What laboratory tests are recommended for evaluating hormonal acne?

Laboratory Tests for Hormonal Acne Evaluation

Routine endocrinologic testing is not recommended for most patients with acne, but laboratory evaluation is specifically recommended for patients who have acne with additional signs of androgen excess. 1

When to Consider Hormonal Testing

Hormonal testing should be considered in patients with:

• Clinical signs of hyperandrogenism in females, such as:

  • Hirsutism 1
  • Oligomenorrhea or irregular menses 1
  • Androgenetic alopecia 1
  • Infertility 1
  • Polycystic ovaries 1
  • Clitoromegaly 1
  • Truncal obesity 1

• In prepubertal children with:

  • Early-onset acne 1
  • Early-onset body odor 1
  • Premature axillary or pubic hair 1
  • Accelerated growth 1
  • Advanced bone age 1
  • Early genital maturation 1

• Treatment-resistant or recalcitrant acne 1

Recommended Laboratory Tests

When hormonal acne is suspected, the following tests should be ordered:

Primary Hormone Panel:

• Free and total testosterone 1
• Dehydroepiandrosterone sulfate (DHEA-S) 1, 2
• Androstenedione 1, 2
• Luteinizing hormone (LH) 1
• Follicle-stimulating hormone (FSH) 1

Additional Tests to Consider:

• Sex hormone binding globulin (SHBG) 1, 2
• Free androgen index (FAI) 1, 2
• 17-hydroxyprogesterone (to rule out non-classical congenital adrenal hyperplasia) 1, 2
• Prolactin 1, 3
• Thyroid stimulating hormone (TSH) 1, 2
• Insulin and glucose levels (if insulin resistance is suspected) 1, 4

Interpretation and Management

• Polycystic ovarian syndrome (PCOS) is the most common cause of elevated androgens in females with acne 1

  • Diagnosis requires 2 of 3 criteria: androgen excess, ovulatory dysfunction, or polycystic ovaries 1
  • In adolescents, diagnosis can be based on hyperandrogenism with persistent oligomenorrhea 1

• Patients with abnormal test results should be referred to an endocrinologist for further evaluation 1

• Hormonal therapy options for confirmed hormonal acne include:

  • Combined oral contraceptives 1
  • Spironolactone 1

Important Considerations

• Most acne patients will have normal hormone levels despite having acne 1
• Hormonal testing is complex and interpretation requires expertise 1
• Growth charts and hand films for bone age are good screening tools for prepubertal children before specific hormonal testing 1
• The association between acne severity and androgen levels remains unclear, with some studies showing positive associations while others show no associations 1
• Microbiologic testing may be considered for patients with monomorphic truncal papules and pustules to diagnose pityrosporum folliculitis 1