Acne is a skin condition that arises when excess oil production, disordered skin cell shedding, bacterial overgrowth, and the immune system cause clogged pores and inflammation.
While mild cases of acne may respond to topical treatments and diligent skincare routines, more severe or persistent cases often require a deeper, more integrative approach. Studies show that 12.2-80% of individuals experience relapse or treatment failure with conventional acne medications, depending on the treatment modality (36, 65).
This highlights the need for more comprehensive strategies to address acne's underlying causes. Laboratory testing helps identify the root causes of acne beyond surface-level symptoms.
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When Are Lab Tests Necessary for Acne?
In most cases, acne can be diagnosed with a thorough physical examination and medical history. However, the clinical utility of laboratory tests becomes evident in specific scenarios – such as severe cases, those unresponsive to first-line treatments, or when underlying triggers like hormonal imbalances or food allergies are suspected and require confirmation.
What triggers one person's acne may differ from another's. Lab tests are valuable for dermatologists because they help identify the specific factors responsible for an individual's acne. This enables providers to move beyond generic treatments and adopt a targeted strategy that enhances treatment outcomes and minimizes unnecessary interventions.
Signs and symptoms that indicate it's time to consider lab tests to personalize your acne treatment protocol include:
- Persistent or severe acne that does not improve with standard treatments
- Sudden onset of acne without known cause, especially after age 25
- Irregular menstrual cycles
- Excessive hair growth or hair loss
- Chronic fatigue
- Weight gain
Common Lab Tests for Acne: What to Expect
Although not all of these tests are necessary for every patient, they represent common options that individuals might consider discussing with their healthcare providers.
Hormonal Testing
Androgens, often called male sex hormones (but also present in women in smaller amounts), increase the size and activity of sebaceous (oil) glands in the skin. Dehydroepiandrosterone (DHEA), testosterone, and dihydrotestosterone (DHT) are examples of androgens.
Elevated androgen levels lead to overproduction of sebum, which can clog pores and create an environment conducive to the growth of acne-causing bacteria (59). Conditions characterized by androgen excess, such as polycystic ovary syndrome (PCOS), often present with acne as a symptom.
In addition to having an excess of androgens, women with PCOS commonly have an LH:FSH ratio of greater than 1. To calculate this ratio, measure the serum levels of luteinizing hormone (LH) and follicle-stimulating hormone (FSH). Then, divide the LH level by the FSH level.
Changes in estrogen and progesterone related to the menstrual cycle influence skin health, which is why many women experience acne breakouts as a physical symptom of premenstrual syndrome (PMS), pregnancy, and menopause.
While estrogen and progesterone can be measured in blood, the natural fluctuations in their levels from day to day can make catching hormonal imbalances difficult. Instead, providers often use multi-day salivary or urinary tests to measure these hormones throughout a menstrual cycle. (30)
Use the following labs to screen for hypothalamic-pituitary-gonadal (HPG) axis dysfunction and sex hormone imbalances as a cause of acne:
- FSH & LH blood test by Access Med Labs
- DHEA-S by Access Labcorp Draw
- Testosterone, Free & Total w/ SHBG by Access Med Labs
- DHT (Dihydrotestosterone) by Access Med Labs
- Female Hormone Panel by Precision Point
- DUTCH Cycle Mapping by Precision Analytical (DUTCH)
Insulin and Blood Sugar Tests
Insulin resistance occurs when the body's cells do not respond effectively to insulin, leading to impaired glucose uptake and elevated blood sugar levels. This is problematic for acne-prone skin because insulin stimulates the production of androgens and insulin-like growth factor 1 (IGF-1). Like androgens, IGF-1 promotes sebum production. (55)
High blood sugar and insulin resistance are also linked to systemic inflammation, which can worsen acne symptoms. Inflammatory processes in the skin can lead to increased redness, swelling, and discomfort associated with more severe acne types, like nodulocystic acne.
The Homeostasis Model Assessment of Insulin Resistance (HOMA-IR) is a widely used method for estimating insulin resistance based on fasting blood glucose and insulin levels. A score below 1.0 indicates optimal insulin sensitivity, scores between 1.0 and 1.9 suggest early insulin resistance, and scores above 2.9 indicate significant insulin resistance (39).
Studies have found that nearly 43% of patients with acne are insulin-resistant, with a positive correlation between HOMA-IR and acne severity, meaning that acne tends to worsen as insulin resistance increases.
Use the following labs to screen for dysglycemia (abnormal blood sugar) and insulin resistance as a cause of acne:
- Glucose, Fasting, Plasma by Access Med Labs
- Insulin, Fasting by Access Med Labs
- HOMA-IR by Boston Heart Diagnostics
Cortisol and Stress Hormone Testing
Chronic stress impacts skin health through the activation of the hypothalamic-pituitary-adrenal (HPA) axis, which leads to increased corticotropin-releasing hormone (CRH) and cortisol secretion. Chronic elevations of CRH cortisol are linked to increased systemic inflammation and heightened oil production from sebaceous glands, which aggravates existing lesions and creates an environment that promotes new breakouts.
Cortisol testing can be performed using blood, saliva, or urine samples to assess the impact of stress on the body. Each method provides insights into cortisol levels at different times of the day or in response to specific stressors.
Use the following labs to screen for chronic stress and cortisol dysregulation as a cause of acne:
- Cortisol by Boston Heart Diagnostics
- Adrenal Stress Profile with CAR by Genova Diagnostics
- DUTCH Adrenal by Precision Analytical (DUTCH)
Thyroid Function Tests
The thyroid is a butterfly-shaped gland that regulates metabolism by secreting thyroid hormones (T4 and T3), which influence various physiological processes, including skin cell proliferation, differentiation, and function. When thyroid hormone levels are imbalanced, as seen in conditions like hypothyroidism or hyperthyroidism, it can lead to dermatological changes, including:
- Dry skin
- Oily skin
- Excessive sweating
One study found that 72% of patients with severe acne had autoimmune thyroid disease (Hashimoto's thyroiditis or Graves' disease), and the presence of thyroid antibodies called anti-thyroglobulin (anti-TG) doubled the risk of severe acne.
Use the following labs to screen for thyroid dysfunction as a cause of acne:
- TSH by Access Med Labs
- T3, Free by Access Med Labs
- T4, Free by Access Med Labs
- Comprehensive Thyroid Panel w/ Antibodies by Precision Point
Blood Tests for Nutrient Deficiencies
Vitamin D is essential for numerous bodily functions, including immune system regulation and inflammation control. Studies have shown that individuals with acne often have lower levels of vitamin D, and supplementation improves acne severity by reducing inflammation, decreasing sebum secretion, and inhibiting the growth of acne-causing bacteria (52).
Zinc is an antioxidant mineral that is another critical nutrient for skin health through its involvement in immune function, DNA synthesis, cell division, and wound healing. Zinc possesses anti-inflammatory and antibacterial properties, making it particularly beneficial for acne management. Supplementation with zinc has been shown to improve acne symptoms in various studies. (48, 52)
Use the following labs to screen for nutrient deficiencies as a cause of acne:
- Vitamin D, 25-Hydroxy by Empire City Laboratories Inc.
- Zinc RBC by Access Med Labs
- Micronutrient Test by SpectraCell Laboratories
Additional Tests for Specific Cases
In specific scenarios, your doctor may also recommend ordering additional tests.
Polycystic Ovary Syndrome (PCOS) Panel
PCOS is a common hormonal disorder that affects 7% of women of reproductive age in the United States.
Doctors should suspect PCOS in patients with the following:
- Irregular periods
- Hirsutism (excessive male-pattern hair growth)
- Acne
- Weight gain/difficult weight loss
- Polycystic ovaries as seen on ultrasound (9)
PCOS is diagnosed using the Rotterdam Criteria, but a more comprehensive laboratory evaluation is warranted for this condition, given its association with cardiometabolic disease.
These labs help assess hormonal imbalances and screen for high cholesterol, insulin resistance, high blood sugar, and inflammation:
- Female Hormone Panel by Boston Heart Diagnostics
- HOMA-IR by BostonHeart Diagnostics
- Metabolomic Profile by Doctor's Data
- CardioPro Advanced by Access Med Labs
Comprehensive Metabolic Panel (CMP)
Isotretinoin is an oral prescription medication used to treat severe nodular acne unresponsive to conventional therapy. The FDA issued a black box warning for isotretinoin for its potential to cause severe, life-threatening congenital disabilities if taken during pregnancy. (51)
Other side effects associated with its use include:
- Dyslipidemia (high cholesterol and triglycerides)
- Elevated liver enzymes
- High blood sugar
To monitor patients on isotretinoin therapy, healthcare providers should:
- Order two pregnancy tests before therapy and one test at monthly intervals during treatment
- Evaluate blood sugar frequently
- Measure lipid levels at weekly or biweekly intervals for one month
- Perform hepatic function tests at weekly or biweekly intervals for one month (51)
Blood sugar and hepatic function tests are included in a comprehensive metabolic panel (CMP).
How Test Results Influence Treatment Plans
Laboratory test results allow healthcare providers to personalize a root-cause approach to acne management.
Hormonal Therapies
Identifying hormonal imbalances in androgens, estrogen, and/or progesterone should prompt healthcare providers to consider hormonal treatments for acne.
Prescription medications that target hormonal imbalances include:
- Combined oral contraceptive pills
- Antiandrogen drugs, such as spironolactone
Natural options for balancing hormones and supporting a healthy menstrual cycle include:
- Chasteberry
- B vitamins
- Omega-3 fatty acids
Dietary and Lifestyle Modifications
Reversing insulin resistance requires a holistic approach that begins with lifestyle adjustments, including:
- Dietary modifications that focus on balancing blood sugar
- Exercising regularly to support heart health, reduce blood sugar, and increase muscle mass
In some cases, natural supplements and prescription medications may be recommended to control blood sugar levels, improve insulin sensitivity, and reduce acne symptoms more quickly. Examples include:
- Chromium improves insulin's binding to its receptors, increases insulin-mediated glucose uptake into cells, and enhances the activity of enzymes involved in carbohydrate metabolism.
- Cinnamon supports lower blood sugar levels by facilitating glucose uptake into cells.
- Magnesium acts as a cofactor for various enzymes involved in insulin signaling,
- Metformin decreases the amount of glucose the liver produces, reduces intestinal absorption of glucose, and increases glucose uptake in peripheral tissues.
Stress Management Interventions
Cortisol testing can reveal both hyper-responsiveness and hypo-responsiveness of the adrenal glands, depending on the duration of stress exposure.
Excessive cortisol production requires interventions aimed at reducing cortisol levels and managing symptoms of stress and anxiety. Treatment options include:
- Mind-body therapies, such as mindfulness meditation or deep breathing
- Calming adaptogenic herbs that reduce cortisol secretion, such as ashwagandha
Insufficient cortisol production requires interventions that focus on nourishing the adrenal glands:
- Nutrient support with B vitamins, vitamin C, magnesium, and zinc
- Stimulating adaptogenic herbs, such as licorice, which prolongs the half-life of cortisol
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Key Takeaways
- Laboratory tests help identify acne's underlying causes and triggers.
- Utilizing lab test results, healthcare providers can develop targeted therapies that address specific triggers, ultimately leading to more effective management of even the most stubborn acne cases.
- If you suspect hormonal imbalances, nutritional deficiencies, or other medical conditions are affecting your skin, talk to your doctor about ordering investigative labs.
- With the right diagnosis and implementation of a targeted treatment protocol, acne can be managed effectively, achieving clearer skin.
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