Why adult acne is different from teenage acne
Adolescent acne is driven primarily by the surge in androgens that accompanies puberty, which increases sebum production and creates the environment for Cutibacterium acnes (formerly Propionibacterium acnes) overgrowth and inflammation. Most patients expect acne to resolve as puberty ends.
Adult acne — defined as acne persisting after age 25 or newly emerging in adulthood — has a different profile. It is more common in women than men (adult acne predominantly affects women; the reverse is true in adolescence). It tends to cluster along the lower face: the jaw, chin, and lower cheeks, corresponding to the areas with the highest density of androgen-sensitive sebaceous glands. And it is more likely than teenage acne to have a hormonal driver.
The hormonal patterns that cause adult acne
Several hormonal mechanisms are implicated in adult female acne:
Relative androgen excess. Sebaceous glands are regulated by androgens — testosterone, DHEAS, and their metabolite 5-alpha-dihydrotestosterone. Elevated androgens increase sebum production. In adult women, androgen levels do not need to be dramatically elevated by clinical standards to drive acne; even within the "normal" range but at the higher end, sebaceous glands may be responsive.
Increased androgen sensitivity. Some women have sebaceous glands that are more sensitive to normal androgen levels. This is the mechanism in women whose hormonal panels are entirely normal but who have persistent acne — the issue is the tissue's response, not the hormone level itself.
PCOS. Elevated androgens from ovarian and adrenal sources are a central feature of hyperandrogenic PCOS phenotypes. Acne, often described as "hormonally triggered" and following the jaw-chin distribution, is one of the clinical manifestations of androgen excess in PCOS. The evaluation of adult female acne should always include a PCOS assessment.
Perimenstrual flare. Many adult women with hormonal acne describe a predictable flare in the days before menstruation, corresponding to the luteal phase drop in oestrogen and relative progesterone-androgen dominance. This cyclical pattern is itself a diagnostic clue.
The evaluation your doctor performs
When adult acne — particularly in women, and particularly in a jaw/chin distribution — presents for evaluation, the clinical assessment includes:
Hormonal panel. The most informative tests in adult female acne:
- Total and free testosterone: elevated in hyperandrogenic states
- DHEAS: an adrenal androgen; elevated in congenital adrenal hyperplasia (CAH) and some PCOS phenotypes
- LH and FSH: elevated LH relative to FSH is a feature of many PCOS phenotypes
- Prolactin: hyperprolactinaemia can drive androgen excess
- TSH: hypothyroidism is associated with acne through changes in sebum composition and skin barrier function
Assessment for PCOS. Given the high overlap between adult acne and PCOS, an evaluation for cycle regularity, ovarian morphology on ultrasound, and the full Rotterdam criteria features is appropriate.
Medication history. Several medications can cause or worsen acne: high-androgenic progestogens (in certain OCPs), lithium, some antiepileptics, and systemic corticosteroids.
Skin evaluation. The distribution (comedonal, papulopustular, nodular), severity, and location guide both diagnosis and treatment.
The treatment framework
Adult hormonal acne responds differently from adolescent acne to standard topical treatment. Patients who have used over-the-counter topical retinoids and benzoyl peroxide without satisfactory results may need hormonal management rather than stronger topical agents.
Oral contraceptive pills (OCPs) with low-androgenic or anti-androgenic progestogens. Not all OCPs are equivalent for acne — the progestogen component matters significantly. Desogestrel, gestodene, and cyproterone acetate-containing OCPs are anti-androgenic; norethisterone and levonorgestrel are more androgenic and may worsen acne.
Spironolactone. An aldosterone antagonist with anti-androgenic properties, used off-label for adult hormonal acne in women. It reduces sebum production and is particularly effective for the jaw-chin distribution. It is not appropriate in pregnancy.
Topical retinoids. Adapalene and tretinoin remain effective components of adult acne management, particularly for comedonal components.
Addressing underlying conditions. If PCOS is identified, treating the metabolic-hormonal root — including insulin sensitisation — may improve acne substantially. Acne in PCOS that is treated only with topical agents without addressing the underlying hormonal environment often responds incompletely.
The appropriate management depends on severity, hormonal findings, contraceptive needs, and the patient's reproductive plans. It is a clinical decision, not a formulaic protocol.