What laboratory tests should be ordered for a patient with persistent or severe acne?

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Last updated: March 11, 2026 • View editorial policy

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Blood Work for Acne

Routine laboratory testing is not indicated for most patients with acne. 1

General Approach to Laboratory Testing

The 2024 American Academy of Dermatology guidelines are clear: routine endocrinologic testing is not indicated for most patients with acne, as the association between acne severity and androgen levels remains unclear. 1

Laboratory testing should be reserved for two specific clinical scenarios:

1. Patients with Clinical Signs of Hyperandrogenism

Order hormonal testing only when patients present with acne PLUS clinical signs or symptoms of hyperandrogenism, including: 1

  • Hirsutism
  • Oligomenorrhea or amenorrhea
  • Androgenic alopecia
  • Infertility
  • Clitoromegaly
  • Truncal obesity

For these patients, consider the following tests: 1

  • Serum total and/or free testosterone
  • Dehydroepiandrosterone sulfate (DHEAS)
  • Luteinizing hormone (LH)
  • Follicle-stimulating hormone (FSH)
  • 17-hydroxyprogesterone (to screen for nonclassic congenital adrenal hyperplasia due to 21-hydroxylase deficiency) 1

Additional tests that may be abnormal in some patients with severe acne include sex hormone-binding globulin, free androgen index, lipid panel, insulin, prolactin, estrogen, and progesterone. 1

Refer patients with abnormal endocrine testing or persistent concern for underlying endocrine disorder to an endocrinologist. 1

2. Patients Starting Isotretinoin

For patients initiating isotretinoin therapy, monitor only liver function tests (LFTs) and lipids. 1

Specific monitoring protocol based on 2024 AAD guidelines and 2022 Delphi consensus: 1, 2

  • Check alanine aminotransferase (ALT) within one month prior to initiation 2

  • Check ALT at peak dose 2

  • Do NOT check ALT monthly 2

  • Do NOT check ALT after treatment completion 2

  • Check triglycerides within one month prior to initiation 2

  • Check triglycerides at peak dose 2

  • Do NOT check triglycerides monthly 2

  • Do NOT check triglycerides after treatment completion 2

Do NOT routinely check the following during isotretinoin treatment: 2

  • Complete blood cell count
  • Basic metabolic panel parameters
  • Gamma-glutamyl transferase
  • Bilirubin
  • Albumin
  • Total protein
  • Low-density lipoprotein (LDL)
  • High-density lipoprotein (HDL)
  • C-reactive protein

Potassium monitoring is of low usefulness in patients without risk factors for hyperkalemia (e.g., older age, medical comorbidities, medications) when using spironolactone for acne. 1

Special Microbiologic Testing Scenarios

Consider lesion culture for Gram-negative folliculitis in patients with eruptive uniform pustules to nodules in periorificial areas, particularly with prolonged amenorrhea during tetracycline treatment. 1

Consider microbiologic testing for pityrosporum folliculitis in patients presenting with monomorphic truncal papules and pustules. 1

Key Clinical Pitfall

The most common error is over-testing. The evidence shows that laboratory abnormalities during isotretinoin treatment are infrequent and typically not clinically significant. 3, 4 Monthly monitoring lacks strong evidence and carries unnecessary financial and emotional burden for patients. 4

References

1
Guideline

guidelines of care for the management of acne vulgaris.

Journal of the American Academy of Dermatology, 2024

3
Research

Standardized laboratory monitoring with use of isotretinoin in acne.

Journal of the American Academy of Dermatology, 2016

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.