Hormonal acne is one of my favorite topics to discuss—and I’m going to be upfront and tell you that there’s a lot of fuzzy information out there. So many of my patients wonder what role hormones play in acne. Let me tell you: A huge one.

Acne erupts when hormonal levels are elevated, in adolescence and puberty in particular, but also during a woman’s menstrual cycle and pregnancy. The hormones we’re largely talking about here are estrogen and testosterone (you may also hear a lot about androgens, a blanket term for male hormones including testosterone). We know that hormones can increase sebum production, a waxy oil-like substance produced by the sebaceous glands that live in your pores. They also play a role in inflammation and in the plugging of your pores—all major components of acne. But are hormonal breakouts their own category of acne? Let’s get to that. 

The truth: All acne is hormonal 

Hormones are one of the root causes of all acne; if you don’t have hormones, you don’t have acne. We know this because people who are born without functional androgen receptors never break out. Literally, never. In adult women, we tend to see acne appear on the lower face (we don’t see pimples concentrated in the same area in adolescent girls or men), so this has been mislabeled as “hormonal” acne. It’s a bad name: Whether you’re a teen, a man, or a woman, whether it’s on your face or your back, it’s always hormonal acne. Any event that causes a hormonal imbalance or shift has the potential to cause a hormonal acne breakout, from puberty to pregnancy.

So, why does acne appear on that part of the face in older women? We don’t really know. Research has shown that in most women, we still see a mixed picture of acne. We see red pimples, blackheads, and whiteheads, and they are scattered across the face. Still, there’s a huge difference between adolescent and adult female acne. For the most part, adolescent acne appears in the T-zone, and it’s not as inflammatory as adult female acne.  

Hormonal acne may get worse during your period

I saw one study that said that 44 percent of women experienced a worsening of their acne during their menstrual cycle, [1] but researchers don’t know why this occurs. We do know that your hormones are all over the place during your “time of the month.” There are times that estrogen surges way up and then comes way down. I’ve read hypotheses that suggest that estrogen is involved in keeping skin’s barrier (its outermost layer) healthy and helping the skin retain its moisture. That could be why, when estrogen levels are higher the skin is more moisturized and that impacts the sebaceous glands and the pore in general. But again, we don’t know the answer for sure.  

"So many of my patients wonder what role hormones play in acne. Let me tell you: A huge one."

The deal with acne and pregnancy

Pregnancy does seem to affect acne, but it’s not the same for all women. In some, it seems to actually help improve acne. I had horrible acne growing up, and in pregnancy I had the best skin ever. But there are women—and it's usually those who've had acne earlier in their life—who experience acne flares ups, especially in the latter parts of pregnancy. The hard part is what to do about it. There are some medications that aren’t safe to use during pregnancy. So, that limits us, but it is important to treat it. More on that below.

Stress can cause hormonal acne breakouts too

Sex hormones such as estrogen and testosterone aren’t the only ones that play a role in acne. Cortisol, a hormone secreted by the body during stressful moments, can also affect your complexion. This hormone increases inflammation and is thought to stimulate your sebaceous glands to produce more oil. And we know inflammation and excess oil are two of the major causes for acne.

How do you treat hormonal acne? 

So, we already know that hormones go hand-in-hand with acne, but what can we do to manage breakouts around all those fluctuations? If a patient comes in and says her acne gets worse at a certain time of the month, I’m more inclined to use hormonal acne therapy. There are four oral contraceptives that are FDA-approved to treat acne: Yaz, Ortho-Tri-Cyclen, Beyaz, and Estrostep FE. They’re all combinations of estrogen and progestin. If someone doesn’t want an oral contraceptive, we can use the anti-androgen drug, spironolactone, off-label because it’s not approved for acne. Topical prescription medications may include retinoids, which speed up cell turnover so pores stay clear, and antibiotics with benzoyl peroxide.

During pregnancy, I often recommend my A-B-C method for safe topical treatment. A is azelaic acid, which has antibacterial properties and works by clearing pores. B is for benzoyl peroxide, which kills acne-causing bacteria and has a mild anti-inflammatory effect. C is clindamycin, a topical antibiotic. For oral acne treatments during pregnancy, I recommend A-C-E for the oral antibiotics amoxicillin, cephalexin, and erythromycin. These can be used for short-term treatment of acne during pregnancy. 

It’s also important to have a good skincare regimen in place, and that should be consistent through your period cycle or pregnancy: a gentle facial cleanser, a moisturizer that has both humectants like glycerin or hyaluronic acid (to draw moisture into the skin) and occlusives (to seal it in), and a non-comedogenic sunscreen that protects skin without clogging pores.

References:
[1]: The effect of the menstrual cycle on acne