PCOS: How to treat hormonal acne

Hormonal acne is one of the most common symptoms of polycystic ovary syndrome (PCOS). More than just an aesthetic concern, it can significantly impact patients' quality of life, self-esteem, and mental health. This form of acne is primarily caused by a hormonal imbalance, particularly the overproduction of androgens, which stimulates sebum production and promotes skin inflammation. The high prevalence of acne among women with PCOS, combined with its psychological, social, and sometimes financial repercussions related to the search for effective treatments, highlights the need for tailored 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 have acne of hormonal origin. Far more than just a skin condition, this acne can significantly impair quality of life by affecting self-esteem and psychological health.

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, visible blemishes. Without appropriate management, these lesions can leave permanent scars, lasting marks on the skin and sometimes on the patients' lives.

In women, androgens, male sex hormones including testosterone, are produced primarily by the ovaries, adrenal glands, and in tissues through peripheral conversion. Their production is increased in women with PCOS. These androgens act on receptors in the skin, particularly in the sebaceous glands. Sensitive to testosterone, these glands have their activity stimulated: they promote follicular cell proliferation, 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 proliferation, and leads to the formation of inflammatory comedones that cause acne.

The treatment of acne related to PCOS is based on a comprehensive approach, combining lifestyle improvements and the management of hormonal disorders, particularly hyperandrogenism.

Prioritizing a low glycemic index, high-fiber, antioxidant- and essential fatty acid-rich diet can help reduce inflammation and stabilize hormone production. A varied, balanced diet, prioritizing whole and organically grown foods, aligns with the Mediterranean model and the recommendations of the National Nutrition Health Program (PNNS).

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

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

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

Among medical options, combined oral estrogen-progestin contraceptives (COCs) represent the first line of 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 preparation that is superior for patients with PCOS, but low-dose estrogen formulations, often natural, are 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 estrogen component stimulates hepatic production of sex hormone-binding globulin (SHBG), which reduces 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 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, thus alleviating acne.

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

However, strict 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 risk of thrombosis, but remains an option under monitoring 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 the skin irritation common at the beginning of treatment, it is recommended to space 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 the dryness and peeling (loss of small layers of skin) associated with treatment.

Topical antibiotics are generally not recommended, except to delay or avoid oral antibiotics. The latter primarily rely 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 pregnant women or those wishing to become pregnant.

Finally, in severe forms of acne, oral isotretinoin treatment may be considered, either after the failure of the combination of oral antibiotics and local treatment, or as a first-line treatment in cases of a 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 ensuring effective contraception in the patient, confirming the absence of pregnancy, and providing a monitoring card.

This article is for informational purposes only and does not replace a consultation or the advice of your doctor. Ask a healthcare professional for advice before starting to take a dietary supplement.

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