Hormonal acne: causes, PCOS links and treatment options in the UK

Hormonal acne is not a separate skin disease. It is acne in which hormone changes appear to play a larger part: spots that cluster along the jaw, flare before a period, begin in the late twenties or later, or arrive alongside other hormone-related symptoms.

The British Association of Dermatologists says acne usually starts at puberty and in most cases goes away by the early to mid twenties, but that it can last longer or appear for the first time in the late twenties and beyond. That pattern is why so many adults, particularly women, look for a hormonal explanation.

The first step in both the NHS and BAD advice is gentle skincare. The NHS suggests washing the skin twice a day with a gentle cleanser, removing make-up at the end of the day and choosing non-comedogenic products, which will not clog pores. It advises against picking or squeezing spots, which can cause scars, and against scrubbing, which irritates the skin.

Active treatments sold without a prescription include benzoyl peroxide, azelaic acid, nicotinamide and salicylic acid, and a pharmacist can advise. The leaflet says most treatments take 2 to 4 months to show their full effect, and that if over-the-counter products have not worked it is advisable to see a healthcare professional.

Prescription treatments are stronger than shop and pharmacy products. The NHS describes topical retinoids and antibiotic creams, antibiotic tablets, the combined pill to manage hormone levels, and isotretinoin to reduce inflammation and oiliness. The British Association of Dermatologists sets out how each is used and the cautions.

The British Association of Dermatologists says isotretinoin is highly effective for severe acne and its improvements can be long lasting, but that it has the potential to cause serious side effects. The skin, especially around the lips, usually becomes dry, and acne often gets a little worse for a few weeks before it improves.

The MHRA has strict rules. People able to become pregnant must join a pregnancy prevention programme, have a negative pregnancy test before starting, use reliable contraception for at least 4 weeks before, during and at least 4 weeks after treatment, and repeat tests monthly unless a highly effective user-independent method such as an implant, coil or intrauterine system is used.

The leaflet also describes a 2023 expert working group report raising concerns about mental health and sexual function. It says current research does not clearly show whether isotretinoin causes mental health problems in some people, that acne itself raises the chance of anxiety and depression, and that you should tell your clinician about any personal or family history of low mood. If your mood changes on treatment, report it without delay.

The British Association of Dermatologists (BAD) says most acne treatments take 2 to 4 months to produce their full effect, and that you should expect to use your treatments for at least 12 weeks before you see much improvement. Oral antibiotics need to be taken for at least 12 weeks and are usually continued until there is no further improvement.

On how long acne itself lasts, BAD says it usually starts at puberty and in most cases goes away by the early to mid twenties, but it can last longer or appear for the first time in the late twenties and beyond. It also says acne can get a little worse before it improves with some treatments, such as retinoids and isotretinoin.

The British Association of Dermatologists explains that acne comes from several factors working together. Oil glands near the surface of the skin respond to hormones and, in acne, make too much oil. The lining of the pores thickens, and dead skin cells and oil plug them to form blackheads and whiteheads. Bacteria that live harmlessly on everyone's skin then multiply in the oily environment and cause inflammation, producing red, swollen or pus-filled spots.

The NHS lists changes in hormone levels, such as during puberty, periods, menopause and pregnancy, among causes, along with PMOS and rosacea, certain medicines, and skin or hair products that make the skin greasy. The leaflet adds that some hormonal contraceptive preparations, high-dose steroids and the anabolic steroids some bodybuilders take can trigger or worsen acne, and that if acne suddenly gets worse it is worth discussing with a healthcare professional.

Acne can run in families, but the leaflet says many people with acne have no affected relatives, and that genetic, hormonal and lifestyle factors such as stress, skincare products and smoking probably act together. It says there is not enough evidence to support specific diets for acne, though a healthy balanced diet is advisable.

The NHS now uses the name polyendocrine metabolic ovarian syndrome (PMOS) for the condition previously called polycystic ovary syndrome, and lists oily skin and acne among its symptoms. Others are irregular periods or long gaps between them, excessive hair growth or hair loss, weight gain or difficulty losing weight, difficulty getting pregnant, low mood or anxiety, tiredness, and thick dark patches of skin on the neck or armpits.

The British Association of Dermatologists describes the condition as a hormonal imbalance causing irregular periods, unusual hair growth and hair thinning, and says that in some women excess hormones cause or worsen acne. If you have acne together with these other features, see a GP, because testing and treatment may then involve hormone and metabolic care as well as skin care.

The NHS says a GP may arrange tests with a gynaecologist or endocrinologist, including blood tests to check hormone levels and insulin resistance, and an ultrasound scan of the ovaries, which is only done if you are over 18.

BAD says there is not enough evidence to support specific diets for treating acne, although a healthy balanced diet is advisable. The NHS lists changes in hormone levels, certain medicines and skin or hair products that make the skin greasy among the things that can cause or worsen acne.

If your acne gets suddenly worse, BAD says it is worth discussing with a healthcare professional, since some hormonal contraceptive preparations, high-dose steroids and the anabolic steroids some bodybuilders take can trigger or worsen acne.

The leaflet stresses acting early, because controlling acne as soon as it appears helps avoid permanent scarring. Scars can be raised or pitted, and marks can be red or darker or lighter than the surrounding skin. Treatments for scars such as laser resurfacing, chemical peels, microneedling and steroid injections are, according to the leaflet, not routinely available on the NHS, and laser should not be carried out for at least a year after isotretinoin.

Acne can seriously affect how people feel. The NHS says it can cause anxiety, depression and low self-esteem, and the leaflet notes that severe acne has been associated with suicidal behaviour. If acne is affecting your mood, tell your GP; if you are in crisis, call 999 or contact NHS 111.