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All cases of acne have their roots in hormone production, but some acne is a symptom of an underlying hormonal condition that can cause far more than facial blemishes. If troublesome blemishes are plaguing you long after your teen years are over, it’s possible that they’re telling you to look beyond your skin for the problem.

“Acne is caused by an excess of oil production, which in turn is caused by the action of testosterone,” says Geoffrey Redmond, MD, a New York endocrinologist specializing in female hormone problems. “The oil glands are the most testosterone-sensitive tissue in the human body.”

Typical adolescent acne starts when testosterone levels start to increase during puberty (in both boys and girls), but certain diseases and conditions can also send testosterone and estrogen levels up. These are particularly common in girls and women, and the most common is polycystic ovarian syndrome (PCOS).

PCOS

The most common female endocrine disorder, PCOS affects between 5%-10% of all women. It involves multiple organ systems, and although it’s not fully understood, doctors believe that it is caused by insensitivity to the hormone insulin. In addition to irregular menstrual cycles and ovulation, weight gain, and thinning hair, one of the most notable symptoms of PCOS is acne.  

“Any female patient who presents to me with either persistent acne -- they had it in their teens and it’s continued past the age of 25 -- or acne starting after age 25, I’ll evaluate for PCOS,” says Bethanee Schlosser, MD, assistant professor and director of the women’s skin health program in the department of dermatology at Northwestern University’s Feinberg School of Medicine.

PCOS-related acne tends to flare in areas that are usually considered “hormonally sensitive," especially the lower third of the face. This includes:

  • Cheeks
  • Jawline
  • Chin
  • Upper neck, especially at the angles of the jaw

“Patients with PCOS tend to get acne that involves more tender knots under the skin, rather than fine surface bumps, and will sometimes report that lesions in that area tend to flare before their menstrual period,” says Schlosser. “They take time to go away.”

So if you tend to get acne in the places Schlosser describes and have noticed irregular periods, it’s a good idea to ask your dermatologist to refer you for PCOS testing.

Diabetes

Many women with PCOS also have diabetes, which isn’t surprising, given that both conditions appear to be related to how the body reacts to insulin. Could that mean that diabetes causes acne, or that your acne might be a symptom of diabetes?

If you look online, you may see a lot of speculation about diabetes causing acne, but Redmond says that’s false. “Acne is not a symptom of diabetes. Obviously, people with diabetes can develop acne, but the presence of acne by itself does not indicate a need to test for diabetes.”

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