27F Adrenal PCOS, Hormonal Acne - Seeking Perspective

[DrProfessorPhD]

#adrenalpcos #hormonalacne #guthealth

Hi everyone,

I'm a 27-year-old female PhD student in biochemistry defending next month, so stress is definitely a factor. I've had persistent hormonal acne for a decade and despite doing everything "right" - my skin still isn't clearing. Sharing my full picture and hoping for perspectives.

I first developed acne in college and it got really bad during COVID - I also got underweight during that period which looking back probably stressed my system significantly. Birth control and spironolactone helped manage things but never fully cleared my skin. When I stopped both, everything flared back up again.

I was diagnosed with PCOS after coming off birth control when my periods became extremely irregular and my androgens came back elevated. Since starting metformin and myo-inositol my cycles have normalized from 50+ day anovulatory cycles down to a regular 31-35 days - and I'm now showing signs of ovulation which is genuinely exciting progress.

I've since tried tretinoin, retinol, dapsone, and benzoyl peroxide topically - all either didn't work or made things worse. I use exclusively acne-safe non-comedogenic products with no pore-clogging ingredients, no fragrance, and no seed oils in my skincare. Despite all of this my skin still isn't clear, which tells me the problem is entirely internal.

My case is unusual because my metabolic markers are excellent:

• Fasting insulin: 4.9 — essentially optimal
• HbA1c: 5.1%
• SHBG: 101 nmol/L — high, maintained off OCP
• FAI: 1.07 — very low bioavailable androgens
• DHEA-S: was 423 (above range), now 328 on metformin
• Total testosterone: 31 ng/dL — normal
• AMH: 5.06 — elevated, confirms PCOS

This is not insulin-driven PCOS. Primary drivers appear to be adrenal androgen overproduction and intrinsic CYP17A1 upregulation — confirmed by DENND1A G;G variant (3-4x PCOS risk) and NR3C1 A;A (glucocorticoid receptor resistance driving chronic cortisol overproduction).

My acne pattern is Exclusively cheeks and jaw — classic gut-hormone axis pattern. Mostly PIH with some active inflammatory lesions. Root causes I've identified:

• Tissue-level 5α-reductase overactivity despite normal circulating androgens
• Adrenal cortisol overproduction via NR3C1 GR resistance
• Possible past mold exposure — HLA-DRB1*1501 G;G susceptibility, acne onset in college

Current Protocol

• Metformin — cycles normalized 50 days → 31-35 days
• Myo-inositol 4g, NAC 1800mg, Zinc 30mg, Methylfolate 400mcg
• Ashwagandha, Phosphatidylserine, CoQ10, TUDCA, Taurine
• Holy basil, Black seed oil, Sulforaphane, Fish oil EPA/DHA
• Magnesium glycinate + threonate, P5P, B12, Vitamin D + K2
• Day 21 of 30 day no sugar no dairy Mediterranean fat distribution cleanse
• Returning to resistance training 7 weeks post breast augmentation surgery
• Daily walking, occasional sauna for HLA-DRB1*1501 mold detox support
• Exclusively acne-safe skincare — HOCl spray, niacinamide, azelaic acid, GHK-Cu copper peptide, zinc oxide

Despite normalized labs, regular cycles, clean diet, acne-safe products, and a comprehensive supplement protocol — acne persists. I understand this is partly expected given LHCGR T;T hypersensitive LH receptor and hardwired DENND1A CYP17A1 upregulation. But after years of trying everything it's genuinely frustrating and disheartening.

My Questions

1. Has anyone with adrenal-dominant low-insulin PCOS found something that finally moved the needle for their skin specifically?

2. Ray Peat's perspective on sugar — I've been avoiding it targeting suspected candida. But given my excellent insulin markers and adrenal dominance, could carb restriction itself be worsening my cortisol load? Could fruit and honey actually be supportive for my phenotype?

3. Anyone connect past mold exposure to hormonal acne onset? Mine started in college, got significantly worse during COVID when I was also very underweight, and I have HLA-DRB1*1501 biotoxin susceptibility.

4. Normal circulating androgens but persistent hormonal acne — tissue-level 5α-reductase overactivity. What specifically helped?

I'm a biochemist so mechanistic detail is very welcome. Completely open to perspectives that challenge my current approach — especially around diet and the low carb question. Thank you.

[CrumblingCookie]

@DrProfessorPhD said:

dapsone, and benzoyl peroxide topically - all either didn't work or made things worse.

Failure of topical ABx and Bp suggests fungal acne. Dermatologists are notoriously bad at discerning it from "regular" bacterial acne. Look up images of both to compare. It's tricky but perhaps you can mark out one over the other.
Perhaps try topical miconazole and or blast massive amounts of oral nystatin for two weeks and reevaluate.

If mold toxins are still an issue do the VCS test online on a proper desktop monitor. If there are mold toxins endlessly circulating then consider a long course of oral cholestyramine to bind them.

The whole PCOS hormonal axis (and to a lesser extent antifungal defense) may be lack of iodide.

Not commenting on the genetic testing and supplement range .

[DrProfessorPhD]

@CrumblingCookie thanks for your response. I was thinking it might be fungal, but due to the fact, I have bangs and its not on my forehead and concentrated around my jaw, I am certain it’s hormonal. That’s why spironolactone , metformin, and inositol reduce it. I agree with mold I will look into that. I’m also looking into getting a gut microbiome and Dutch test. My partner also recommended taking iodine. I’ll give you feedback once I have more results.

In the middle of my 30 day cleanse my cheek acne has reduced, but I still have some jaw acne so hopefully that’s a sign that it’s a combination of hormonal and gut so time will tell, thank you!