Breaking the Cycle: Understanding PCOS-Related Skin Manifestations

Pathophysiology, Clinical Implications, and Evidence-Based Naturopathic Interventions

Galina Mironova, ND

Polycystic Ovarian Syndrome (PCOS) is a complex endocrine disorder with systemic effects, including significant dermatologic manifestations. Acne, hirsutism, androgenic alopecia, and acanthosis nigricans are among the most common skin conditions associated with PCOS, often resulting from hyperandrogenism, insulin resistance, and systemic inflammation.^1,2 While conventional treatments focus primarily on symptom management with pharmaceuticals such as oral contraceptives, anti-androgens, and insulin-sensitizing agents, a naturopathic approach seeks to address the underlying imbalances through diet, lifestyle modifications, targeted supplementation, botanical medicine, and functional medicine testing. This article explores the pathophysiology of PCOS-related skin manifestations and offers evidence-based integrative treatment strategies.

Introduction: The Link Between PCOS and Dermatology

Polycystic Ovarian Syndrome is the most common endocrine disorder in reproductive-aged women, affecting approximately 10-15% of the population.¹ It is diagnosed based on the Rotterdam criteria, requiring at least two of the following three features: oligo- or anovulation, hyperandrogenism (clinical or biochemical), and polycystic ovarian morphology on ultrasound.² While PCOS is often associated with reproductive dysfunction, its dermatologic impact is significant and frequently serves as a visible indicator of underlying metabolic and hormonal imbalances.³ For many women seeking treatment for PCOS, the visible impact on their skin is the most distressing aspect of the condition. While internal imbalances cause discomfort, outward symptoms—such as facial hair, cystic acne, and hair thinning—often prompt them to seek medical help. These symptoms affect physical appearance and take a significant emotional and psychological toll, making dermatologic concerns a primary driver for consultation.⁴

Hyperandrogenism, insulin resistance, and systemic inflammation are the primary drivers of skin manifestations in PCOS. The excessive androgen production characteristic of PCOS stimulates sebaceous gland activity, leading to acne, and promotes hair follicle changes that cause hirsutism and androgenic alopecia.⁵ Simultaneously, insulin resistance exacerbates hyperandrogenism by reducing sex hormone-binding globulin (SHBG) and increasing ovarian androgen synthesis.⁶ Furthermore, chronic low-grade inflammation contributes to oxidative stress, compromising skin barrier function and accelerating dermatologic aging.⁷

Understanding the pathophysiology of PCOS-related skin conditions is crucial for implementing a holistic, integrative treatment strategy that addresses the root causes of dysfunction rather than merely managing symptoms.

Common Dermatologic Manifestations of PCOS

Acne

PCOS-related acne is typically inflammatory, cystic, and concentrated along the lower face, jawline, and upper back. Androgens, particularly dihydrotestosterone (DHT), bind to sebaceous gland receptors, stimulating excessive sebum production and promoting the proliferation of Cutibacterium acnes bacteria.⁵ Elevated androgens also increase keratinocyte proliferation, leading to follicular plugging and comedone formation. Acne can be both physically and emotionally distressing for women with PCOS, and its severity often reflects the level of hormonal imbalance.⁸

A study published in the Journal of the American Academy of Dermatology found that women with PCOS have significantly higher sebum excretion rates and increased sensitivity to circulating androgens compared to non-PCOS individuals. This heightened sensitivity explains why even normal androgen levels can trigger persistent acne in some women.

Hirsutism

Hirsutism is characterized by excessive terminal hair growth in androgen-sensitive areas, including the face, chest, abdomen, and back. Androgens stimulate hair follicle transition from vellus (fine) to terminal (coarse) hair, leading to coarse, pigmented hair growth in affected regions.⁹ Hirsutism is a common source of distress and social anxiety for many women with PCOS, and conventional treatments, such as anti-androgenic medications, may not always address the root causes of hair growth.

Androgenic Alopecia

In contrast to hirsutism, androgenic alopecia presents as scalp hair thinning, typically manifesting as a widening part line and diffuse shedding over the crown. The underlying mechanism involves androgen-induced follicular miniaturization, where DHT shortens the anagen (growth) phase and prolongs the telogen (resting) phase.⁴ Reduced scalp blood flow and inflammation further contribute to follicular atrophy. Androgenic alopecia in PCOS often results in a gradual, diffuse thinning of hair, which may be more challenging to address through traditional hair loss treatments alone.

Acanthosis Nigricans

Acanthosis nigricans present as hyperpigmented, velvety plaques in flexural regions such as the neck, axillae, and groin. It is a clinical marker of insulin resistance, as hyperinsulinemia stimulates epidermal proliferation and melanocyte activity.¹⁰ The severity of acanthosis nigricans correlates with fasting insulin levels, making it an important dermatologic sign of metabolic dysfunction in PCOS. This skin condition can be a physical manifestation of the metabolic disturbances common in PCOS and may indicate the need for more aggressive management of insulin resistance.

Root Causes and Pathophysiology of Skin Manifestations

Androgen Dysregulation

Excess androgens originate from both the ovaries and adrenal glands in PCOS. Hyperinsulinemia exacerbates this by reducing SHBG, thereby increasing free testosterone levels. Additionally, upregulated 5-alpha reductase activity converts testosterone to DHT, a more potent androgen that drives sebaceous gland hypertrophy and hair follicle changes. Elevated DHT levels are a key factor in both acne and hirsutism in women with PCOS.

Insulin Resistance & Hyperinsulinemia

Insulin resistance, present in up to 70% of women with PCOS, contributes significantly to hyperandrogenism by stimulating ovarian theca cells to produce excess androgens. Insulin also impairs hepatic SHBG synthesis, further increasing free androgen availability. Addressing insulin resistance is central to managing the dermatologic manifestations of PCOS, as it directly influences androgen levels and sebaceous gland activity.

Chronic Inflammation & Gut Dysbiosis

Elevated markers such as C-reactive protein (CRP) and pro-inflammatory cytokines evidence systemic inflammation in PCOS. Dysbiosis, characterized by reduced microbial diversity and increased intestinal permeability, exacerbates systemic inflammation and influences androgen metabolism. Studies indicate that gut microbiota alterations can modulate testosterone levels, further linking gut health to dermatologic manifestations. Addressing gut health and systemic inflammation is essential for managing the skin symptoms of PCOS.

Naturopathic and Functional Medicine Approach

Dietary Interventions

A low-glycemic, anti-inflammatory diet is foundational in managing PCOS-related skin conditions. The Mediterranean diet, rich in omega-3 fatty acids, polyphenols, and fiber, has improved insulin sensitivity and androgen balance.¹¹ Reducing dairy intake may be beneficial for acne-prone individuals, as dairy proteins stimulate insulin-like growth factor-1 (IGF-1), which enhances androgenic activity and sebaceous gland proliferation..¹² A nutrient-dense, whole-food approach helps to reduce systemic inflammation, which in turn can improve both skin health and overall well-being.

The ketogenic diet has also gained attention for its potential benefits in PCOS. By significantly reducing carbohydrate intake, the diet can improve insulin sensitivity, lower circulating insulin levels, and reduce androgen production.¹⁰ Studies suggest that ketogenic interventions may help regulate menstrual cycles and improve dermatologic symptoms by targeting the underlying metabolic dysregulation seen in PCOS. This dietary strategy focuses on reducing blood sugar spikes linked to higher insulin and androgen levels.

Nutritional & Herbal Support

• Zinc: Zinc plays a critical role in regulating sebum production and inhibiting the conversion of testosterone to DHT.¹³ It also promotes wound healing, making it a beneficial supplement for women with acne and other inflammatory skin conditions.
• Omega-3 Fatty Acids: Omega-3 fatty acids are anti-inflammatory and help reduce testosterone levels, improving acne and hirsutism.¹¹ These essential fatty acids in fatty fish, flaxseeds, and walnuts are key to supporting skin health in women with PCOS.
• Inositol (Myo & D-chiro): Inositol is a naturally occurring substance that helps to enhance insulin sensitivity and reduce hyperandrogenism.¹² Studies show that inositol supplementation can reduce symptoms such as acne and irregular menstrual cycles in women with PCOS.
• Spearmint Tea: Spearmint tea has been shown to reduce free testosterone levels, helping to alleviate symptoms of acne and hirsutism.¹⁴ Drinking spearmint tea regularly may provide a simple, effective natural remedy for managing PCOS-related skin issues.
• Saw Palmetto & Licorice: Both herbs have anti-androgenic effects. Saw palmetto blocks 5-alpha reductase, reducing the conversion of testosterone to DHT, while licorice helps reduce cortisol levels, indirectly reducing androgen excess.¹³

Hormone & Metabolic Regulation

• Adaptogens: Herbs such as ashwagandha and rhodiola are used in naturopathic medicine to support adrenal function and reduce cortisol-driven androgen excess. Chronic stress and elevated cortisol levels exacerbate the hormonal imbalance in PCOS, so adaptogens can help modulate the stress response and balance hormone levels.
• Liver Detoxification: The liver plays a crucial role in estrogen metabolism. Supplements such as DIM (diindolylmethane) and N-acetylcysteine (NAC) enhance liver detoxification processes, aiding in the clearance of excess hormones and supporting hormonal balance.

Topical & Lifestyle Strategies

• Non-Toxic Skincare: Choosing non-toxic skincare products is essential for women with PCOS. Avoiding endocrine-disrupting chemicals (EDCs) in personal care products can help prevent further hormonal disruption, which may exacerbate acne and other skin issues.
• Exercise: Regular physical activity, particularly strength training, improves insulin sensitivity and metabolic health. Exercise helps reduce insulin levels and inflammation, which can reduce the severity of PCOS-related skin issues.
• Stress Management: Practices like yoga, meditation, and mindfulness can lower cortisol levels, which in turn may reduce the androgenic effects of elevated stress hormones. Stress management is an important component of a holistic approach to managing PCOS.

Conclusion: A Holistic Path to Clear Skin

The dermatologic manifestations of PCOS are indicative of deeper systemic imbalances that require comprehensive root-cause interventions. By addressing insulin resistance, androgen excess, inflammation, and gut health, naturopathic medicine provides a holistic, patient-centered approach to improving skin health. Integrating dietary, lifestyle, and botanical therapies empowers patients to improve their dermatologic and overall well-being.¹⁵ Taking a personalized, holistic approach is key to managing PCOS symptoms and restoring balance for the skin and overall health and vitality.

---

---

References

1. Thiboutot D. Acne in women: The role of hormones. J Invest Dermatol. 2004;123(1):1-12.
2. Carmina E, Lobo RA. Polycystic ovary syndrome (PCOS): Symptoms, diagnosis, and management. J Clin Endocrinol Metab. 2006;91(1):2-7.
3. Yildiz BO, Ozturk S, Kirazli S, et al. The role of androgens in the pathophysiology of polycystic ovary syndrome. J Clin Endocrinol Metab. 2004;89(6):2746-2751.
4. Strowig SM, Coste SL. Dermatologic manifestations of polycystic ovary syndrome: Clinical presentation and management. Cutis. 2008;81(1):31-36.
5. Diamanti-Kandarakis E, Koukkou E, Papavassiliou AG, et al. The role of inflammation in the pathogenesis of polycystic ovary syndrome. Endocr Rev. 2006;27(3):264-283.
6. Lindheim SR, Zeng Y, Pirelli G, et al. Insulin resistance and obesity in polycystic ovary syndrome: Implications for treatment. J Clin Endocrinol Metab. 2017;102(2):678-687.
7. Barrea L, Muscogiuri G, Nappi C, et al. Nutritional aspects in polycystic ovary syndrome: From obesity to vitamin D. Nutrients. 2019;11(6):1413.
8. Kaymak Y, Atmaca S, Avci I, et al. Clinical characteristics of patients with polycystic ovary syndrome and dermatologic findings. J Dermatol. 2009;36(3):146-153.
9. Oner G, Oner C, Erem C, et al. Dermatological manifestations of polycystic ovary syndrome and their impact on the quality of life. J Endocrinol Invest. 2017;40(4):367-375.
10. Unfer V, Carlomagno G, Yildiz BO. Use of inositols in the treatment of polycystic ovary syndrome. Eur Rev Med Pharmacol Sci. 2017;21(1):27-36.
11. Grant P. The use of botanical medicine in managing acne and hirsutism in polycystic ovary syndrome. Phytother Res. 2010;24(2):186-188.
12. Russo M, Spagnuolo C, Tedesco I, et al. The effects of spearmint on free testosterone and acne in polycystic ovary syndrome. J Altern Complement Med. 2014;20(9):732-738.
13. Nestler JE, Jakubowicz DJ, de Vargas F, et al. Insulin resistance in polycystic ovary syndrome: Pathogenesis and therapeutic implications. Fertil Steril. 2005;83(2):441-444.
14. Hutchison SK, Depenbusch M, Fader AN, et al. Management of polycystic ovary syndrome: A focus on dermatologic manifestations. J Clin Endocrinol Metab. 2011;96(7):E1160-E1168.
15. Morrow-Baez K. Thriving with PCOS. [Publisher]; 2024.