The Ultimate Guide to Hormonal Acne

The Role Of Androgens In Hormonal Acne

Learn how testosterone and other androgen hormones cause acne, and how can it be that most women with acne have normal testosterone levels.

This page is part of The Ultimate Guide to Hormonal Acne series. Access the other parts using the table of contents below.

Androgen is a generic term for male sex hormones. There are several androgens, but the ones implicated in acne are:

  • Dehydroepiandrosterone (DHEA) and dehydroepiandrosterone sulfate (DHEAS)
  • Androstenedione
  • Testosterone (T)
  • Dihydrotestosterone (DHT)

In the acne development process, DHEA, DHEAS, and androstenedione act primarily as precursors to testosterone and DHT. The skin contains all the necessary enzymes for converting these precursors to T and DHT, both of which stimulate skin cell growth and sebum production far more than the precursor hormones.

Testosterone & DHT

Testosterone and dihydrotestosterone (DHT) are the classic acne hormones. When a dermatologist checks your hormones, these (among others) are the ones he/she is looking for. And when the doctor says your hormones are normal, they usually mean your testosterone levels are within the normal range.

Testosterone and DHT cause acne primarily by increasing the size and activity of the sebaceous glands (source) – in other words, they boost the amount of oil (sebum) the skin produces.

Increasing the amount of sebum the skin produces has many knock-on effects that contribute to acne:

  • When the skin produces more sebum, the concentration of linoleic acid (LA) in sebum goes down. Insufficient amount of LA in sebum is known to irritate the skin cells and has been linked to acne (source).
  • UV radiation, air pollution, and other forms of oxidative damage cause damage to squalene and turn it into squalene peroxide. Squalene peroxide is a highly comedogenic and inflammatory substance, and many scientists believe that oxidation of squalene into squalene peroxide is the trigger that starts the acne formation process (source).
  • Increased amount of sebum feeds acne-causing P. Acnes bacteria, which thrives on sebum.

If you are interested, you can learn more about how acne happens and what you can do to fix it by reading this page.

PCOS and hyperandrogenic conditions

Hormonal acne is closely linked to polycystic ovary syndrome (PCOS) and other hyperandrogenic conditions. Because they have abnormally high androgen levels, women who suffer from these problems frequently also get acne. A 1997 study showed that 39.2% of women with acne also had PCOS. Treating these conditions with diet or medications that reduce androgen levels has been shown to also reduce acne (source).

Tumors in the adrenals, ovaries, or testes sometimes lead to increased androgen production, and such tumors are known to increase the prevalence of acne (source).

Androgens also explain why bodybuilders who abuse anabolic steroids get acne. A 2007 study showed that around 50% of people who take anabolic steroids get acne.

More evidence of androgens causing acne comes from studies on people undergoing sex change. A European study from 2014 showed that acne scores increased by 375% in female – male transgenders who received male sex hormones. In contrast, acne completely disappeared in male – female transgenders who received androgen-reducing treatments.

I could list more studies and evidence, but I think you get the point.

Between 15 and 40% of women with acne have higher than normal androgen levels (hyperandrogenism). 

If you show symptoms of high androgens, please talk to a doctor about getting your hormones checked. However, keep in mind that just because you have acne doesn’t mean your testosterone levels are too high.

Symptoms of high androgen levels

  • Excessive hair growth (hirsutism) on the face, chest, abdomen, and pelvic area
  • Severe acne or sudden onset of acne
  • Acne that doesn’t resolve with typical treatments
  • Absence of, or irregular menstrual periods
  • Muscle enlargement
  • Deepening of a woman’s voice
  • Reduced breast size and enlargement of the clitoris
  • Insulin resistance
  • Polycystic ovary syndrome (PCOS)

Having acne doesn’t mean your testosterone levels are too high

There’s overwhelming scientific evidence to show that androgens cause acne, but that’s not the whole story. It’s too simplistic to say that people with acne too high androgen levels – because in most cases women with acne don’t have obvious androgen abnormalities. In fact, a 2000 study showed that severity of acne in women doesn’t depend on blood androgen levels. Women with the most severe acne had lower testosterone levels than women with milder acne.

So how is it possible to have hormonal acne if your hormone levels are normal? Because the skin produces the hormones that cause acne from precursor hormones.

15 to 40% of women with acne have higher than normal androgen levels

DHEA and other androgen precursor hormones

I have read over a dozen studies looking at hormone levels in women with acne. Most show minor abnormalities. The most consistent finding was that women with acne have higher levels of DHEA than women without acne.

Dehydroepiandrosterone (DHEA) and its sulfate DHEAS are precursor hormones for more potent testosterone and DHT. While they have many effects on their own, we are mainly interested in them as raw materials for making testosterone and DHT.

The skin has all the enzymes required for converting DHEA and DHEAS into testosterone and DHT. And many scientists believe that the conversion that happens in the skin is the source of acne causing hormones – rather than high blood levels of testosterone.

“Androgens leading to acne vulgaris are produced within the sebaceous gland from dehydroepiandrosterone sulfate DHEAS”

Arora, M. K., Yadav, A. & Saini, V. Role of hormones in acne vulgaris. Clin. Biochem. 44, 1035–40 (2011).

A Swedish study published in 2000 supports this. The researchers gave nine women who suffered from Adrenal failure (Addison’s disease) DHEA supplements. 7 of the 9 women developed acne, which disappeared when the supplementation stopped.

7 out of 9 women develop acne after DHEA supplementation

Another study that followed 4th and 5th-grade girls for five years found that the girls who developed severe acne during the study had significantly higher DHEAS levels and earlier onset of menarche (the first menstrual cycle), whereas the girls who had only mild acne got their periods up to two years later.

Studies looking at androgen production in the skin also raise the possibility that the higher than normal androgen levels in acne are a result, rather than the cause, of acne. That is, acne-prone skin pumps androgens into the bloodstream, and this results in higher than normal androgen levels. This is supported by the observation that isotretinoin (Accutane) treatment reduces blood levels of DHT but has no effect on the levels of the precursor hormones.

I won’t bore you by going through all the studies. The takeaway message is that most women with acne don’t have abnormally high testosterone levels. The hormones that stimulate oil production and cause acne are produced within the skin from DHEA.

This is why it’s possible to have hormonal acne even if tests show your hormone levels are normal. These tests don’t always measure DHEAS levels and thus may not pick up the most common hormonal imbalance in women with acne.

Studies have shown that insulin and insulin like growth factor-1 (IGF-1) affect how readily the skin converts DHEA into T and DHT, and, I believe, these are the cornerstone hormones in acne.