Androgens are the primary hormones that cause acne. Specifically, a potent form of testosterone called dihydrotestosterone (DHT) drives the overproduction of skin oil that clogs pores and leads to breakouts. But androgens aren’t the only hormonal player. Stress hormones, insulin, and the rise and fall of estrogen throughout the menstrual cycle all influence whether your skin stays clear or breaks out.
How Androgens Trigger Breakouts
Your skin’s oil glands contain androgen receptors, and when androgens bind to them, two things happen: the glands grow larger and they produce more oil (sebum). This process is why acne so reliably appears during puberty, when androgen levels surge for the first time.
Testosterone itself isn’t the most powerful trigger. Inside the oil glands, an enzyme called 5-alpha reductase converts testosterone into DHT, which is far more potent at stimulating oil production. The type 1 version of this enzyme is especially concentrated in the oil glands of the face and scalp, which helps explain why those areas are the most acne-prone. The enzyme’s activity is similar in both normal skin and acne-affected skin, meaning even normal androgen levels can cause breakouts if your oil glands are particularly sensitive to DHT.
Not all androgens come from the same place. The ovaries and testes produce testosterone, but the adrenal glands (small glands on top of your kidneys) produce a different androgen called DHEA-S. Rising levels of DHEA-S are actually what kick off acne in childhood and early puberty, sometimes years before other signs of development appear. In adults, elevated DHEA-S can be the sole androgen abnormality behind persistent breakouts, particularly in women.
The Menstrual Cycle Connection
If your skin reliably worsens in the days before your period, hormones are the reason. A retrospective study of women’s acne patterns found a statistically significant increase in breakouts during the late luteal phase and early follicular phase, which correspond to the premenstrual and menstrual days of the cycle. Women in the study averaged five to six additional acne lesions during this window.
The mechanism involves the balance between estrogen and androgens. Estrogen has a protective, anti-androgenic effect on oil glands. It can reduce sebum secretion by as much as 65% when used therapeutically. During the first half of the menstrual cycle, rising estrogen keeps oil production in check. But in the days before your period, both estrogen and progesterone drop sharply. With less estrogen to counterbalance them, androgens have a stronger relative effect on your oil glands, and breakouts follow.
What Stress Hormones Do to Your Skin
Stress doesn’t just make you feel like your skin is worse. It activates a hormonal signaling system directly inside your oil glands. Research has found that the complete stress hormone signaling pathway, centered on corticotropin-releasing hormone (CRH), is overexpressed in acne-affected skin, with the oil glands showing the most activity.
CRH acts as a local trigger within the skin itself, promoting oil production in the same glands that androgens target. It also stimulates the skin to produce cortisol and inflammatory molecules. This creates a double problem: more oil and more inflammation, both of which worsen acne. The skin essentially runs its own miniature stress-response system, independent of the broader hormonal stress response happening in your brain and adrenal glands.
How Diet Raises Acne-Promoting Hormones
High-glycemic foods (white bread, sugary drinks, processed snacks) cause a rapid spike in blood sugar, which triggers your body to release more insulin. Chronically elevated insulin raises levels of another hormone called insulin-like growth factor 1, or IGF-1. This is where the connection to acne becomes direct: IGF-1 amplifies androgen signaling in the skin by activating the same 5-alpha reductase enzyme that converts testosterone to DHT. It also boosts oil production on its own by increasing the activity of oil-producing cells.
Dairy has received attention for a similar reason. Milk naturally contains hormones and bioactive compounds that can raise IGF-1 levels. The pathway is the same: more IGF-1 means stronger androgen activity in your oil glands. This doesn’t mean everyone who eats dairy or sugar will break out, but for people whose skin is already androgen-sensitive, these dietary factors can tip the balance.
When Hormonal Acne Signals a Bigger Issue
Persistent acne in women, especially when paired with irregular periods, excess body hair, or thinning hair on the scalp, can point to polycystic ovary syndrome (PCOS). Up to 89% of women with PCOS and elevated androgens have high levels of free testosterone, while 25 to 35% have elevated DHEA-S. The challenge is that measuring androgens in women is technically difficult because the concentrations are much lower than in men, and standard lab tests can be unreliable at those levels. If your doctor suspects PCOS, they may order specialized hormone panels to get accurate readings.
Adrenal conditions can also produce excess androgens. In some cases, the adrenal glands are the sole source of the androgen excess driving acne, which requires a different treatment approach than ovarian-driven hormonal imbalances.
Hormonal Acne Treatments
Because androgens are the root driver, the most targeted treatments work by blocking their effects on oil glands. For women, the two main approaches are combination birth control pills and a medication called spironolactone.
Three combination oral contraceptives are FDA-approved specifically for treating moderate to severe acne. They all contain ethinyl estradiol (a synthetic estrogen) paired with a progestin. The estrogen component raises a protein in the blood that binds to free testosterone and takes it out of circulation, while certain progestins also directly block androgen receptors. Combinations containing drospirenone, norgestimate, or norethindrone have demonstrated the strongest anti-acne effects. These are approved for adolescents 14 or 15 and older who have started menstruating.
Spironolactone works differently. It blocks androgen receptors directly in the skin, preventing DHT and testosterone from stimulating oil glands. It’s typically started at 50 mg daily and increased to 100 mg if tolerated. Most clinicians evaluate results at 8 to 12 weeks, though full improvement often takes longer. It’s taken in the morning to avoid its mild diuretic effect later in the day. Spironolactone is used only in women because blocking androgens in men causes unwanted side effects.
For both men and women, reducing IGF-1 through dietary changes offers a complementary approach. Shifting toward lower-glycemic foods won’t replace medical treatment for moderate or severe hormonal acne, but it can reduce one of the signals that amplifies androgen activity in the skin.