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Hormonal acne

Acne is not just a teenage problem. Many women are surprised and distressed to still be affected by acne in their 20s, 30s, occasionally their 40s and/or at the time of menopause.

This type of acne usually begins in the early 20s and can affect individuals who were blemish free during their teenage years.

Unfortunately, because acne is such a visible condition, hormonal acne has a detrimental affect on a person's self-confidence, mood and well-being. Even mild acne can have a big impact on older women.

Adult acne is not the same as teenage acne which is usually more severe in the oilier facial areas including the forehead and central face. Hormonal acne more prominently involves the jaw line and chin area, then extends down the lower face and neck. These skin areas are more sensitive and easily irritated by topical agents.

Hormonal acne ranges in severity.

It may be confined to a few small red papules and pustules on the chin which appear during the premenstrual phase of your cycle, especially if you are stressed. Others have more severe acne with deeper, tender nodules that can appear at any stage of the menstrual cycle and can result in permanent scars. These lesions appear on your face and neck as well as your trunk and shoulders.

Adult females with persistent oily skin will usually have normal hormone levels and skin that will age well. Testing is worthwhile in females with persistent 'seborrhoea' (the medical term for overly oily skin) as some will have hormonal changes warranting treatment.

Hormones (and stress) are also responsible for acne that flares up during the first half of pregnancy or the peri-menopausal period.

Causes

Hormonal acne is thought to result from the interplay of:

  • sex hormones, such as progesterones, oestrogens and testosterone
  • hormones such as insulin
  • chemical substances produced by the body during stressful periods and/or illness

Female hormones, produced mainly in the ovaries, include oestrogen and progesterone. Women aslo produce low levels of testosterone and androstenedione. These cause male-like effects and are known as androgenic hormones.

The upside of these hormones is they maintain muscle and stimulate your libido. The downside is that they also stimulate oil production in the skin which can result in dilated pores, oily skin, acne and excessive body or facial hair

Skin and sun care


Pore clogging or irritating skin care products will aggravate adult acne. If you're acne prone, products labelled 'non-comodegenic' or 'oil free' are more suitable for you.

These should feel light and spread easily on the skin as opposed to more heavy products that give the skin a greasy or coated feeling. Definitely avoid using vitamin E cream or sorbolene containing products on your face (these are both oils).

In summer:

  • go for a face cream with an SPF of 12 to 15 (or 20 in those with a very fair complexion) rather than 30 for your everyday skin care.
  • when spending prolonged time in the sun use an SPF 25-30 either in a gel or spray formulation and/or a light gel/cream or lotion (labelled oil free and 'non-comedogenic')
  • face creams and sunscreens containing the ingredients Mexoryl SX and Mexoryl XL (ecamsule) provide excellent broad spectrum UV protection without clogging or irritating pores. Similarly, skincare products and sunscreens using 'Helioplex technology' are also suitable for hormonal acne sufferers

Stress


Studies have shown that women who work in competitive environments under stress can overproduce male hormones. High levels of these male hormones trigger acne outbreaks in adult females.

Many women juggle jobs, friends, family, financial commitments and many other life stresses which make their adrenal glands produce more cortisol hormones, which can set off acne. Also, acne itself can cause stress!

Polycystic ovarian syndrome


Acne can also be a symptom of polycystic ovarian syndrome (PCOS) a common, treatable condition affecting up to one in ten women. See your doctor to rule out this as a cause of acne.

You should consider being tested for insulin resistance and diabetes if you have any of the symptoms mentioned above or if you:

  • Have polycystic ovaries
  • Family history of diabetes
  • Irregular periods; and/or
  • Despite diet and exercise, you are having trouble loosing excess body fat

Excess weight


Adult women who have excess body weight are more prone to acne.

Surplus fat converts the female hormone (oestrogen) into hormones that behave like male hormones (androgens) and promotes acne through various ways including increasing the production and composition of sebum (natural oil that prevents skin from drying out)

Extra sebum mixed with dead skin cells clogs pores. Inflamed or irritated pores contribute to formation of whiteheads or blackheads that turn into pimples.

Obesity also makes female acne more resistant or difficult to treat.

Insulin resistance


Metabolic abnormalities, such as high insulin levels, also play a role in female adult acne.

Insulin is important for tightly regulating the body's levels of sugar and storage of fat. People with abnormally high levels of insulin are prone to developing diabetes.

The harmful effects of high insulin levels include over-stimulation of the ovaries, which can lead to ovarian cyst formation (e.g. polycystic ovaries), menstrual cycles of variable duration, infertility and higher levels of hormones with testosterone-like effects.

The pill


Some contraceptive pills including high dose progesterone pills, the 'mini' (progestogen only) pill and contraceptive implants can also cause acne by boosting sebum production, while all other pills usually help improve acne (some more effectively than others).

Fertility and acne


For females with acne and polycystic ovarian syndrome, metformin can be beneficial not only for acne but also for increasing fertility and therefore the chance of falling pregnant.

Unfortunately, most other treatments used to assist fertility in females trying to conceive either traditionally or by in vitro fertilisation may temporarily worsen acne.

Treatment

For mild hormonal acne, treatment is similar to that of mild teenage acne however more gentle products are usually preferable.

Over the counter products containing salicylic acid microgel complex, benzoyl peroxide (2.5 - 4.5 per cent to minimise irritation) or an acne wash containing Montaline C40 may be enough to treat mild cases of acne.

If that doesn't work, a doctor can prescribe either a topical retinoid that keeps pores open and prevents inflammation, or a combination treatment such as Epiduo (retinoid + benzoyl peroxide) or Duac (antibiotic + benzoyl peroxide).

If you're still not seeing a response or if the acne is more severe, an oral antibiotic works well. However as this type of acne can be very persistent, hormonal agents can be very effective and are another safe option.

Severe acne of all types usually improves with the prescription drug isotretinoin (eg, Roaccutane).

The treatment of hormonal acne

What can be done for female adult acne? The good news is that plenty can be done!

Adult acne will usually respond to acne treatments used for teenage acne including medicated creams, gels and oral antibiotics.

If you have more severe acne, if your acne fails to respond to topical therapy or if you can't tolerate topical treatment, there are other alternatives. The combined oral contraceptive pill, plus or minus anti-androgens such as spironolactone, may help achieve longer-term acne control.

Checking hormone levels

Most adult females with acne have relatively normal levels of androgens (testosterone) and only about 10 per cent will have abnormally high levels of androgens - including females with polycystic ovarian syndrome.

The regularity of your menstrual cycle is one of the best ways to assess how well regulated your hormones are. If your period is  regular, an abnormality in your hormone levels is unlikely.

You should consider checking with your doctor about possible hormonal abnormalities if you have acne accompanied by any of the following:

  • Abnormal menstrual cycle, such as a significant variation in the time to your period or in its duration
  • Extremely oily skin, excessive facial or body hair growth, or thinning or loss of scalp hair
  • Failure of your acne to improve well with treatment
  • Darkening of skin on the side of your neck and armpits or
  • A male rather than female pattern of fat distribution - in other words, more fat on your torso or belly rather than on your hips

Obesity and insulin resistance

A useful treatment for females with hormonal acne and insulin resistance/high insulin levels is a low dose of metformin, a drug normally used for diabetes. This treatment has many advantages. It not only reduces androgen levels and improves acne but also normalises insulin levels and helps with weight loss and the prevention of diabetes.

Patience is required because the beneficial effects of metformin take time. If used on its own, it can take three to six months before an improvement in acne is seen. This improvement is likely to continue for more than a year. Moreover, metformin's beneficial effects on weight and metabolism, plus its ability to delay or prevent diseases such as diabetes and bowel cancer, can be life-long.

For rapid acne control, metformin is best used in combination with other acne treatments such as topical creams and lotions during the first three to six months.

'Low androgenic' combined oral contraceptive pills (including Loette and Microgynon 20) normally have beneficial skin effects in females with acne. These can include a reduction in the oiliness of skin and pore size (starting after one cycle), fewer pimples less often (this may take three cycles to start but improvements continue for up to six to nine cycles), and a reduction in excessive body hair (after three or more cycles). These beneficial effects are often lost or greatly reduced when taken by females who are overweight or obese. 

Combined oral contraceptives

The heartening news is that no matter how mild or severe your acne, the combined oral contraceptive can often be effective.

The combined oral contraceptive regulates the menstrual cycle and has direct and indirect anti-androgenic actions, which can help in controlling acne.

As with any medication, combined oral contraceptives have varying benefits and side effects.

For more severe and difficult to control acne, combined oral contraceptives containing cyproterone acetate have the best proven benefits in female hormonal acne.

However, it is important to know they carry a slightly higher risk of some side effects including venous thrombosis (e.g. deep vein thrombosis) and embolism (e.g. blood clots that travel through the veins and heart).

The oral contraceptive pill also has a number of medical benefits such as reducing the risk of uterine or endometrial cancers.

If you have mild to moderate acne, you may want to opt for other combined oral contraceptives which also have proven benefits in hormonal acne but have a lower risk profile.

Combined oral contraceptives (Loette, Microgynon 20ED) that contain low doses of oestrogen and levonorgestrel (100mg) have a lower side effect risk ratio, including a lesser risk of venous thrombosis. However, breakthrough bleeding is a more frequent side effect of such lower dose pills.

Common side effects of combined oral contraceptives include mood changes, nausea, weight gain, menstrual spotting and breast tenderness. If you smoke or have high blood pressure, you increase your risk of important side effects such as blood clots and strokes.

Combined oral contraceptives have a slow onset of action so your doctor may suggest a combination of a combined oral contraceptive and other acne therapies, such as a topical retinoid, during the first 3-6 months to improve acne control.

Other combined oral contraceptive pills with proven benefits include those containing Cyproterone acetate (Brenda 35ED, Diane 35ED, Estelle 35ED, Juliet 35ED). Those containing drospirenone (Yasmin), desorgestrel (Marvelon) and gestodene (Femoden and Minulet) are also of proven benefit.

It is generally wise to steer clear of progesterone-only contraceptive pills - also known as minipills - as they are likely to worsen acne. Similarly, contraceptive implants can make acne worse.

Spironolactone

An advantage of spironolactone is that you are likely to see benefits sooner than with a combined oral contraceptive.

You may notice a reduction in skin oils after the first month. By the end of the second month, your acne should begin to improve and continue to do so for another few months.

There can be side effects such as irregular or heavy periods and breast tenderness but these are eased or prevented if you also take a combined oral contraceptive. Spironolactone is taken daily at doses of 50-100mg for acne.

 

This page last updated 9 May 2012.

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