Why does PCOS cause acne, and what helps?

Acne in PCOS is hormonal acne. Androgens bind receptors in the sebaceous gland, the gland enlarges, sebum production rises and its composition changes, and the follicle becomes blocked and inflamed. That is why PCOS acne concentrates along the lower face, jawline and neck, why it tends to be deep and tender rather than superficial, and why topical treatment alone often plateaus. Treating the androgen side is what shifts it.

Hormonal treatments that work

The 2024 American Academy of Dermatology acne guideline gives conditional recommendations for combined oral contraceptives and for spironolactone to address hormonal causes of acne, and a conditional recommendation for clascoterone, a topical androgen receptor blocker. Combined oral contraceptives lower ovarian androgen output and raise sex hormone binding globulin. Spironolactone blocks the androgen receptor at the sebaceous gland. Both take about three months before a fair judgement can be made.

What stays in the plan alongside

Hormonal treatment does not replace standard acne care. A topical retinoid plus benzoyl peroxide remains the backbone for most people, and oral antibiotics have a role in inflammatory acne but should be time limited rather than run for years. For severe acne, or acne that has failed standard oral and topical therapy, the AAD gives isotretinoin a strong recommendation. Scarring acne is a reason to escalate sooner rather than to wait out another six month trial.

Spironolactone requires contraception

Spironolactone is an anti-androgen and it carries the same reproductive caution in acne as in hirsutism. The FDA label states the drug "may affect sex differentiation of the male during embryogenesis" and advises avoiding it in pregnancy. The 2023 PCOS guideline requires that anti-androgens be used in combination with effective contraception, with explicit counselling about undervirilisation of a male fetus. In practice the pill and spironolactone are often used together, which covers both the acne and the contraception.

If you have PCOS and jawline acne, ask for the hormonal options to be discussed at the same visit as the topicals, rather than after a year of antibiotics. If lesions are leaving marks or scars, say so explicitly, because that changes how quickly treatment should escalate.