As we age, we expect many things to change, including our skin. But acne can be a particularly surprising symptom of aging and decreasing hormones for adults. With the advent of social media, an obsession with flawless skin was born. Even the most “liked” influencer is not the equivalent of a board-certified dermatologist (skin specialist), and unfortunately, inaccurate or ineffective information can circulate easily.
While we all want beautiful, clear skin, home extractors can make it tempting to scrub or squeeze normal skin pores that should be left alone. The hyper-focus on pores and blackhead extraction can actually lead to skin damage and scarring, and this kind of overaggressive, repetitive extraction will damage your skin.
As you notice adult acne, a common reaction is to turn to the acne treatments that worked during our teen years. For women over the age of 40, those teen treatments may actually damage your skin, make acne worse, and lead to acne marks and scars1. The holy grail of acne treatment for women in midlife is something that is effective, tolerable, and has anti-aging benefits. But rather than grab those old favorites, it’s time to try something different.
Reasons for Adult Acne
Whether you haven’t had acne in years, or you’ve always struggled with it, you may notice it develops or gets worse with perimenopause (around age 40). It is possible to get acne for the first time, and adult-onset acne is most common among women going through menopause1.
As adolescents, acne tended to be the product of hormonally-induced oil excess and sticky skin cells (keratinocytes) plugging up the pores. Because of this abundant oil, we were able to tolerate the drying side effects of those popular, topical acne medications. What worked well in our teens included improved diet, hygiene, and over-the-counter topical acne treatment, but those things aren’t necessarily going to help us in midlife.
As women move through their 20s and 30s, many are introduced to the challenges of hormonal fluctuations from contraceptives, pregnancies, breastfeeding, and the stresses of balancing work and home life. At that age, skin is less oily but begins to become more sensitive and less tolerant of the products we once relied on. In addition, women may start to develop other skin conditions like rosacea and periorificial dermatitis, which complicate the treatment approach.
From the 30s to early 40s, when many women enter perimenopause, it is common to notice early signs of sun damage that manifest as sunspots and fine lines. Additionally, there is a relationship between menopause and acne. As a woman begins the menopause transition, more dramatic hormone changes and imbalances occur, and this can result in hormonal acne. Adult female hormonal acne typically presents as cystic breakouts along the jawline.
5 Effective Ways to Prevent Adult Acne
Regardless of your acne history, be it adolescent, chronic, or new, there are a number of ways to successfully address it:
Manage fluctuating hormone levels that occur with age via Hormone Replacement Therapy (HRT). Imbalances in hormones (especially estrogen and progesterone) can lead to breakouts. Women experience fluctuating hormones:
Around their periods
During pregnancy, perimenopause, and menopause
After beginning or discontinuing birth control pills
Reduce stress as much as possible to prevent acne flare-ups. Hormonal levels shift with stress, which can stimulate the oil glands and hair follicles in the skin to produce acne.
Check your hair and skincare products for specific ingredients. Remember to read the labels on your products, and try to find products that are the least likely to cause acne. Your products should include at least one of the following terms:
Non-comedogenic
Non-acnegenic
Oil-free
Won’t clog pores
Check your current medications for side effects, as acne can be a side effect of some medicines. Talk with your doctor if you think a medication they prescribed is making your acne worse.
Consider that you may have an undiagnosed medical condition. Sometimes, acne is a sign of something underlying. Once the medical condition is diagnosed and treated, the acne often clears.
Common Questions About Adult Acne
It’s important to understand that acne varies in severity based on age, sex, and hormone levels, so treatment will depend on the individual. There is no singular treatment that will address all types of acne, nor is there one particular treatment that is well-tolerated across the board by all patients. However, treatment goals commonly include prevention and resolution of acne and the scars that sometimes result. While approach varies from person to person, many people have the same common questions:
1. Why do I have acne scars?
Scars (and infection) can result from picking or popping acne, so that is strongly discouraged. Prevention is the best course of action, especially if acne is leading to scarring. There are a wide variety of skin marks that people call “acne scars.” High-risk areas for these include the jawline, earlobes from piercing, shoulders, and chest. Types of acne scars can include:
Hyper- or hypopigmentation (coloration) of the area where the acne was (post-inflammatory)
Dilated pores
Pitting or “ice-pick” scars
Atrophic (thin) scars
Hypertrophic (thick) scars
Keloids (thick, raised scar) - persons of color are at higher risk for formation of keloids, but they can occur with any skin type
2. How do I treat acne and scars?
Acne scarring that results in textural changes is best evaluated by a board-certified dermatologist or plastic surgeon. Once it is determined your acne scarring is not keloidal* in nature, treatment options include:
Staying out of the sun - beneficial if you’re suffering from skin discoloration after acne has resolved.
Lifestyle changes
Daily walks, meditation, yoga, and self-care practices can lower stress; keeping cortisol, the stress hormone, in check is crucial for skin health and overall well-being.
An anti-inflammatory diet, rich in antioxidants and limited in refined sugars, will improve skin appearance and decrease breakouts.
Hormone replacement therapy (HRT) can help normalize hormone levels to calm acne flare-ups. Just like in puberty, hormone fluctuations cause skin to revolt. Teenage girls are often put on hormonal birth control to try to relieve acne, so similarly HRT (at much lower hormone levels than birth control) can help clear up your skin.
Azelaic acid is a naturally occurring acid found in grains like wheat and barley. Prescription-strength (15% and 20%) azelaic acid formulations are expensive and unlikely to be covered by insurance, but OTC 10% azelaic acid is reasonably priced. In addition to helping with mild to moderate acne, azelaic acid also decreases pigment production and can help with unwanted dark spots. Azelaic acid can also be helpful for rosacea, a common skin condition that is often mistaken for acne in midlife.
Topical or oral niacinamide (vitamin B3) is anti-inflammatory and can help both acne and hyperpigmentation. While not as potent as retinoids or HRT, niacinamide can be a beneficial addition to acne treatment and can also improve rosacea, hyperpigmentation, and ultraviolet-induced skin damage.
Retinoids (the vitamin A family) help with acne, anti-aging, and hyper- pigmentation, but they can cause irritation and require an adjustment period. Less-potent OTC retinoids (retinol and adapalene) offer better tolerability but may not be as effective for acne as prescription-strength retinoids. Follow directions carefully**.
Spironolactone is an option for individuals intolerant of retinoids or with more pronounced hormonal acne. Low-dose spironolactone can be used for its anti-androgen effects. Benefits include improvement in cystic acne and decreased facial hair growth and female-pattern alopecia (hair thinning). Spironolactone is available as a prescription tablet or can be compounded as a topical treatment.
Hydroquinone 2% is available without a prescription, but may not work for darker skin types. Prescription (4%) hydroquinone is readily available and may be custom compounded in concentrations as high as 18% with other active ingredients or 20% by itself. It cannot be used chronically, due to risk of paradoxical hyperpigmentation (ochronosis), so breaks should be scheduled every 12-16 weeks.
Topical vitamin C can have some beneficial effects.
Kojic Acid is a popular ingredient in Asia for treating acne and pigmentation. It is a natural byproduct of fermented soy sauce and rice wine. Do not use it if you have a history of allergy to mushrooms or penicillin. In addition to skin lightening properties, it has antimicrobial benefits that may improve acne as well.
Spa Facials can help improve the appearance of skin temporarily via hydration (steam and topical moisturizers), but there is little proof they prevent future breakouts.
Gentle peels may help with hyperpigmented acne scars.
3. Are there other options for treating acne scars?
For darker skin types prone to hyperpigmentation, short-term prescription steroids may be used to decrease inflammation. However, they should be closely monitored due to potential risk of skin thinning and worsening of acne.
Skin treatments like microneedling, chemical peels, dermabrasion*, and ablative and non-ablative lasers can help.
Surgical options include punch excision* of pitted scars and subcision, which employs a needle under the skin to break up scar tissue.
Various soft tissue fillers may be used to fill in depressed scars. They generally last about a year but may stimulate new collagen production.
Other treatment options include injections, silicone or pressure bandages, and even radiation.
*Always consult with an experienced provider, as excision or dermabrasion can result in worsening of keloid scars.
**Be careful with Retinoids
When beginning a retinoid regimen, use only a small, pea-sized amount. This should be applied at bedtime, starting no more than 2 or 3 non-consecutive nights (i.e. Monday, Wednesday, Friday). Avoid the eye area and corners of the mouth, and use a thick moisturizer over it. Don’t forget your sun protection, as all retinoids can increase sun sensitivity and result in burning more easily.
Summary
Winona encourages women to embrace their new, more mature skin and to treat it well. While acne can be an unexpected and particularly frustrating symptom of aging and decreasing hormones, there are many acne treatments that can help. Try some of the options that are available, but be sure to seek out the assistance of a licensed, board-certified, dermatologist if you want to try some of the more aggressive approaches. If you’re interested in trying HRT for your adult acne, reach out to Winona today, and we’ll be happy to help you find the treatment that is right for you.
