What is the best approach to treating hormonal acne in males?

Treatment of Hormonal Acne in Males

For males with hormonal acne, start with topical adapalene 0.1-0.3% combined with benzoyl peroxide 2.5-5% as foundation therapy, escalating to oral doxycycline 100 mg daily plus the topical regimen for moderate-to-severe disease, and reserve isotretinoin for severe or treatment-resistant cases—hormonal testing is only indicated if acne is recalcitrant to standard therapy or if clinical signs of hyperandrogenism are present. 1, 2

Initial Assessment and Hormonal Evaluation

Routine endocrinologic testing is NOT recommended for the majority of male acne patients. 1 Laboratory evaluation is only warranted when:

• Acne is resistant to conventional therapy after 3-4 months of appropriate treatment 1, 2
• Clinical features of hyperandrogenism are present (prepubertal acne with early body odor, accelerated growth, advanced bone age, or genital maturation) 1
• Recalcitrant acne suggests possible nonclassical congenital adrenal hyperplasia 1

If hormonal testing is indicated, obtain free and total testosterone, DHEA-S, androstenedione, LH, and FSH. 1 Consider endocrinology referral if elevated testosterone is confirmed with resistant acne. 2

Severity-Based Treatment Algorithm

Mild Acne

• Start with adapalene 0.1% gel (available over-the-counter) combined with benzoyl peroxide 2.5-5% as first-line therapy. 2, 3
• Adapalene is preferred because it lacks photolability and can be applied with benzoyl peroxide without oxidation concerns. 2, 3
• Apply adapalene once nightly and benzoyl peroxide once daily in the morning. 4
• Use daily sunscreen due to photosensitivity risk. 2

Moderate Acne

• Use fixed-dose combination of topical retinoid plus benzoyl peroxide. 2, 3
• Add topical antibiotic (clindamycin 1% or erythromycin 3%) combined with benzoyl peroxide for inflammatory lesions. 2, 3
• Fixed-combination products (clindamycin 1%/BP 5%, clindamycin 1%/BP 3.75%, or erythromycin 3%/BP 5%) enhance compliance. 3, 4
• Never use topical antibiotics as monotherapy—resistance develops rapidly without concurrent benzoyl peroxide. 1, 2, 3

Moderate-to-Severe Acne

• Initiate triple therapy: oral doxycycline 100 mg daily + topical retinoid + benzoyl peroxide. 2, 3
• Doxycycline is strongly recommended with moderate evidence as first-line systemic antibiotic. 2, 4
• Minocycline 100 mg daily is conditionally recommended as an alternative. 3, 4
• Limit systemic antibiotics to 3-4 months maximum to minimize resistance. 2, 3, 4
• Always use benzoyl peroxide concurrently with oral antibiotics to prevent resistance. 2, 3

Severe or Treatment-Resistant Acne

• Isotretinoin is indicated for severe acne, treatment-resistant moderate acne after 3-4 months of appropriate therapy, or any acne with scarring or significant psychosocial burden. 2, 3, 4
• Standard dosing: 0.5-1.0 mg/kg/day targeting cumulative dose of 120-150 mg/kg. 2, 4
• Daily dosing is preferred over intermittent dosing. 2, 4
• Monitor liver function tests and lipids, but CBC monitoring is not needed in healthy patients. 2
• Population-based studies have not identified increased risk of neuropsychiatric conditions or inflammatory bowel disease. 2

Male-Specific Hormonal Treatment Options

Clascoterone (topical antiandrogen) is conditionally recommended and may be particularly relevant for androgen-driven acne in males. 2, 4, 5 This is the only FDA-approved topical antiandrogen and has limited systemic effects on reproductive hormones, making it suitable for male patients. 5

Unlike females, males cannot use:

• Combined oral contraceptives (mechanism targets ovarian androgen production) 1
• Spironolactone (feminizing side effects in males) 6, 7

If confirmed elevated testosterone with resistant acne, endocrinology consultation is recommended to identify underlying endocrine disorders such as nonclassical congenital adrenal hyperplasia or androgen-secreting tumors. 1, 2

Maintenance Therapy

Continue topical retinoid monotherapy indefinitely after achieving clearance to prevent recurrence. 2, 3, 4 Benzoyl peroxide can also be continued as maintenance therapy. 2, 3

Critical Pitfalls to Avoid

• Never use antibiotics (topical or oral) as monotherapy—resistance develops rapidly without concurrent benzoyl peroxide. 1, 2, 3, 4
• Never extend oral antibiotics beyond 3-4 months without re-evaluation—this dramatically increases resistance risk. 2, 3, 4
• Do not underestimate severity when scarring is present—this warrants more aggressive treatment regardless of lesion count. 2, 4
• Do not routinely order hormonal testing in males with typical acne—reserve for treatment-resistant cases or clinical hyperandrogenism. 1

Key Distinction from Female Hormonal Acne Treatment

The fundamental difference is that males lack access to the primary hormonal therapies used in females (oral contraceptives and spironolactone), making the treatment approach essentially identical to standard acne management with severity-based escalation. 1, 6 The only male-appropriate hormonal option is topical clascoterone, which can be incorporated at the moderate acne stage. 2, 5