Hormonal Acne in Adults:
Causes, Treatment, and When It Is Fungal

Acne does not end with the teenage years. About one in four women in their 30s and one in six in their 40s have acne, and in adults it usually follows a hormonal pattern: deep, tender bumps along the jawline, chin, and lower cheeks that flare in the week before a period. Hormonal acne responds to treatments that target the hormone signal, including spironolactone, clascoterone cream, and certain birth control pills, alongside retinoids and benzoyl peroxide. A separate condition, fungal acne, causes uniform itchy bumps on the forehead, chest, and back, gets worse with antibiotics, and is treated with antifungals. A dermatologist can tell them apart and treat both at either Belaray office.

What Is Hormonal Acne?

All acne is influenced by hormones, because androgens (testosterone and related hormones) drive the oil glands. “Hormonal acne” describes the adult pattern in which normal hormone fluctuations produce acne in skin that is especially sensitive to them. It is most common in women, but men can have persistent adult acne as well. The hallmarks are:

• Location: the lower third of the face, the jawline, chin, around the mouth, and the neck. Teen acne, by contrast, favors the forehead, nose, and cheeks.
• Type of lesion: deep, tender, inflamed bumps and cysts rather than many blackheads and whiteheads. These heal slowly and often leave dark marks.
• Timing: flares in the week before a period, around ovulation, during perimenopause, after stopping or starting birth control, and in pregnancy.
• Resistance to usual treatment: benzoyl peroxide and antibiotics help only partly, because they do not address the hormone signal.

What Causes Hormonal Acne?

In the days before a period, estrogen falls and the relative effect of androgens rises, increasing oil production and inflammation in the pores. Most women with hormonal acne have normal hormone levels; their skin is simply more responsive. In some, however, acne is a sign of polycystic ovary syndrome (PCOS), especially when it comes with irregular or absent periods, excess facial or body hair, scalp hair thinning, or weight gain. Other contributors include stress (cortisol stimulates oil glands), high-glycemic diets and skim dairy in some people, certain medications (corticosteroids, some birth control progestins, testosterone, anabolic steroids), and hair and skin products that clog pores.

How Is Hormonal Acne Treated?

Treatment combines a pore-clearing foundation with a hormone-targeted medication when needed. Results take eight to twelve weeks, and treatment is continued to keep acne controlled.

Topical Foundation (for everyone)

• A topical retinoid (adapalene, tretinoin, or tazarotene) at night to keep pores clear and fade marks. Adapalene 0.1 percent is available over the counter.
• Benzoyl peroxide or a topical antibiotic combination for inflamed lesions.
• Azelaic acid, which reduces inflammation and dark marks and is safe in pregnancy.
• Clascoterone cream (Winlevi), the first topical medication that blocks androgen receptors in the skin. It is approved for ages 12 and up, works for both women and men, and is applied twice daily.

Hormone-Targeted Treatment (for women)

• Spironolactone is an oral medication that blocks the effect of androgens on the oil glands. Used off-label for acne at low doses, it clears jawline and chin acne in most women within three to six months and is often continued long term. It is not used in pregnancy, so reliable contraception is required. Your dermatologist reviews blood pressure and, in some cases, potassium.
• Combined oral contraceptives that contain estrogen reduce androgen activity. Several are FDA-approved for acne. They take three or more cycles to show full effect and are prescribed after reviewing clotting and other risk factors.
• These can be combined with each other and with the topical foundation above.

Other Options

• Oral antibiotics (doxycycline, minocycline, sarecycline) for a limited course of inflamed acne, always with benzoyl peroxide to prevent resistance.
• Isotretinoin for severe, scarring, or treatment-resistant acne. It is the only treatment that can produce long-term remission, and it requires monthly monitoring and strict pregnancy prevention.
• Cortisone injections into a painful cyst shrink it within one to two days.
• Treatment for scars and dark marks once acne is controlled: azelaic acid and retinoids for marks; laser resurfacing or RF microneedling with the Cutera Secret Pro at our Hicksville office for pitted scars.

Is It Hormonal Acne or Fungal Acne?

“Fungal acne” is not true acne. It is Malassezia folliculitis, an overgrowth of the same yeast that causes dandruff inside the hair follicles. It is often mistaken for acne and treated with antibiotics, which make it worse. Clues that bumps are fungal rather than hormonal:

• Small (1 to 2 mm), uniform, dome-shaped pink bumps and pustules that all look alike, with no blackheads or deep cysts.
• Location on the forehead, hairline, temples, chest, shoulders, and upper back rather than the jawline.
• Itching, which ordinary acne rarely causes.
• Worse with sweating, tight workout clothing, occlusive sunscreens or moisturizers, humid weather, and after a course of oral antibiotics.
• No improvement, or worsening, on standard acne treatment.

Fungal acne is treated with an antifungal: a ketoconazole or selenium sulfide shampoo used as a body wash and left on for five minutes, antifungal creams, and for stubborn cases a short course of oral antifungal medication. Switching to lightweight, oil-free products and showering promptly after exercise prevents recurrence. A dermatologist can confirm the diagnosis in the office by examining the bumps and, if needed, a quick skin scraping.

Daily Habits That Help

• Wash twice daily with a gentle cleanser; scrubbing worsens inflammation.
• Use only oil-free, non-comedogenic moisturizer, sunscreen, makeup, and hair products, and keep hair products off the face.
• Do not pick or squeeze; it drives inflammation deeper and causes scars and dark marks.
• Change pillowcases weekly and clean your phone screen.
• If dairy or high-sugar foods clearly flare your skin, reducing them may help; the evidence is strongest for skim milk and high-glycemic diets.
• Give any treatment eight to twelve weeks before judging it.

When Should I See a Dermatologist?

• Acne that has not improved after two to three months of over-the-counter treatment.
• Deep, painful cysts, or acne that is leaving scars or dark marks.
• Acne together with irregular periods, excess facial or body hair, or scalp hair thinning, which may signal PCOS.
• Itchy, uniform bumps on the forehead, chest, or back that antibiotics have not helped.
• Acne that started or worsened with a new medication.

Frequently Asked Questions

What does hormonal acne look like?

Deep, tender, inflamed bumps and cysts along the jawline, chin, around the mouth, and on the lower cheeks and neck, with few blackheads. It flares in the week before a period, around ovulation, in perimenopause, and after starting or stopping birth control, and it heals slowly, often leaving dark marks. Teen acne, by contrast, favors the forehead, nose, and cheeks.

Does spironolactone work for hormonal acne?

Yes. Spironolactone blocks the effect of androgens on the oil glands and clears jawline and chin acne in most women within three to six months. It is used off-label at low doses, is generally well tolerated, and is often continued long term. It is not used in pregnancy, so reliable contraception is required, and your dermatologist monitors blood pressure and in some cases potassium.

Why am I getting acne in my 30s and 40s?

Adult acne is common, affecting about one in four women in their 30s and one in six in their 40s. It is usually hormonal, driven by normal fluctuations in androgens and estrogen that stimulate oil glands in skin that is sensitive to them. Perimenopause, stress, stopping birth control, certain medications, and pore-clogging products also contribute. New acne after 30 with persistent redness or flushing may be rosacea instead.

Is my acne a sign of PCOS?

It can be. Most women with hormonal acne have normal hormone levels, but acne together with irregular or absent periods, excess facial or body hair, scalp hair thinning, or difficulty losing weight can signal polycystic ovary syndrome. A dermatologist may order hormone blood tests and coordinate with your gynecologist or endocrinologist. Treating PCOS improves the acne.

What is fungal acne, and how do I know if I have it?

Fungal acne is Malassezia folliculitis, an overgrowth of a yeast inside hair follicles that looks like acne but is not. Clues are small, uniform, itchy pink bumps on the forehead, hairline, chest, shoulders, or upper back, with no blackheads or cysts, that worsen with sweat, tight clothing, and oral antibiotics. It is treated with antifungal shampoo used as a wash, antifungal creams, or a short oral antifungal course, not with acne antibiotics.

Does birth control help acne?

Combined oral contraceptives that contain estrogen reduce androgen activity and improve hormonal acne in most women; several are FDA-approved for acne. Full effect takes three or more cycles. Progestin-only methods, including some implants and IUDs, can worsen acne in some women. Your dermatologist and gynecologist can choose an option based on your acne, health history, and clotting risk factors.

Can diet cause hormonal acne?

Diet is not the main cause, but it can contribute. The strongest evidence links high-glycemic diets (sugar, white bread, sweetened drinks) and skim milk to worse acne in some people, likely through insulin and hormone effects. Chocolate and greasy food have not been shown to cause acne. If a food clearly flares your skin, reducing it is reasonable, but diet changes alone rarely clear hormonal acne.

Related reading: acne treatment, acne vs. rosacea, dandruff and seborrheic dermatitis (the same yeast as fungal acne), and the patient education hub.