Testosterone brought my spark back… and my acne
I saw it coming
It did not take long for me to notice a difference with testosterone therapy. First came increased energy through the afternoon into late evening, then came motivation to exercise, improved endurance through my workouts, and finally – a lifting of my brain fog. My memory was sharper, my work was more efficient, and I finally felt like me again. Success!
Unfortunately, along with all these incredible changes, came an old nemesis: acne. I had horrible acne growing up. Truly horrible – the kind you get bullied for. I was prescribed Accutane twice (RIP to my gut microbiome, but wow did it work), and eventually found a long-term regimen that worked for me.
Now, I’ve prescribed testosterone to women long enough to know what I was in for. Given my history, I knew my acne would likely return, but to what extent I wasn’t sure. What I was sure of? I was feeling so depleted and exhausted, and my testosterone level was so low, that a recurrence of my acne was worth it.
This post is about the science behind testosterone-induced acne, what can help, and the specific combination that finally gave me clear skin without giving up the hormone therapy that was making the rest of my life so much better.
This is a long one, but I promise it's worth it!
Why testosterone causes breakouts
Even at physiological doses, testosterone is associated with mild increases in acne and body or facial hair growth in some women. The Endocrine Society notes that these effects are dose-related and are uncommon when supraphysiological levels are avoided, but "uncommon" doesn't mean "never." And when it's your face, even "mild" acne can feel distressing.
So what's actually happening in your skin?
Testosterone gets converted into a more potent androgen called dihydrotestosterone (DHT) in your skin cells. DHT binds to androgen receptors in your sebaceous (oil) glands and hair follicles, and it tells those glands to increase oil production. More oil = more clogged pores. More clogged pores = more food for the bacteria that live on your skin. And more bacteria means inflammation, redness, swelling, and pimple formation.
The jawline and chin pattern is a classic tell, because that’s where androgen receptors are most concentrated on the face. If your breakouts are clustering there, hormones are almost certainly playing a role.
What I tried and what didn’t work
I went through a frustrating period of trial and error. I tried over-the-counter salicylic acid washes, benzoyl peroxide spot, and glycolic acid toner. I increased my fiber, ate clean(er), and hydrated like crazy.
Some of it helped a little, but overall my skin just appeared more irritated/red and still with pimples. Eventually I realized the acne I was dealing with wasn't the same as the acne I had as a teenager. Teenage acne is largely driven by the initial surge of androgens during puberty, and the skin is young, resilient, and bounces back quickly. Midlife acne is happening in skin that is simultaneously dealing with estrogen and collagen loss - meaning it's thinner, drier, more sensitive, and slower to heal. My barrier function was/is compromised!
The combination that worked for me
I decided to compound several ingredients together to focus on exactly what my skin needed. After researching the options, I decided on: tretinoin, estriol, and niacinamide. Each one does something different, and together, they addressed every aspect of what my skin was going through.
Let’s walk through each one:
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Tretinoin is a form of vitamin A (a retinoid) and it is the most well-studied and effective topical treatment for acne. The American Academy of Dermatology (AAD) calls topical retinoids the "cornerstone" of acne treatment because they work on multiple levels:
- They unclog pores. Tretinoin speeds up the turnover of skin cells, loosens the connections between cells in the outer layer of skin, and helps clear out the tiny plugs (called microcomedones) that are the starting point of every pimple.
- They reduce inflammation. Retinoids have direct anti-inflammatory effects, which helps calm the redness and swelling of active breakouts.
- They improve skin texture and tone. Over time, tretinoin stimulates collagen production and can improve the appearance of fine lines, uneven pigmentation, and acne scars.
So tretinoin was a no-brainer for the acne itself. But there was a concern: tretinoin can be irritating, especially for midlife skin. About 30% of people who use it experience some degree of dryness, peeling, burning, or stinging (sometimes call "retinoid dermatitis"). Given my skin’s already impaired barrier and reactivity towards other interventions, that risk of irritation concerned me.
That's where the other two ingredients come in. -
Your skin is loaded with estrogen receptors, and those receptors start declining in perimenopause. When estrogen drops, your skin loses collagen (up to 30% in the first five years after menopause), becomes thinner, drier, less elastic, and slower to heal. The barrier function weakens, meaning your skin loses moisture more easily and is more vulnerable to irritation.
Estriol is a weaker form of estrogen (much less potent than estradiol, the main estrogen your ovaries produce). Research going back to the 1990s has shown that topical estriol can improve skin elasticity and firmness, increase moisture, reduce wrinkle depth, and boost collagen production; specifically Type III collagen, which gives skin its suppleness. One study found that wrinkle depth decreased by 61 to 100% after six months of topical estrogen treatment, with no systemic hormonal side effects detected on blood testing!
In the context of my compounded cream, estriol serves a dual purpose:
1. It counterbalances the androgen effects on the skin. While testosterone and DHT are ramping up oil production, estriol helps restore some of the estrogen signaling that keeps skin balanced.
2. It buffers the irritation from tretinoin. By supporting the skin barrier, improving hydration, and promoting collagen, estriol helps the skin tolerate tretinoin better with less peeling and less redness. -
Niacinamide is a form of vitamin B3, and it might be the most underappreciated ingredient in skincare. It does a remarkable number of things:
- It reduces oil production. Multiple studies have shown that topical niacinamide decreases sebum on the skin surface, directly addressing one of the causes of hormonal acne.
- It's anti-inflammatory. It reduces the production of inflammatory chemicals (like IL-8) in the skin and inhibits the migration of immune cells that drive acne inflammation. Research has shown that 4% niacinamide gel is comparable in effectiveness to 1% clindamycin (a topical antibiotic) for inflammatory acne.
- It strengthens the skin barrier. It reduces transepidermal water loss, helping your skin hold onto moisture. This is huge for midlife skin that's already struggling with dryness.
- It helps with hyperpigmentation. Niacinamide inhibits the transfer of pigment within the skin, which can help fade the dark spots that acne leaves behind.
- It's incredibly well-tolerated. Side effects are minimal, and it's even considered safe during pregnancy.
In my compounded cream, niacinamide works synergistically with the other two ingredients. It calms inflammation while tretinoin clears pores, it reduces oil while estriol restores moisture, and it protects the barrier while tretinoin remodels the skin. A midlife skin hat trick!
What to avoid while on tretinoin:
Benzoyl peroxide: Standard (non-microsphere) tretinoin is broken down and inactivated by benzoyl peroxide. If you're using both, they need to be applied at different times of day — tretinoin at night, benzoyl peroxide in the morning. (Some newer tretinoin formulations, like microsphere versions, are more stable, but it's best to check with your provider.)
Products with high concentrations of alcohol, astringents, or strong drying agents: These can amplify the irritation from tretinoin and compromise your skin barrier — exactly what you don't want when your skin is already sensitive.
Sulfur, resorcinol, and salicylic acid: The FDA label for tretinoin specifically cautions about using these ingredients concurrently. If you've been using products containing them, it's advisable to let your skin rest and recover before starting tretinoin.
Harsh scrubs and exfoliants: Your skin is already turning over faster with tretinoin. Adding physical or aggressive chemical exfoliation on top of that is a recipe for raw, irritated skin.
Sun exposure without protection: Tretinoin increases your skin's sensitivity to UV light. Daily sunscreen is non-negotiable. This is true for everyone, but especially for midlife skin that's already more vulnerable to sun damage.
Other Ingredients Worth Knowing About
The beauty of compounding is we can individualize your skin care to you. Depending on your specific situation, we can consider other ingredients in a compounded formulation, or as separate treatments alongside it. Here are a few worth mentioning:
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can rejuvenate the skin on a cellular level and helps age-related skin issues like fine lines, wrinkles, and loss of elasticity.t goes here
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can increase collagen production which can reduce wrinkles and increase elasticity of the skin. Vitamin C also provides antioxidant protection, combating unwanted dark spots and preventing signs of premature aging.
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retains moisture in the skin which can help visibly plump the skin to fill in fine lines and wrinkles and restore supple smoothness.
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reduces unwanted hair growth by inhibiting DHT (see above!). This is a great option for women with increased hair growth on testosterone therapy. You might wonder if this also helps with DHT-induced acne, but unfortunately not so much! Finasteride specifically works on receptors at the hair follicle rather than the sebaceous glands.
What About Spironolactone?
You might have heard about spironolactone as a treatment for hormonal acne. It's an oral medication that blocks androgen receptors throughout the body, and it can be very effective for acne in women, especially women with PMOS.
Here’s why I don’t love it in midlife: if you're taking testosterone specifically to restore your androgen levels and improve your sexual health, taking a systemic antiandrogen at the same time can work against the very goal you're trying to achieve. Even if you’re not taking testosterone, I’ve seen too many women in my office with low libido while taking spironolactone; dermatology may love it, but in sexual medicine? Not a fan.
A Few Practical Tips From Someone Who's Been There
Start slow. Start by treating the chin and jawline it every other night or even every third night, then gradually increase to nightly as your skin adjusts. A pea-sized amount is plenty!
Moisturize. This is not optional! A good, fragrance-free moisturizer applied after your treatment cream (or mixed together as a buffer, if your skin is very sensitive) makes a huge difference in tolerability.
Wear sunscreen every single day. Rain or shine. SPF 30 or higher. This protects your skin from UV damage that tretinoin makes you more susceptible to, and it prevents the hyperpigmentation that acne can leave behind.
You Don't Have to Choose
If there's one thing I want you to take away from this post, it's this: you do not have to choose between feeling good in your body and feeling good in your skin.
Testosterone therapy can be genuinely life-changing for women dealing with low libido, low energy, low motivation, and generally just not feeling like themselves through the menopause transition. If acne shows up as a side effect, there are smart, science-backed, skin-friendly solutions that can address it, without taking away the benefits you're getting from treatment.
You deserve both. And we're here to help you get there!
Relevant Research:
1. Davis SR, Baber R, Panay N, et al. Global Consensus Position Statement on the Use of Testosterone Therapy for Women. J Clin Endocrinol Metab. 2019.
2. Committee on Practice Bulletins—Gynecology. ACOG Practice Bulletin No. 141: Management of Menopausal Symptoms. Obstet Gynecol. 2014.
3. Wierman ME, Arlt W, Basson R, et al. Androgen Therapy in Women: A Reappraisal: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2014.
4. Eichenfield DZ, Sprague J, Eichenfield LF. Management of Acne Vulgaris: A Review. JAMA. 2021.
5. Reynolds RV, Yeung H, Cheng CE, et al. Guidelines of Care for the Management of Acne Vulgaris. J Am Acad Dermatol. 2024.
6. Yuan Y, Wang Y, Xia J, et al. Topical, Light-Based, and Complementary Interventions for Acne: An Overview of Systematic Reviews. Cochrane Database Syst Rev. 2024.
7. Liu H, Yu H, Xia J, et al. Topical Azelaic Acid, Salicylic Acid, Nicotinamide, Sulphur, Zinc and Fruit Acid (Alpha-Hydroxy Acid) for Acne. Cochrane Database Syst Rev. 2020.
8. Kapoor K, S S, Begum RF, S AS, N A. Exploring Niacinamide as a Multifunctional Agent for Skin Health and Rejuvenation. Curr Pharm Biotechnol. 2025.
9. Schmidt JB, Binder M, Macheiner W, et al. Treatment of Skin Ageing Symptoms in Perimenopausal Females With Estrogen Compounds. A Pilot Study. Maturitas. 1994.
10. Schmidt JB, Binder M, Demschik G, Bieglmayer C, Reiner A. Treatment of Skin Aging With Topical Estrogens. Int J Dermatol. 1996.
11. Verdier-Sévrain S, Bonté F, Gilchrest B. Biology of Estrogens in Skin: Implications for Skin Aging. Exp Dermatol. 2006.
12. Committee on Clinical Consensus–Gynecology. Compounded Bioidentical Menopausal Hormone Therapy: ACOG Clinical Consensus No. 6. Obstet Gynecol. 2023.
13. Crandall CJ, Mehta JM, Manson JE. Management of Menopausal Symptoms: A Review. JAMA. 2023.
14. Committee on Clinical Consensus–Gynecology. Compounded Bioidentical Menopausal Hormone Therapy: ACOG Clinical Consensus No. 6. Obstet Gynecol. 2023.
15. Food and Drug Administration. Tretinoin. 2025.
16. Yuan Y, Wang Y, Xia J, et al. Topical, Light-Based, and Complementary Interventions for Acne: An Overview of Systematic Reviews. Cochrane Database Syst Rev. 2024.
17. Reynolds RV, Yeung H, Cheng CE, et al. Guidelines of Care for the Management of Acne Vulgaris. J Am Acad Dermatol. 2024.
18. Reynolds RV, Yeung H, Cheng CE, et al. Guidelines of Care for the Management of Acne Vulgaris. J Am Acad Dermatol. 2024.
19. Hebert A, Thiboutot D, Stein Gold L, et al. Efficacy and Safety of Topical Clascoterone Cream, 1%, for Treatment in Patients With Facial Acne: Two Phase 3 Randomized Clinical Trials. JAMA Dermatol. 2020.
20. Archer DF. Postmenopausal Skin and Estrogen. Gynecol Endocrinol. 2012.
