Acne vulgaris
Also known as: acne
Medically reviewed by Hormone Journal Editorial Team · Last reviewed 2026-05-22
Acne vulgaris is the most common chronic skin disease worldwide, affecting up to 80% of people aged 11–30 by causing hair follicles to become blocked with sebum and dead skin cells.
What it is
Acne vulgaris is the most common chronic inflammatory skin disease worldwide, affecting up to 80% of people between the ages of 11 and 30, with a significant proportion of adults — particularly women — continuing to experience it into their 30s, 40s, and beyond. Also called simply acne, acne vulgaris is a disorder of the pilosebaceous unit in which excess oil (sebum) and dead skin cells block hair follicles, creating conditions where bacteria proliferate and inflammation follows. The result is a spectrum of lesions: blackheads, whiteheads, papules, pustules, nodules, and cysts.
Hormones are central to acne pathogenesis. Androgens — including testosterone and DHEA-S — stimulate sebaceous glands to overproduce sebum, which is why acne commonly flares at puberty, around the menstrual cycle, during pregnancy, and at perimenopause. In Canada, acne is among the most frequent reasons patients visit a family physician or dermatologist, and access to prescription treatments — including isotretinoin and spironolactone — varies by province under public drug benefit programs.
Acne is not a cosmetic inconvenience. Untreated inflammatory acne can cause permanent scarring and carries a well-documented burden on self-esteem and mental health.
Causes and mechanism
Acne develops through four interconnected processes:
- Excess sebum production — androgens stimulate sebaceous glands to overproduce oil; this is the primary hormonal driver in both adolescents and adults.
- Abnormal follicular keratinization — dead skin cells inside the follicle fail to shed normally, clumping together and blocking the pore.
- Bacterial colonization — Cutibacterium acnes (formerly Propionibacterium acnes) lives naturally on skin but multiplies rapidly inside blocked follicles, triggering an immune response.
- Inflammation — the immune response to bacterial overgrowth produces the redness, swelling, and pain characteristic of inflammatory lesions.
Key hormonal contributors include:
| Hormone / factor | Role in acne |
|---|---|
| Androgens (testosterone, DHEA-S) | Stimulate sebum overproduction; central driver at all ages |
| Elevated insulin / IGF-1 | High-glycaemic diets and insulin resistance amplify sebocyte activity and androgen production |
| Cortisol (stress) | Increases androgen activity and sebum output; triggers flares |
| Progesterone fluctuations | Contribute to cyclical premenstrual breakouts |
| PCOS-related hyperandrogenism | Most common hormonal cause of persistent adult female acne |
Symptoms and diagnosis
Lesions appear most often on the face, neck, chest, shoulders, and back — areas with the highest density of sebaceous glands. Lesion types range from non-inflammatory comedones (open blackheads, closed whiteheads) to inflammatory papules and pustules, and in more severe cases, deep nodules and pus-filled cysts capable of causing scarring.
Severity is classified as mild, moderate, or severe based on lesion count and type. Diagnosis is clinical, made through visual examination. In adult women with persistent acne — especially along the jawline and chin — clinicians may order additional investigations:
- Serum androgens (total and free testosterone, DHEA-S, androstenedione)
- Sex hormone-binding globulin (SHBG) — low SHBG increases free androgen activity
- FSH, LH, and prolactin — to evaluate for polycystic ovary syndrome (PCOS) or other endocrine causes
- TSH — thyroid dysfunction can contribute to hormonal acne
- Pelvic ultrasound if PCOS is suspected
In Canada, these blood panels are available through LifeLabs and Dynacare and are typically covered under provincial health insurance when ordered by a physician.
Treatment options
Treatment is selected based on acne severity and whether a hormonal component is identified.
Topical treatments (first-line for mild to moderate acne):
- Retinoids (tretinoin, adapalene) — promote cell turnover and prevent follicle blockage
- Benzoyl peroxide — reduces bacterial load and inflammation
- Topical antibiotics (clindamycin) — usually combined with benzoyl peroxide to limit resistance
- Azelaic acid — reduces inflammation and post-inflammatory pigmentation
Systemic treatments (moderate to severe acne):
- Oral antibiotics (doxycycline, minocycline) — prescribed for limited courses to reduce resistance risk
- Isotretinoin (sold as Accutane and generics in Canada) — the most effective option for severe or cystic acne; reduces sebum production and has durable effects, but requires monitoring and pregnancy prevention protocols
Hormonal treatments (primarily for women with a hormonal component):
- Combined oral contraceptives — lower circulating androgen levels and reduce sebum production
- Spironolactone — an anti-androgen that blocks androgen receptors in the skin; highly effective for adult female hormonal acne
- Metformin — considered in women with PCOS and concurrent insulin resistance
Canadian patients can access prescription hormonal acne treatments through their family physician, a dermatologist, or virtual care platforms such as Felix, Maple, Cleo, or Phoenix, depending on provincial prescribing scope.
When to see a clinician in Canada
Seek assessment from a family physician or dermatologist if:
- Over-the-counter treatments have not improved acne after 8–12 weeks of consistent use
- Acne is causing scarring, persistent dark marks, or painful nodules and cysts
- Breakouts are significantly affecting confidence or mental wellbeing
- You are an adult woman with persistent jawline or chin acne, particularly alongside irregular periods, excess facial or body hair, or unexplained weight gain — patterns that suggest an underlying hormonal cause worth investigating
Referral to a dermatologist is appropriate for moderate-to-severe acne, treatment-resistant cases, or when isotretinoin is being considered. Wait times vary by province; virtual dermatology services can shorten access in some regions.
Limitations and open questions
Research is still emerging on several aspects of acne management. The long-term safety profile of spironolactone for acne — particularly at doses above 100 mg/day and over multi-year use — has not been established in large randomized controlled trials. Evidence linking specific dietary patterns (beyond high-glycaemic diets and dairy) to acne severity remains inconsistent across studies. The optimal duration of oral antibiotic therapy before switching strategies is debated, and antibiotic resistance patterns in C. acnes are an active area of concern. Health Canada has not issued specific guidance on the use of low-dose spironolactone for acne outside of its approved indication for fluid retention and hypertension, meaning prescribing for acne remains off-label. Patients considering hormonal treatments should discuss individual risk-benefit profiles with their clinician.
FAQs
Is acne purely a skin condition or is it related to hormones?
Acne is deeply connected to hormones. Androgens — including testosterone and DHEA-S — stimulate sebaceous glands to overproduce oil, which is the starting point of most acne. This is why acne is so common during puberty, around menstrual cycles, in pregnancy, and in conditions like polycystic ovary syndrome (PCOS). In adult women especially, persistent acne along the lower face and jawline is often a sign of an underlying hormonal imbalance, and a hormonal workup — including serum androgens and SHBG — can help identify the cause.
Why does acne get worse before a period?
In the days before menstruation, progesterone rises after ovulation, increasing oil production and causing slight follicular swelling that makes pores more likely to clog. At the same time, estrogen levels fall, removing some of its skin-protective effects. Together, these shifts make premenstrual breakouts very common — studies suggest up to 44% of women report cyclical acne flares. For women with PCOS or elevated androgens, this pattern tends to be more pronounced.
Can acne cause permanent scarring?
Yes. Inflammatory acne — particularly nodules and cysts — can damage the dermis and leave permanent scars if not treated early. Picking or squeezing lesions significantly increases scarring risk. Post-inflammatory hyperpigmentation (dark marks left after a spot heals) is also common and can take 3–6 months or longer to fade, especially in people with deeper skin tones. Starting effective treatment early is the most reliable way to reduce both outcomes.
What is the most effective treatment for hormonal acne in women?
For adult women with hormonal acne, spironolactone is considered one of the most effective options; it blocks androgen receptors in the skin, reducing sebum production and breakout frequency. Combined oral contraceptives are also commonly prescribed, as they lower circulating androgen levels. A 2017 review in the Journal of the American Academy of Dermatology found that both treatments produce meaningful lesion reduction, though response typically takes 3–6 months. A clinician can assess whether hormonal blood work is appropriate before starting either therapy.
Is isotretinoin (Accutane) covered by provincial drug plans in Canada?
Coverage varies by province. In Ontario, isotretinoin is listed on the Ontario Drug Benefit formulary for eligible patients, typically requiring a dermatologist prescription and enrolment in a pregnancy prevention program. British Columbia and Alberta have similar coverage with conditions. Patients on private insurance plans are generally covered, though prior authorization may be required. Because isotretinoin is teratogenic, Health Canada mandates pregnancy testing and contraception counselling before and during treatment regardless of coverage status.
Sources
- Acne Vulgaris — StatPearls, NCBI Bookshelf (NIH)
- Zaenglein AL et al. Guidelines of care for the management of acne vulgaris. Journal of the American Academy of Dermatology. 2016;74(5):945–973.
- Elsaie ML. Hormonal treatment of acne vulgaris: an update. Clinical, Cosmetic and Investigational Dermatology. 2016;9:241–248.
- Ebede TL, Arch EL, Berson D. Hormonal treatment of acne in women. Journal of Clinical and Aesthetic Dermatology. 2009;2(12):16–22.
- Thiboutot D et al. New insights into the management of acne: An update from the Global Alliance to Improve Outcomes in Acne. Journal of the American Academy of Dermatology. 2009;60(5 Suppl):S1–50.
- Health Canada — Drug Product Database: Isotretinoin (Accutane and generics)