Hormonal Acne: Causes and Targeted Treatment

Acne isn't only a teenage problem. In my clinic I often see breakouts in men who have started testosterone, trans men starting testosterone and women with jawline acne before their periods. All these groups have one thing in common: hormones. The good news is that it can be treated if you choose the right approach.

How do hormones cause acne?

Male hormones, or androgens, such as testosterone and DHT, stimulate the oil glands to grow and produce more oil. Together with blocked pores, the bacterium Cutibacterium acnes and inflammation, the result is acne.

Common situations:

• Men on TRT, especially injections where hormone levels rise and fall a lot; see TRT side effects
• Trans men starting testosterone, often worst in the first year; see Testosterone side effects in trans men
• People using anabolic steroids for muscle: severe acne on the back and chest is a common sign; see Steroids and PEDs
• Women: acne along the jawline and chin before periods, or together with irregular periods, excess hair growth or thinning hair, which may be polycystic ovary syndrome (PCOS)
• Whey supplements and high-sugar foods: moderate evidence that they make acne worse in some people

Treatment by severity

The American Academy of Dermatology (AAD) 2024 guidelines summarize the evidence-based options as follows.

Mild to moderate acne: start with topical treatments

• Benzoyl peroxide kills bacteria and reduces antibiotic resistance; it can bleach fabric
• Topical retinoids, such as adapalene and tretinoin, reduce blocked pores. You need to use them consistently for 8–12 weeks to see results, and at first they may cause dryness and peeling.
• Topical antibiotics, such as clindamycin, should always be used together with benzoyl peroxide, never alone
• Clascoterone, a topical anti-androgen that works locally, can be used by both men and women, but may still be hard to find in Thailand

Moderate to severe inflammatory acne: add oral medicines

• Tetracycline-class antibiotics, such as doxycycline, used together with topical treatment, and limited to about 3–4 months to reduce antibiotic resistance
• Combined hormonal contraceptives for women without contraindications, for example not smoking at age 35 or over, no migraine with aura and no history of blood clots
• Spironolactone, an anti-androgen for women and trans women, some of whom already take it as part of their hormone regimen; see MTF hormone regimens. It isn't used in men or trans men because it blocks male hormones.

Severe acne, nodular acne or early scarring

Oral isotretinoin works very well in severe acne, but must be used as prescribed by a doctor with close monitoring.

• Pregnancy must be absolutely avoided, because it causes severe birth defects. Anyone who can become pregnant must use effective contraception throughout treatment and for as long afterwards as the doctor advises.
• Liver tests and blood fats are monitored
• Watch for low mood or thoughts of self-harm
• Never combine it with tetracycline antibiotics
• Dry lips, dry skin and a dry nose are normal and manageable

Mild–moderateStart with topicalsBenzoyl peroxide, topical retinoids; use for 8–12 weeks

Moderate–severeAdd oral treatmentAntibiotics for 3–4 months, or hormonal pills in women

Severe / scarringIsotretinoinAs prescribed, close monitoring, no pregnancy

MildSevere

All medicines are used as assessed by your doctor.

If acne comes from TRT or gender-affirming hormones, do I have to stop?

Mostly, no. The approach is:

1. Check hormone levels and hematocrit to see whether the dose is too high
2. Adjust the form or frequency, for example smaller, more frequent injections, or switching to gel, to reduce hormone peaks; see Testosterone injections vs gel
3. Treat the acne with standard treatment at the same time
4. Isotretinoin can be used by people on hormones, but only under a doctor's care

1. 1Check hormone levelsAnd hematocrit, to see if the dose is too high
2. 2Adjust the regimenSmaller, more frequent injections, or switch to gel to smooth peaks
3. 3Treat the acne tooBy standard severity-based care
4. 4Severe acneIsotretinoin can be used under medical care

Everyday skin care

• Wash your face twice a day with a gentle cleanser; don't scrub hard
• Use non-comedogenic moisturizer and sunscreen, especially when using retinoids
• Don't squeeze, pick or press pimples yourself, as this increases dark marks and scars
• Change pillowcases and wash helmets and cloth face masks often
• Cut down on high-sugar foods and notice whether whey or milk makes you break out
• Extraction, steroid injections into spots, chemical peels and lasers are add-on treatments, not the main treatment

When to see a doctor

• Inflamed lumps, deep painful spots, or the start of pitted scars
• No improvement after 2–3 months of over-the-counter topical treatment
• Acne together with irregular periods, excess hair growth or thinning hair
• Breakouts after starting hormones or steroids
• Acne that makes you stressed or avoid social situations

At Dr. Kris Clinic I manage hormone-related acne together with your hormone care, both TRT and gender-affirming hormones, adjust doses appropriately, and refer you to a dermatologist when acne is severe or scarring is significant. English-speaking consultations are available.