Hormonal Acne

Hormonal acne describes acne whose pattern and timing follow androgen activity: deep, tender inflammatory lesions and nodules concentrated on the lower face — jawline, chin and neck — that flare in the week before menstruation and often persist well into adult life. It differs from adolescent acne, which spreads across the forehead and cheeks with more blackheads and whiteheads. The driver is sebaceous gland sensitivity to androgens rather than necessarily high androgen levels; most affected women have normal blood tests, and the sensitivity is at the receptor level in the skin. Androgens enlarge sebaceous glands and thicken sebum, which combines with abnormal keratin plugging and Cutibacterium acnes colonisation to produce inflammation. Polycystic ovary syndrome is the main underlying condition to consider, particularly with irregular periods, unwanted hair growth or difficulty losing weight. Practically, hormonal acne responds poorly to the scrubbing and drying approach many people try, and well to treatments that address the hormonal axis: combined oral contraceptives, spironolactone, and topical retinoids, with isotretinoin for severe scarring disease. Because deep nodular lesions scar, early effective treatment matters more than waiting it out.

• •Deep, tender, painful lumps under the skin rather than surface whiteheads
• •Concentration along the jawline, chin and neck
• •Predictable flares in the week before menstruation
• •Onset or persistence in the twenties, thirties and beyond
• •Slow resolution over weeks with post-inflammatory marks
• •Scarring from nodular lesions
• •Associated features suggesting PCOS: irregular periods, excess facial or body hair, scalp thinning

• •Sebaceous gland sensitivity to normal androgen levels
• •Polycystic ovary syndrome
• •Menstrual cycle hormonal fluctuation
• •Stopping combined oral contraception
• •Progestogen-only contraception in susceptible individuals
• •Insulin resistance raising free androgens
• •High glycaemic load diets
• •Anabolic steroid and testosterone use
• •Perimenopause with shifting oestrogen-androgen balance
• •Stress-related cortisol and androgen effects
• •Rarely, androgen-secreting tumours or congenital adrenal hyperplasia

Androgens — including normal levels acting on hypersensitive receptors — stimulate sebaceous gland enlargement and sebum output. Progesterone-dominant and oestrogen-low phases of the cycle shift the effective androgen balance, explaining premenstrual flares. Insulin resistance amplifies the picture by raising free androgens through lowered sex hormone binding globulin, which links PCOS, dietary glycaemic load and acne severity. Follicular hyperkeratinisation plugs the pore, and the resulting anaerobic, lipid-rich environment favours C. acnes proliferation and inflammatory cascade activation.