PCOS, how to treat hormonal acne

What is the link between hormonal acne and PCOS?

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

Acne: A Common Symptom of PCOS

According to the National Institutes of Health criteria for the assessment of hyperandrogenism, more than 75% of women with PCOS have hormonally induced acne. Far beyond a simple cutaneous manifestation, this acne can significantly impair quality of life, affecting self-esteem and psychological health.

In its severe forms, it results in the appearance of erythematous cysts (red and swollen lesions) or comedones (blackheads), replacing the smooth and even appearance of the skin with painful and visible imperfections. In the absence of appropriate treatment, these lesions can give way to permanent scars, lastingly marking the skin and sometimes the patients' experiences.

The role of androgens in the onset of acne

In women, androgens, male sex hormones including testosterone , are produced mainly 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 . The latter, sensitive to testosterone, see their activity stimulated: they promote the proliferation of follicular cells, increase the production of sebum and alter skin cell renewal.

Additionally, these glands contain enzymes that can convert inactive hormone precursors , such as dehydroepiandrosterone (DHEA) and androstenedione, into active androgens like testosterone and dihydrotestosterone (DHT), amplifying their effect on the sebaceous glands. This excessive sebum production clogs pores, promotes bacterial proliferation, and leads to the formation of inflammatory comedones that cause acne.

Natural approaches and healthy living

Treatment of PCOS-related acne is based on a comprehensive approach, combining lifestyle improvements and regulation of hormonal disorders, particularly hyperandrogenism.

The impact of diet and dietary supplements

Favoring a diet with a low glycemic index , rich in fiber , antioxidants and essential fatty acids can help reduce inflammation and stabilize hormone production . A varied , balanced diet, favoring raw and organic products , is part of a Mediterranean model in accordance with the recommendations of the National Nutrition Health Program (PNNS).

Furthermore, supplementation with vitamin D3, myo-inositol and folic acid has been shown to be effective in reducing acne as early as eight weeks in women with PCOS, with a 69% reduction in inflammatory acne lesions.
and 63% of non-inflammatory lesions. This synergy of active ingredients, enriched with omega-3, also helps regulate hyperandrogenism by reducing the basal level of LH, improving the LH/FSH ratio characteristic of PCOS, as well as lowering testosterone levels.

The importance of a healthy lifestyle and physical activity

Finally, a healthy lifestyle : stopping smoking, moderating alcohol consumption, regular moderate-intensity physical activity, in theory at least 150 minutes per week (walking, cycling, etc.) and weight control can reduce hyperandrogenism and its symptoms . Targeted support to better manage stress, anxiety or sleep disorders can also support the overall balance of the body.

Medical Solutions to Treat PCOS Acne

Contraceptive pills

Among medical options, combined estrogen-progestin oral contraceptives (COPs) represent the first line of pharmacological treatment. These pills, which combine estrogen and progestin, are widely prescribed to regulate irregular menstrual cycles and reduce the effects of androgen excess . There is no specific 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 is based on two main effects. On the one hand, the estrogenic component stimulates the hepatic production of sex hormone binding globulin (SHBG), which decreases the amount of free testosterone , responsible for skin manifestations. On the other hand , the progestin component inhibits the release of gonadotropin-releasing hormone (GnRH), leading to a decrease in LH levels , a key factor in ovarian androgen production. These combined effects help to alleviate acne while restoring menstrual regularity.

Spironolactone and other antiandrogens

When estrogen-progestin contraception does 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 inhibiting a key enzyme in their synthesis and increasing SHBG . This dual mechanism reduces the production and action of androgen hormones, thereby reducing acne.

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

However, careful medical supervision is essential when taking spironolactone to prevent side effects such as hypotension or malaise. 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 remains an option under surveillance for resistant acne.

Skin care and antibiotics: treating inflammation at the source

Topical treatment of acne 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 renewal . To limit frequent skin irritations 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 flaking (loss of small layers of skin) associated with treatment.

Topical antibiotics are generally not recommended , except to delay or avoid oral antibiotic therapy. The latter is mainly based on cyclines , such as doxycycline or lymecycline, used in combination with local treatment. However, cyclines should be avoided in cases of significant sun exposure, due to the risk of photosensitization, as well as in women who are pregnant or planning to become pregnant.

Finally, in severe forms of acne, treatment with oral isotretinoin may be considered, either after the failure of the combination of oral antibiotics and local treatment, or as a first-line treatment in the event of a high risk of scarring. This drug, effective but potentially dangerous , requires strict monitoring due to its teratogenic and psychiatric effects. The prescription is accompanied by a rigorous protocol, including in particular the guarantee of effective contraception in the patient, the absence of pregnancy and the provision of a monitoring card.

This article is for informational purposes only and does not replace consultation or advice from your doctor. Seek professional advice before starting any dietary supplement.

[Scientific references]

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