PCOS acne: signs, causes and treatment

Polycystic ovary syndrome, or PCOS, is a common hormone condition, and acne is one of its signs. The condition has been renamed polyendocrine metabolic ovarian syndrome, or PMOS. The NHS, MedlinePlus and NICE now use the new name, and most people still search for PCOS, so this guide uses both. It covers why PCOS causes acne, the signs that point to it, how doctors diagnose it, and how PCOS acne is treated. The wider plan for hormonal acne is in the hormonal acne treatment guide.

Skinli gives general education and is not a doctor. PCOS is a medical condition. Only a doctor can diagnose it, and it affects more than the skin.

What PCOS is

The NHS describes PMOS as a hormone condition that can affect hair growth, periods, fertility and mood. MedlinePlus says the new name reflects that it affects many systems in the body. The main symptoms the NHS lists are:

• Irregular periods or long gaps between periods
• Extra hair growth on the face or body, or hair loss
• Weight gain or trouble losing weight
• Trouble getting pregnant
• Depression or anxiety
• Oily skin and acne
• Tiredness
• Thick, dark patches of skin on the neck or in the armpits

The NHS says symptoms can be mild or severe, or absent. They usually start at puberty and continue until menopause.

PCOS also matters beyond the skin. The NHS says it can raise the risk of type 2 diabetes, high blood pressure, heart disease, fatty liver disease and cancer of the womb, and that regular check-ups lower the risk. This is the main reason to get acne checked when it comes with other signs on the list.

Why PCOS causes acne

The American College of Obstetricians and Gynecologists (ACOG) says PCOS may be linked to insulin resistance, raised levels of androgens and irregular cycles working together. Androgens are male-type hormones that women also make. ACOG says high androgen levels cause the unwanted hair growth and acne seen in many women with PCOS.

NIAMS, part of the US National Institutes of Health, explains the link to the skin: androgens enlarge the oil glands and make them produce more oil. More oil means more plugged pores, and plugged pores turn into acne.

How often is PCOS behind acne? A 1997 study of 51 women at a skin clinic found PCOS in 37.3% of the women with acne, and in none of the 20 women without acne. The study was small and done at one clinic, so the share will differ elsewhere. Its authors advised asking every woman with acne about her periods.

Signs that acne may be PCOS

PCOS acne looks like other acne. What sets it apart is how it behaves and what comes with it. NICHD, the NIH's institute for women's and children's health, describes it as "severe, late-onset, or persistent acne that does not respond well to common treatments." ACOG uses similar words: acne that is severe, or that appears after the teenage years and does not respond to usual treatment.

Clue	Where it is described
Acne that is severe, starts late, or will not clear with usual treatment	NICHD and ACOG
Acne on the face, chest or back	MedlinePlus
Irregular periods or long gaps between them	NHS
Extra hair on the face, chest, belly or upper thighs	NICHD and ACOG
Hair thinning on the head	NHS and the American Academy of Dermatology
Dark, thick, velvety skin on the neck or armpits	NHS and NICHD

The American Academy of Dermatology (AAD) says women who have PCOS often have acne, and usually have other signs of a hormone problem. It says women who suspect PCOS should see their dermatologist or primary care doctor right away.

NICHD adds that many women do not mention oily skin, extra hair or acne to their doctor, because they do not think of them as signs of a serious condition. As a result, many are not diagnosed until they have trouble getting pregnant. Mention your skin at the visit.

Chin acne alone is covered in forehead and chin acne, and acne along the jaw in the jawline acne guide.

How PCOS is diagnosed

NICHD says most ways of diagnosing PCOS need two of these three features:

1. Irregular or absent ovulation, seen as irregular, light or skipped periods
2. High androgen levels, or signs of them such as extra body or facial hair
3. Growths of a certain size on the ovaries, seen on an ultrasound scan

The NHS says a doctor may arrange blood tests to check hormone levels and insulin resistance, and an ultrasound scan of the ovaries for people over 18. NICHD says there are no diagnostic criteria for teenagers yet, because many of the signs can also be part of normal puberty.

How PCOS acne is treated

Standard acne treatment comes first

The UK's NICE guideline gives an order for people with PMOS and acne. First, treat the acne with a standard first-line option, such as a gel that combines adapalene and benzoyl peroxide. If that does not work, consider adding a combined birth control pill, such as co-cyprindiol, a pill used in the UK, or another combined pill. NICE says to review co-cyprindiol at 6 months.

The standard options are covered in the hormonal acne treatment guide. Skinli's free acne plan builds a first-line routine from a photo.

Medicines that treat the hormone side

NICHD lists these options for women with PCOS. Each is a prescription medicine, and the choice depends on symptoms, overall health and pregnancy plans.

Medicine	What NICHD says it can do	Things to know
Combined birth control pills	Make periods more regular, lower androgen activity, help clear acne and reduce hair growth	NICHD says no single pill works best for PCOS. See birth control for acne
Anti-androgens, such as spironolactone	Lower androgen levels, reduce hair growth, clear acne	Can cause birth defects, so often taken with birth control pills. See spironolactone for acne
Insulin-sensitizing medicines, such as metformin	Help clear acne and reduce hair growth, help weight loss	Not FDA approved for PCOS

NICHD says many of these medicines are not FDA approved specifically for PCOS, and doctors use them to treat its symptoms. The NHS lists spironolactone to reduce hair growth and metformin to help tiredness and weight problems, along with skin creams or tablets for acne.

Weight and lifestyle

ACOG says that for women who are overweight, weight loss can relieve symptoms such as excess hair growth and acne, and even a small loss of weight may help make periods more regular. NICHD says the same about acne and hair growth. The NHS advises a healthy, balanced diet and regular exercise. The natural remedies guide covers what else has been studied.

When a specialist helps

NICE says to consider referring people with acne and PMOS who have other signs of high androgens to a specialist, such as a reproductive endocrinologist, a doctor who treats hormone problems. A 2019 review of acne in older women says that when acne returns right after a course of isotretinoin, a hormone disorder should be suspected. The Accutane guide covers isotretinoin.

PCOS acne at different life stages

• Pregnancy. A 2020 study of 295 pregnant women with acne found that those with PCOS, irregular periods before pregnancy, extra hair or higher body weight tended to have more severe acne. Spironolactone must stop in pregnancy. See pregnancy acne.
• Menopause. The NHS says some PMOS symptoms stop or change after menopause. See menopause acne and when does hormonal acne stop?.

Questions to bring to your appointment

A short list helps you get more from one visit:

• Do my periods, hair growth and skin together suggest PMOS, and which tests do I need?
• Should my acne be treated first with a gel or cream, as NICE suggests, or with a pill?
• Is a combined birth control pill safe for me, given my blood pressure, migraines and smoking?
• If I take spironolactone, what birth control do I need, and which blood tests?
• Do I need a check for diabetes, blood pressure or cholesterol?
• Should I see a hormone specialist?

When to see a doctor

See a doctor if you have acne along with irregular periods, new hair growth, hair thinning or dark patches of skin, or if acne has not cleared after a few months of steady treatment. Bring a list of your symptoms and the dates of your last few periods. The NHS says to see a GP if you think you might have PMOS or if symptoms affect your daily life.