Testosterone and Acne: What Your Levels Mean for Your Skin

Short answer: testosterone and the other androgens are the main hormones that tell your oil glands to make more oil, and extra oil is where many breakouts start. But acne tracks the testosterone your skin can actually use, which depends on free testosterone and a protein called SHBG, more than the total number on a standard lab report. That's why "normal testosterone" doesn't rule out hormonal acne, in women or in men. Acne causes differ from person to person, so the way to know is to test.

Does testosterone cause acne? How androgens drive oil

Androgens are the most important hormones regulating sebum, the oil your skin makes. From puberty on, they switch on oil production and acne in both sexes (Elsaie, 2016). Here's how it works:

• Testosterone reaches the oil gland. Only the free, unbound part can attach to androgen receptors and act on the cell. That's just 1% to 2% of the testosterone in your blood (Elsaie, 2016).
• The skin makes it stronger. An enzyme in the oil gland, 5-alpha reductase, converts testosterone into DHT, which is 5 to 10 times more active (Elsaie, 2016).
• The gland makes more oil. More oil, plus dead skin cells that don't shed properly, plugs the pore. Bacteria and inflammation do the rest (Elsaie, 2016; Zouboulis, 2020).

So testosterone is one of the strongest levers on the oil acne feeds on. The question is how much of it is active in your skin.

Free vs total testosterone, SHBG and the free androgen index

Most of your testosterone is parked on carrier proteins in the blood. The main one is SHBG (sex hormone-binding globulin), which holds testosterone tightly and keeps it out of action. Albumin holds it loosely. What's left over is free testosterone, the part that drives oil.

That means two people with the same total testosterone can have very different amounts acting on their skin. When SHBG drops, more testosterone is released, and you get stronger androgen effects even with a normal total (Elsaie, 2016). We go deeper on this in low SHBG and acne.

Marker	What it tells you	Why it matters for acne
Total testosterone	All the testosterone in your blood, bound and free	Can look normal even when your skin is getting too much
Free testosterone	The unbound part that can act on oil glands	Closer to what your skin actually sees
SHBG	The protein that locks testosterone away	Low SHBG means more free testosterone. In women with acne, lower SHBG went with more severe acne (Borgia et al., 2004)
Free androgen index (FAI)	A ratio: 100 x total testosterone divided by SHBG	A quick read on the balance between the two (Vermeulen et al., 1999)
DHEA-S	An androgen made mostly by the adrenal glands	Linked to acne lesion counts and to adult-onset acne (Cappel et al., 2005; Seirafi et al., 2007)

One honest note on the FAI: it's a simple ratio, and it gets less precise when SHBG is very high or very low. Free testosterone calculated from total testosterone and SHBG tracks the gold-standard lab method closely (Vermeulen et al., 1999). That's why it helps to see all of these markers side by side instead of any one alone.

Why "normal" testosterone can still mean acne

"My doctor checked my testosterone and it was normal." Here's why that result can miss the picture:

1. Only total testosterone was checked. Unless free testosterone is measured separately, total testosterone can sit in range despite clear signs of too much androgen (Elsaie, 2016).
2. SHBG was low. In a study of 129 adult women with acne, most had at least one raised androgen, only 19% had PCOS, and acne severity tracked lower SHBG (Borgia et al., 2004). The authors recommended checking SHBG in women with acne.
3. Your skin is more sensitive. Some people have more responsive androgen receptors or more 5-alpha reductase activity in the skin, so normal blood levels still produce strong effects (Elsaie, 2016).

"Normal" also means normal for the general population, not normal for your skin. If this sounds like you, read normal bloodwork but still have acne.

High testosterone acne in women and PCOS

In women, too much androgen often shows up as acne before anything else. Adult female acne tends to sit on the lower face: inflammatory spots on the lower chin, jawline and neck (Dréno et al., 2013). If you first got acne after 25, see our guide to adult-onset acne.

The most common cause of high androgens in women is PCOS (polycystic ovary syndrome), which accounts for more than 90% of cases of hyperandrogenism (Elsaie, 2016). A meta-analysis of 60 studies found acne in 43% of women with PCOS, compared with 21% of women without it (Ramezani Tehrani et al., 2021). PCOS also tends to come with lower SHBG and blood sugar changes, which push free testosterone up further. Read more in PCOS and hormonal acne.

But PCOS isn't the only route. Many women with acne have a raised androgen without PCOS (Borgia et al., 2004), and the pill matters too: it raises SHBG (Elsaie, 2016), so stopping it can change how much testosterone is free. If your skin changed after stopping birth control, see acne after stopping birth control.

Testosterone acne in men and TRT acne

Men have far more testosterone than women, but it still matters for acne. In one study of adults with persistent acne, androgens appeared to play a bigger role in men's acne than in women's, and DHEA-S and androstenedione tracked lesion counts in men (Cappel et al., 2005).

Does TRT cause acne? Raising testosterone from the outside is one of the clearest ways to see the link. Acne is a known side effect of testosterone replacement, and it's less common with gels and patches than with injections (Basaria and Dobs, 2003). In a three-year study of 323 transgender men starting testosterone therapy, moderate to severe acne rose from about 12% to 39% in the first year. Higher testosterone levels, younger age, a BMI over 25 and existing acne all raised the risk (Madsen et al., 2024). At the extreme end, acne shows up in about half of people misusing anabolic steroids (Melnik et al., 2007).

If you're on TRT and breaking out, your prescriber will want numbers: your total and free testosterone, and your SHBG.

Can low testosterone cause acne?

Low testosterone isn't a recognized cause of acne in itself. But a "low T" result can be misleading. Total testosterone includes the part bound to SHBG, so a low SHBG pulls the total down even when free testosterone is fine. And low SHBG goes hand in hand with insulin resistance in both women and men (Ding et al., 2009). So low total testosterone plus acne is a reason to check free testosterone, SHBG and blood sugar, not to rule hormones out.

DHEA-S: the adrenal androgen

DHEA-S is made mostly by your adrenal glands and can be turned into stronger androgens. It shows up again and again in acne research:

• In girls followed for five years, those who developed severe acne had higher DHEA-S, and it seemed to play an important part in starting acne (Lucky et al., 1997).
• In adults with persistent acne, DHEA-S correlated with lesion counts in both women and men (Cappel et al., 2005).
• In women whose acne started after 25, DHEA-S was the one marker that differed from women without acne (Seirafi et al., 2007).

That's why a testosterone-only check can miss part of the androgen story. More in our guide to DHEA and DHEA-S tests.

How blood sugar lowers SHBG and raises free testosterone

Your liver makes SHBG, and high insulin and sugar both turn it down:

• Insulin. Insulin lowers SHBG production by the liver and also pushes the ovaries and adrenals to make more androgens (Elsaie, 2016). When researchers lowered insulin in women with PCOS, SHBG rose by 32% and unbound testosterone fell by 43% (Nestler et al., 1991).
• Sugar. Glucose and fructose switched off the SHBG gene in liver cells by driving fat production in the liver (Selva et al., 2007).
• The long view. Low SHBG is a strong predictor of type 2 diabetes in both women and men (Ding et al., 2009).

So blood sugar can raise your free testosterone without your testosterone itself changing. HbA1c shows your average blood sugar over about three months, which is why it belongs next to your hormone markers when the question is acne. See how blood sugar affects your skin.

Testing your testosterone for acne: your options

You can ask your doctor for a hormone panel. In practice that usually means booking an appointment, getting a lab slip, traveling to a draw center for a needle draw, and waiting for results that come back as a list of numbers with no one reading them for acne.

For acne, the useful set is free testosterone, total testosterone, SHBG, FAI and DHEA-S together, plus HbA1c for the blood sugar side. For a broader look at which labs matter, see blood tests for acne.

Why test with BreakoutLabs

BreakoutLabs checks the main acne suspects in one go:

• At home, with a painless device on your upper arm. No lab visit, no appointment, no needle draw.
• 19 biomarkers across hormones, blood sugar, metabolism and nutrients: Free and Total Testosterone, SHBG, DHEA-S, Free Androgen Index and Albumin; HbA1c, average glucose and a full cholesterol and triglyceride panel; ALT, Creatinine and eGFR; and Vitamin D.
• Results in 5 business days after a CLIA-certified lab receives your sample.
• A personalized Clear Skin Blueprint that reads your results through the lens of acne, including how your SHBG and blood sugar shape your free testosterone.
• $199, HSA/FSA eligible, and backed by our 30-day money-back guarantee.

Collect in the morning after an 8 to 10 hour fast, Monday to Thursday, and on days 3 to 7 of your cycle if you menstruate. For ages 14 and up (14 to 17 with a parent or guardian).

Get the Acne Root Cause Test

Frequently asked questions

Does high testosterone cause acne?

High androgens increase oil production, and that's one of the main routes to acne. What matters most is the active, free part of your testosterone, which depends on SHBG. Checking free testosterone, total testosterone and SHBG together shows whether this is part of your acne.

Can you have hormonal acne with normal testosterone?

Yes. Total testosterone can be normal while free testosterone is high because SHBG is low, and some people's skin is simply more sensitive to androgens. DHEA-S can also be raised on its own.

What is a free androgen index?

The free androgen index is 100 times your total testosterone divided by your SHBG. It's a quick way to see the balance between testosterone and the protein that holds it back.

Does TRT cause acne?

Acne is a known side effect of testosterone therapy, and it's more likely with higher testosterone levels, younger age and existing acne. Bring your free testosterone and SHBG results to your prescriber.

Does testosterone acne affect women?

Yes. In women, high free testosterone, low SHBG or high DHEA-S often show up as acne on the chin, jawline and neck. PCOS is the most common cause, but many women with androgen-driven acne don't have PCOS.

Ruling out your skincare too? Hormones explain a lot, but not everything. Paste any product into our free pore clogger checker to see which ingredients are likely to clog pores.

Sources

• Elsaie ML. Hormonal treatment of acne vulgaris: an update. Clinical, Cosmetic and Investigational Dermatology. 2016.
• Zouboulis CC. Endocrinology and immunology of acne: two sides of the same coin. Experimental Dermatology. 2020.
• Borgia F, Cannavò S, Guarneri F, et al. Correlation between endocrinological parameters and acne severity in adult women. Acta Dermato-Venereologica. 2004.
• Vermeulen A, Verdonck L, Kaufman JM. A critical evaluation of simple methods for the estimation of free testosterone in serum. Journal of Clinical Endocrinology and Metabolism. 1999.
• Cappel M, Mauger D, Thiboutot D. Correlation between serum levels of insulin-like growth factor 1, dehydroepiandrosterone sulfate, and dihydrotestosterone and acne lesion counts in adult women. Archives of Dermatology. 2005.
• Seirafi H, Farnaghi F, Vasheghani-Farahani A, et al. Assessment of androgens in women with adult-onset acne. International Journal of Dermatology. 2007.
• Dréno B, Layton A, Zouboulis CC, et al. Adult female acne: a new paradigm. Journal of the European Academy of Dermatology and Venereology. 2013.
• Ramezani Tehrani F, Behboudi-Gandevani S, Bidhendi Yarandi R, Saei Ghare Naz M, Carmina E. Prevalence of acne vulgaris among women with polycystic ovary syndrome: a systemic review and meta-analysis. Gynecological Endocrinology. 2021.
• Basaria S, Dobs AS. New modalities of transdermal testosterone replacement. Treatments in Endocrinology. 2003.
• Madsen MC, Berg JN, Fisher AD, et al. The effects of gender-affirming testosterone therapy in transgender men on the development of acne, acne severity and the relationship with clinical parameters: a three-year follow-up study. European Journal of Dermatology. 2024.
• Melnik B, Jansen T, Grabbe S. Abuse of anabolic-androgenic steroids and bodybuilding acne: an underestimated health problem. Journal der Deutschen Dermatologischen Gesellschaft. 2007.
• Ding EL, Song Y, Manson JE, et al. Sex hormone-binding globulin and risk of type 2 diabetes in women and men. New England Journal of Medicine. 2009.
• Lucky AW, Biro FM, Simbartl LA, Morrison JA, Sorg NW. Predictors of severity of acne vulgaris in young adolescent girls: results of a five-year longitudinal study. Journal of Pediatrics. 1997.
• Nestler JE, Powers LP, Matt DW, et al. A direct effect of hyperinsulinemia on serum sex hormone-binding globulin levels in obese women with the polycystic ovary syndrome. Journal of Clinical Endocrinology and Metabolism. 1991.
• Selva DM, Hogeveen KN, Innis SM, Hammond GL. Monosaccharide-induced lipogenesis regulates the human hepatic sex hormone-binding globulin gene. Journal of Clinical Investigation. 2007.

This article is for educational purposes and is not medical advice. Talk to your healthcare provider about testing and treatment.