If you're breaking out long after your teen years are over, you may need to look beyond your skin for the source of the problem.
Sometimes acne is a symptom of an underlying hormone condition that can cause far more than facial blemishes.
Polycystic Ovarian Syndrome (PCOS)
"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, director of the women's skin health program 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 your cheeks, jawline, chin, and upper neck.
"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," Schlosser says. "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.
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 Hormone Center of New York founder Geoffrey Redmond, MD, says that's false.
"Acne is not a symptom of diabetes,” he says. “Obviously, people with diabetes can develop acne, but the presence of acne by itself does not indicate a need to test for diabetes."
There are other hormonal disorders whose symptoms can include acne, but these are much more unusual. For example, people affected by a group of inherited disorders known collectively as congenital adrenal hyperplasia often produce either too much or too little of certain sex hormones, including testosterone.
"People with these disorders have a problem with the adrenal glands, which produce and metabolize hormones," Schlosser says.
Treating Hormonal Acne
Most women who have acne related to a hormonal condition like PCOS have probably found that standard topical acne therapies, such as retinoid gels and creams, don't meet their needs.
"These people do best with hormonal therapy," Schlosser says.
There are two main ways to manage hormone issues that are linked to your acne outbreaks:
It's not an overnight process. "You have to give this approach at least 3 months of use before you can judge its impact," Schlosser says. "That's the point at which studies found a notable difference between placebos [dummy pills] and oral contraceptives. Many patients saw further improvement around the 6-month mark."
If birth control pills aren't working or give only partial relief from your acne, your dermatologist may recommend spironolactone. It may also be the first treatment of choice for hormone-related acne if you smoke or have other risk factors that make hormonal contraceptives undesirable. "Many of my patients get significant added improvement with this drug," Schlosser says.
Redmond usually starts his patients on 100 to 200 milligrams of spironolactone per day. "Most people tolerate it fairly well. Since it is a diuretic [meaning that it causes you to urinate more often], you'll need to keep up your water intake. But as long as you do that, you shouldn't have too many problems."
"For women, spironolactone works in a very high percentage of cases," Redmond says. "For men, it's not optimal because it blocks testosterone."
So how long will you need to take these medications? That's hard to say. "Eventually, the tendency to have acne goes away for most people, but it's hard to know when," Redmond says. "The medications are often necessary for a few years. It's mostly luck in how long it persists."