PCOS: How to treat hormonal acne

Hormonal acne is one of the most common symptoms of polycystic ovary syndrome (PCOS). More than just a cosmetic concern, it can significantly impact patients' quality of life, self-esteem, and mental health. This type of acne primarily results from a hormonal imbalance, particularly an excessive production of androgens, which stimulates sebum production and promotes skin inflammation. The high prevalence of acne in women with PCOS, combined with its psychological, social, and sometimes financial repercussions related to the search for effective treatments, underscores the need for appropriate management.

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

According to the National Institute of Health criteria for assessing hyperandrogenism, more than 75% of women with PCOS exhibit hormonal acne. Far beyond a simple skin manifestation, this acne can significantly impair quality of life by 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 homogeneous appearance of the skin with painful and visible imperfections. Without appropriate management, these lesions can leave permanent scars, marking the skin and sometimes the experiences of patients.

In women, androgens, male sex hormones including testosterone, are primarily produced 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 sebum production, and alter skin cell renewal.

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

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

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 unprocessed and organic products, aligns with a Mediterranean model consistent with the recommendations of the National Health and Nutrition Program (PNNS).

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

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

In the context of PCOS, acne is often linked to an excess of androgens: several medical treatments can then help regulate this hormonal cause and sustainably improve the skin's condition.

Among the medical options, combined estrogen-progestin oral contraceptives (COCs) represent the first-line pharmacological treatment. These pills, which combine estrogens and progestins, are widely prescribed to regulate irregular menstrual cycles and reduce the effects of excess androgens. 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 relies 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 alleviate acne while restoring menstrual regularity.

When estrogen-progestin contraception does not effectively control hyperandrogenism and acne, an anti-androgen treatment may be considered. Spironolactone, a synthetic derivative of progesterone, is an interesting alternative due to its effectiveness and tolerability. It acts 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 decreasing acne.

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

However, rigorous medical monitoring is essential when taking spironolactone, to prevent side effects such as hypotension or fainting. 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 thrombotic risk, but remains an option under surveillance for resistant acne.

Local 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 renewal. To limit skin irritations common at the start 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) related to the treatment.

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

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

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

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