is important to your health in all ways, but changing your diet may not be able to cure all things.
Consider Zinc Supplements
Zinc is anti-inflammatory and can provide natural benefits for acne. Most studies have been performed with oral zinc supplements, but topical zinc is likely also helpful.
Society makes us believe that acne is only a problem for teenagers, but adult-onset hormonal acne is a common, often-frustrating experience. It typically presents with painful papules and cysts on the lower face, and is best treated with a combination of topical and oral therapies. Since inflammatory acne can be scarring, I recommend seeking out a dermatologist for evaluation and treatment as soon as possible. In the meantime, try out over-the-counter benzoyl peroxide and adapalene, as both can help to provide a degree of relief.