PCOS, how to treat hormonal acne

1. What is the link between hormonal acne and PCOS?

Hyperandrogenism associated with PCOS plays a major role in the development of hormonal acne.

A. Acne: a common symptom of PCOS

According to the National Institutes of Health 's criteria for assessing hyperandrogenism, more than 75% of women with PCOS experience hormonally induced acne. Far beyond a simple skin manifestation, this acne can significantly impair quality of life, affecting self-esteem and psychological well-being.

In its severe forms, it manifests as erythematous cysts (red, swollen lesions) or comedones (blackheads), replacing the smooth, even appearance of the skin with painful and visible imperfections. Without appropriate treatment, these lesions can lead to permanent scarring, leaving a lasting mark on the skin and sometimes on the patients' lives.

B. The role of androgens in the development of acne

In women, androgens, male sex hormones including testosterone , are produced primarily by the ovaries, adrenal glands, and in tissues via peripheral conversion. Their production is increased in women with PCOS . These androgens act on receptors present in the skin , particularly in the sebaceous glands . These glands, sensitive to testosterone, experience stimulated activity: they promote the proliferation of follicular cells, increase sebum production, and impair skin cell renewal.

Furthermore, these glands contain enzymes capable of converting inactive hormonal precursors , such as dehydroepiandrosterone (DHEA) and androstenedione, into active androgens like testosterone and dihydrotestosterone (DHT), thus amplifying their effect on the sebaceous glands. This excessive sebum production clogs pores, promotes bacterial growth, and leads to the formation of inflammatory comedones, which cause acne.

2. Natural approaches and lifestyle

The treatment of acne related to PCOS relies on a comprehensive approach, combining lifestyle improvement and regulation of hormonal disorders, particularly hyperandrogenism.

A. The impact of diet and dietary supplements

Prioritizing a low-glycemic-index diet rich in fiber , antioxidants, and essential fatty acids can help reduce inflammation and stabilize hormone production . A varied , balanced diet, favoring whole, unprocessed, and organically grown foods , aligns with a Mediterranean model consistent with the recommendations of the French National Nutrition and Health Program (PNNS).

Furthermore, supplementation with vitamin D3, myo-inositol, and folic acid has proven effective in reducing acne in as little as eight weeks in women with PCOS, with a 69% reduction in inflammatory acne lesions and a 63% reduction in non-inflammatory lesions. This synergistic blend of active ingredients, enriched with omega-3 fatty acids, also helps regulate hyperandrogenism by lowering basal LH levels, improving the LH/FSH ratio characteristic of PCOS, and reducing testosterone levels.

B. The importance of a healthy lifestyle and physical activity

Finally, a healthy lifestyle —quitting smoking, moderating alcohol consumption, engaging in regular moderate-intensity physical activity, ideally at least 150 minutes per week (walking, cycling, etc.), and maintaining a healthy weight —can help reduce hyperandrogenism and its symptoms . Targeted support for managing stress, anxiety, or sleep disorders can also contribute to overall well-being.

2. Medical solutions for treating acne due to PCOS

A. Contraceptive pills

Among medical options, combined oral contraceptives (COCs) are the first-line pharmacological treatment. These pills, which combine estrogen and progestin, are widely prescribed to regulate irregular menstrual cycles and reduce the effects of excess androgens . There is no single superior preparation for patients with PCOS, but the use of low-dose estrogen formulations, often natural, is preferred to limit side effects and metabolic risks.

The mechanism of action of combined contraceptives relies on two main effects. First, the estrogenic component stimulates the liver's production of sex hormone-binding globulin (SHBG), thereby reducing the amount of free testosterone , which is responsible for skin-related acne. Second , the progestin component inhibits the release of gonadotropin-releasing hormone (GnRH), leading to a decrease in luteinizing hormone (LH) levels , a key factor in ovarian androgen production. These combined effects help to alleviate acne while restoring menstrual regularity.

B. Spironolactone and other anti-androgens

When combined oral contraceptives do not effectively control hyperandrogenism and acne, anti-androgen therapy may be considered. Spironolactone , a synthetic derivative of progesterone, is an attractive alternative due to its efficacy and tolerability. It works by competitively blocking testosterone and DHT receptors , while simultaneously inhibiting a key enzyme in their synthesis and increasing SHBG . This dual mechanism reduces the production and action of androgen hormones, thus diminishing acne.

Cyproterone acetate , often combined with an estrogen such as ethinylestradiol, can also enhance androgenic inhibition in cases of failure or intolerance to the combined pill.

However, close medical supervision is essential when taking spironolactone to prevent side effects such as hypotension or dizziness. Regarding cyproterone acetate, its use at doses ≥ 10 mg is not recommended due to the increased risk of meningioma. Its use is not recommended as a first-line treatment due to the risk of thrombosis, but it remains a monitored option for resistant acne.

C. Skin care and antibiotics: treating inflammation at the source

Topical acne treatment often relies on agents such as retinoids (tretinoin, adapalene, trifarotene) or benzoyl peroxide , sometimes supplemented with azelaic acid. These treatments work by reducing inflammation and regulating cell turnover . To limit the skin irritation that is common at the beginning of treatment, it is advisable to space out applications, for example, once every two or three days, and to use a moisturizer . Regular application of a moisturizer suitable for acne-prone skin helps maintain the skin barrier and reduce dryness and peeling (the shedding of small layers of skin) associated with treatment.

Topical antibiotics are generally discouraged , except to delay or avoid oral antibiotic therapy. Oral therapy primarily relies on tetracyclines , such as doxycycline or lymecycline, used in combination with topical treatment. However, tetracyclines should be avoided in cases of significant sun exposure, due to the risk of photosensitivity, as well as by women who are pregnant or trying to conceive.

Finally, in severe cases of acne, oral isotretinoin treatment may be considered, either after the failure of combined oral antibiotic therapy and topical treatment, or as a first-line treatment in cases of high risk of scarring. This medication, effective but potentially dangerous , requires close monitoring due to its teratogenic and psychiatric effects. The prescription is accompanied by a rigorous protocol, including, in particular, ensuring the patient is using effective contraception, confirming the absence of pregnancy, and providing a monitoring card.

This article is for informational purposes only and is not a substitute for consultation or advice from your doctor. Consult a healthcare professional before starting to take any dietary supplement.

Scientific references

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