Hormonal Acne in Adults: Causes, PCOS Signs and Treatments

“Hormonal acne” isn’t an official diagnosis, but it’s a useful label for something very real: acne in adult women that flares with the menstrual cycle and often clusters around the jawline, chin and neck. Androgens (hormones such as testosterone, which everyone has) drive oil production, so treatments that dial down their effect on the skin can help. The evidence-based toolkit is topical retinoids and benzoyl peroxide first, with prescription options such as spironolactone, combined oral contraceptives or clascoterone to discuss with a clinician. Most women with adult acne have normal hormone levels, but some signs are worth checking for PCOS.

What is hormonal acne in adults?

Acne doesn’t always stop after the teens. The American Academy of Dermatology (AAD) notes that some adults continue to get acne into their 30s, 40s and even 50s, and that women get adult acne more often than men. A 2018 review of adult-onset acne puts the figure at roughly 12% to 22% of adult women in North American data, compared with about 3% of men aged 25 and over in one community survey.

That review describes two patterns. Persistent acne continues from adolescence into adulthood and makes up most cases. Late-onset acne starts after age 25. The authors suggest that late-onset cases are the ones where it’s more worth looking for an underlying hormonal condition.

The AAD lists several contributors to adult acne: hormone fluctuations (around periods, pregnancy, perimenopause, menopause, or starting or stopping birth control), stress, a family history of acne, hair and skin care products, medication side effects and, occasionally, an undiagnosed medical condition.

Is jawline acne always hormonal?

This is where the internet oversimplifies. The classic description is real: StatPearls notes that adult women commonly get acne on the lower face and neck, often flaring with their menstrual cycle, and the 2018 review describes mostly mild to moderate inflamed spots along the jawline, around the mouth and on the side of the neck. The AAD also flags breakouts along the lower face, jawline and neck as a pattern that may respond to hormonal therapy.

But a large international study of 374 adult women with acne found that 89.8% had acne in multiple facial zones (cheeks, forehead, jawline, temples) and 93.7% had comedones, so in most cases the distribution looked similar to teenage acne. The authors concluded treatment should target every lesion type. The practical takeaway: a jawline pattern is a clue, not a diagnosis, and you’ll usually still need a pore-unclogging topical, not just a hormone-focused one. For a refresher on lesion types, see types of acne.

What do androgens have to do with it?

Androgens stimulate the oil glands. StatPearls lists increased sebum production as one of the four core processes behind acne, alongside clogged follicles, Cutibacterium acnes and inflammation. The AAD also points out that stress can increase androgen production, which stimulates oil glands and hair follicles.

Importantly, most adult women with acne do not have abnormal hormone levels. The 2018 review states that most patients don’t have an endocrine disorder capable of causing their acne; when one is present, polycystic ovary syndrome (PCOS) is the main cause. Hormonal treatments don’t depend on an abnormal blood test, either: the SAFA spironolactone trial described below enrolled adult women with persistent acne, not women with a diagnosed hormone disorder.

Could it be PCOS? Signs to mention to a clinician

PCOS is common. MedlinePlus reports prevalence estimates of 4% to 21% depending on diagnostic criteria, often cited as 6% to 10% of women worldwide. It notes that most women with PCOS produce excess androgens, which can cause:

• Excess body or facial hair growth (hirsutism)
• Acne
• Male-pattern hair thinning
• Irregular or absent periods, and difficulty getting pregnant

MedlinePlus also notes that many women with PCOS have raised insulin levels. The AAD adds that new acne, or really severe acne you didn’t have before, can sometimes signal an underlying hormonal problem such as PCOS. If you notice acne alongside irregular periods or new hair growth, raise it with a GP, gynaecologist or dermatologist. Diagnosis isn’t something to do from a checklist.

What treatments have evidence for adult hormonal acne?

Start with the topical basics

The 2024 AAD guideline of care makes strong recommendations for topical retinoids and benzoyl peroxide, and those remain the foundation for adults too. The AAD’s adult acne guidance lists adapalene, azelaic acid, benzoyl peroxide and salicylic acid as useful active ingredients, and suggests starting benzoyl peroxide at 2.5%. Azelaic acid can also help fade dark marks. More on building a routine in adult hormonal acne routine.

Spironolactone

Spironolactone is an older blood-pressure and heart-failure drug that StatPearls describes as an oral anti-androgen: it blocks androgen receptors and reduces androgen production. It’s used off-label for acne: the FDA label doesn’t list acne as an indication. The 2024 AAD guideline gives it a conditional recommendation.

The best trial so far is SAFA, a UK double-blind randomised trial published in the BMJ in 2023. It randomised 410 women with persistent facial acne to spironolactone (50 mg/day, rising to 100 mg/day) or placebo. At week 24, 82% on spironolactone reported improvement versus 63% on placebo; at week 12 the difference in self-reported improvement wasn’t significant (72% vs 68%), though more reached “treatment success” on the investigator’s assessment (19% vs 6%). Headaches were more common (20% vs 12%), and no serious adverse reactions were reported. The lesson: spironolactone is slow, and judging it at 3 months may be too early.

Safety is a real conversation. The AAD warns that it can cause serious birth defects if you get pregnant while taking it, so anyone who could get pregnant needs contraception; it isn’t prescribed for acne in men because of breast development. The FDA label notes that, based on animal data, spironolactone may affect sexual development of a male fetus. Side effects listed by the AAD include irregular or painful periods, breast tenderness, fatigue, headache and dizziness. On potassium, a study of 974 healthy young women on spironolactone for acne found a 0.72% rate of mild high potassium, equivalent to the 0.76% baseline rate, and concluded that routine monitoring is unnecessary for healthy women. Your clinician may still order blood tests, particularly if you have kidney problems or take other medicines. Deeper detail is in spironolactone for acne.

Combined oral contraceptives (COCs)

The Cochrane review of combined pills for acne included 31 trials with 12,579 participants: every placebo-controlled trial found COCs reduced lesion counts and severity, with few consistent differences between pill types. How they compare with other acne treatments is largely unknown. The AAD says some oral contraceptives are FDA-approved for acne and results take 2 to 3 months, but that the pill raises the risk of blood clots, heart attack and high blood pressure. A Scottish NHS pathway also notes that progestogen-only contraception may worsen acne, and StatPearls says progestin-only methods are not considered effective for acne and may exacerbate it. Whether a pill suits you depends on your wider health history, so this is firmly a clinician conversation.

Clascoterone cream

Clascoterone 1% is a prescription topical androgen receptor inhibitor approved for acne in people aged 12 and over. In the two 12-week trials on its FDA label (1,421 participants), 18.8% and 20.9% reached treatment success versus 8.7% and 6.6% with the base cream. The label warns of possible adrenal (HPA axis) suppression and raised potassium, and there are no data on use in pregnancy. It has a conditional recommendation in the AAD guideline.

How long do hormonal acne treatments take?

Longer than you’d like. The AAD says birth control pills take 2 to 3 months to show results. In SAFA, the gap between spironolactone and placebo was much larger at week 24 than at week 12. Topicals need time too; see how long acne treatments take for realistic timelines.

Frequently asked questions