Why Am I Still Getting Cystic Acne at 28? Could High Testosterone Be Causing It?
Acne isn't just a teenage problem. For many women, breakouts continue—or even begin for the first time—well into their 20s, 30s, and beyond.
When adult acne includes stubborn clogged pores, deeper cysts, and dark marks that linger long after pimples disappear, hormones may be one factor worth considering.
Recently, a 28-year-old woman visited Village Dermatology for moderate facial acne that had been present for several months. Her breakouts included blackheads, whiteheads, inflammatory pimples, and occasional deeper cysts or nodules, along with discoloration and scarring from previous breakouts.
She had already tried benzoyl peroxide without adequate improvement and was using azelaic acid (Finacea®) with some benefit. She also reported that previous laboratory testing had shown elevated testosterone levels, and her primary care provider had recommended considering spironolactone.
After reviewing her treatment options, she decided to begin a combination regimen using spironolactone, tretinoin, and clindamycin/benzoyl peroxide.
Can High Testosterone Cause Acne in Women?
Androgens—including testosterone—can influence the sebaceous glands responsible for producing oil.
In some women, increased androgen activity can contribute to:
Increased oil production
Clogged pores
Inflammatory breakouts
Deeper cysts or nodules
Persistent adult acne
However, hormone levels are only one part of the acne picture. Adult acne can have multiple contributing factors, so treatment should be individualized rather than based on a single laboratory result.
In this patient's case, her previously elevated testosterone level and her primary care provider's recommendation were considered alongside her clinical acne findings when discussing spironolactone.
Why Does Adult Acne Leave Dark Marks?
This patient was also concerned about discoloration and scarring left behind by previous breakouts.
After an inflammatory pimple heals, pigment can remain in the skin. This is known as post-inflammatory hyperpigmentation (PIH).
The discoloration can sometimes remain visible much longer than the original acne lesion.
Preventing new acne is therefore an important part of treating pigmentation: fewer inflammatory breakouts mean fewer opportunities for new dark marks to develop.
Daily broad-spectrum SPF 30+ sunscreen is also particularly important because sun exposure can make discoloration more noticeable.
Why Was Spironolactone Recommended?
Spironolactone is an oral prescription medication frequently considered for women whose acne has a hormonal component.
Rather than simply drying out existing pimples, spironolactone reduces the effects of androgens on the skin. For appropriate patients, this can help reduce oil production and inflammatory acne over time.
This patient was prescribed spironolactone 50 mg once daily for two weeks, with instructions to then increase to 50 mg twice daily as directed.
Spironolactone is not an overnight treatment. Patients may need several weeks to months before they can properly judge their response.
What Are the Side Effects of Spironolactone?
Before starting treatment, the patient was counseled about potential adverse effects.
These can include:
Increased urination
Lightheadedness
Gastrointestinal symptoms
Changes in potassium levels
Other medication-related effects
Depending on the patient's medical history and clinical circumstances, blood testing may be recommended to monitor potassium and kidney function.
Importantly, spironolactone should not be used during pregnancy because of potential risks to a developing fetus. Patients who become pregnant or plan to become pregnant should discuss their medications with their healthcare provider.
Why Add Tretinoin?
While spironolactone addresses the hormonal component of acne, tretinoin targets clogged pores and abnormal skin-cell turnover.
The patient was prescribed tretinoin 0.025% cream.
Her treatment instructions were to:
Apply a pea-sized amount to the entire face.
Begin only two to three nights per week.
Gradually increase toward nightly use as tolerated.
Apply moisturizer afterward to reduce dryness and irritation.
Starting slowly can make tretinoin much easier to tolerate.
What Does Clindamycin With Benzoyl Peroxide Do?
For her morning regimen, the patient was prescribed a combination of clindamycin 1% and benzoyl peroxide 5% gel.
This combination helps address inflammatory acne through two complementary approaches.
Benzoyl peroxide helps reduce acne-associated bacteria and clogged pores, while topical clindamycin helps reduce acne-related bacterial activity and inflammation.
The medication was prescribed for application to affected facial areas in the morning.
Why Use Several Acne Treatments at Once?
Moderate adult acne often involves more than one process at the same time.
This patient's regimen was designed to target several components of her acne:
Spironolactone addressed possible hormonal influence.
Tretinoin targeted clogged pores and helped prevent new comedones.
Clindamycin/benzoyl peroxide targeted inflammatory breakouts.
Azelaic acid, which had already provided some improvement, is also commonly used in acne treatment and can be helpful when discoloration is a concern.
Rather than relying on one medication to accomplish everything, combination treatment can address different stages of acne development.
How Long Does It Take for an Acne Routine to Work?
One of the most important parts of acne treatment is patience.
This patient was counseled that meaningful improvement may take approximately two to three months.
During that period, consistency matters. Frequently stopping medications, switching products, or adding harsh over-the-counter treatments can cause irritation and make it more difficult to determine whether the prescribed regimen is working.
Her dermatologist planned to reassess her progress in approximately three months.
What Skincare Should Be Used With Prescription Acne Medication?
A complicated skincare routine isn't necessary.
Patients undergoing acne treatment should generally focus on a few essentials:
Gentle cleanser
Non-comedogenic moisturizer
Broad-spectrum SPF 30+ sunscreen
Prescribed acne medications
Products labeled non-comedogenic are designed to be less likely to clog pores.
Moisturizer is particularly important when using tretinoin or benzoyl peroxide because both can cause dryness and irritation during the adjustment period.
When Should Adult Acne Be Evaluated by a Dermatologist?
Consider seeing a dermatologist if:
Acne is producing cysts or nodules.
Breakouts are leaving scars.
Dark marks persist after pimples heal.
Over-the-counter benzoyl peroxide isn't enough.
Acne continues despite several months of treatment.
You suspect your breakouts may have a hormonal component.
Acne is affecting your confidence or quality of life.
Treating inflammatory acne before additional scarring develops can make long-term management easier.
Adult Female Acne Treatment in Houston & Katy, Texas
Persistent acne in your late 20s doesn't mean you simply need stronger face wash.
Adult female acne can involve clogged pores, inflammation, hormonal influences, pigmentation, and scarring—all of which may require different parts of a treatment plan.
At Village Dermatology, our dermatology team provides individualized treatment for adult acne using options such as tretinoin, benzoyl peroxide, topical antibiotics, azelaic acid, spironolactone, oral antibiotics, and isotretinoin when appropriate.
If you're struggling with stubborn hormonal or cystic acne, schedule a consultation with Village Dermatology in Houston or Katy, Texas, to develop a treatment plan tailored to your skin and acne pattern.
