Cutaneous Manifestations of Polycystic Ovarian Syndrome (PCOS)

Polycystic ovarian syndrome (PCOS) is one of the most common endocrine disorders affecting women of reproductive age, with a global prevalence ranging from 4% to 21%.¹ Due to its complex, multisystemic effects, potential impacts on fertility, and long-term health risks, PCOS can be particularly distressing for patients. While the exact cause of PCOS is not fully understood, it is clear that ovarian cystic abnormalities, anovulation, metabolic syndrome, and hyperandrogenism are contributing factors in its development.

One crucial but often overlooked aspect of PCOS is that many of its hallmark symptoms, including insulin resistance, hyperandrogenism, and metabolic dysfunction, have distinct cutaneous manifestations.²  For many women, these skin changes are the first visible signs that something is unusual.

Acanthosis Nigricans

Insulin resistance, a major component of metabolic syndrome, frequently manifests as acanthosis nigricans. Acanthosis nigricans presents as velvety, hyperpigmented plaques typically found in intertriginous areas, including the neck, axillae, groin, and under the breasts. Elevated insulin levels stimulate epidermal hyperplasia and melanin production, often making these darkened areas particularly prominent.

Hidradenitis Suppurativa

Another condition linked to metabolic dysfunction in PCOS is hidradenitis suppurativa (HS), a chronic inflammatory skin disease that presents as painful nodules, abscesses, and sinus tracts that can lead to scarring and, in many cases, tunneling. HS disproportionately affects individuals with metabolic syndrome, with research even suggesting increased odds of PCOS among those with HS.³

Hyperandrogenism and Dermatologic Symptoms

Hyperandrogenism (the excessive production of male hormones) and ovarian dysfunction also give rise to some of the most distressing dermatologic symptoms of PCOS. Some of these features include hirsutism (excessive hair growth in a male-pattern distribution), hair thinning, and acne. In individuals with darker skin and tightly coiled hair textures, pseudofolliculitis barbae (PFB) may further complicate PCOS-related skin concerns. PFB is characterized by inflamed, ingrown hairs that affect the face and neck, leading to inflammation and scarring.⁴ PFB can cause hyperpigmented scars and chronic irritation, further impacting skin appearance and self-esteem.

Chronic, treatment-resistant acne is another common sign of PCOS, particularly in areas like the jawline, chin, and upper back.⁵ The presence of increased androgens leads to excessive sebum production, clogged pores, and inflammation. In darker Fitzpatrick types, postinflammatory hyperpigmentation often accompanies these acne lesions, leaving persistent hyperpigmentation that can be especially challenging to treat.⁶

By recognizing these dermatologic markers, healthcare providers can help bridge the gap in earlier PCOS diagnosis and intervention, particularly for patients of color who may face delays in receiving care. Understanding the nuances of PCOS presentation across different racial and ethnic groups is essential in fostering more equitable, patient-centered treatment strategies.

1. Lizneva D, Suturina L, Walker W, Brakta S, Gavrilova-Jordan L, Azziz R. Criteria, prevalence, and phenotypes of polycystic ovary syndrome. Fertility and Sterility. 2016;106(1):6-15. doi:10.1016/j.fertnstert.2016.05.003
2. Lee AT, Zane LT. Dermatologic manifestations of polycystic ovary syndrome. Am J Clin Dermatol. 2007;8(4):201-219. doi:10.2165/00128071-200708040-00003
3. Ch’en PY, Toker M, Chen G, Hosgood HD, Campton KL, Cohen SR. Prevalence and association of polycystic ovary syndrome and hidradenitis suppurativa in underrepresented groups. Arch Dermatol Res. 2024;316(7):379. doi:10.1007/s00403-024-02971-9
4. Nguyen TA, Patel PS, Viola KV, Friedman AJ. Pseudofolliculitis barbae in women: a clinical perspective. British Journal of Dermatology. 2015;173(1):279-281. doi:10.1111/bjd.13644
5. Housman E, Reynolds RV. Polycystic ovary syndrome: A review for dermatologists: Part I. Diagnosis and manifestations. Journal of the American Academy of Dermatology. 2014;71(5):847.e1-847.e10. doi:10.1016/j.jaad.2014.05.007
6. Elbuluk N, Grimes P, Chien A, et al. The Pathogenesis and Management of Acne-Induced Post-inflammatory Hyperpigmentation. Am J Clin Dermatol. 2021;22(6):829-836. doi:10.1007/s40257-021-00633-4