As we age, we expect many things to change, including our skin. Acne can be a particularly surprising symptom of aging and decreasing hormones for adults. As the acne worsens, a common reaction to adult acne is to look for the acne treatments that worked during our teen years. Rather than grab those old favorites, it is time to try different acne removal treatments. Those teen years treatments may actually damage your skin, make acne worse, lead to acne marks and acne scars.1 There are much better, more appropriate treatments, for women over the age of 40.
Expectations About Your Skin
The holy grail of acne treatment for women in midlife is efficacy, tolerability, and anti-aging benefits. With the advent of social media, an obsession with flawless skin was born. Unfortunately, even the most “liked” influencer is not the equivalent of a board-certified dermatologist (skin specialist).
This hyperfocus on pores and blackhead removal can actually lead to damage and scarring. While we all want beautiful, clear skin, don’t overthink it. The use of home extractors and magnifying mirrors is discouraged because they can encourage the user to try to scrub or squeeze normal skin pores that should be left alone. This kind of overaggressive, repetitive extractions will damage your skin.
Reasons for Adult Acne
Whether you haven’t had acne in years, or you’ve always struggled with it – you may notice it starts or gets worse with perimenopause (at about 40). It is even possible to get acne for the first time, “adult-onset acne,” and is most common among women going through menopause.1 Yes, women get adult acne more often than men.
If we look back into our teen years, as adolescents our 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 OTC topical acne treatments, but that isn’t necessarily going to help us today.
As we moved on into our 20s and 30s, maybe we started to be subjected to the challenges of hormonal fluctuations due to contraceptives, pregnancies, breastfeeding, and the stresses of balancing work and home life. Our skin was less oily, but maybe become more sensitive and less tolerant of the products we once relied on. In addition, we may have started to develop other skin conditions (rosacea and periorificial dermatitis) which may confuse the treatment picture.
In our 30s and early 40s (perimenopause), we may also start to notice those early signs of sun damage, manifesting as sunspots and fine lines. Perimenopause can bring more dramatic hormone changes, and hormonal acne is often observed. As estrogen levels fall in perimenopause, other hormones can increase and result in adult acne. Adult female hormonal acne typically presents as cystic breakouts along the jawline.
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5 Effective Ways to PREVENT Adult Acne
Regardless of your acne history, be it adolescent, chronic, or now seeing it for the first time, there are a number of ways to successfully treat it:
Level out fluctuating hormone levels that occur with age via Hormone Replacement Therapy (HRT). Fluctuations in hormones (especially estrogen and progesterone) can lead to breakouts. Women experience fluctuating hormones.
Lower your stress as much as possible to prevent acne flare-ups. With stress, our bodies’ hormonal levels shift and can stimulate the oil glands and hair follicles in the skin, which can lead to acne.
Check your hair and skin care 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 – terms on every container should include at least one of these.
Check your current medications for side effects. Acne is a side effect of some medicines. Talk with the doctor who prescribed it if you think it is making your acne worse. Ask if acne is a possible side effect.
Consider that you may have an undiagnosed medical condition. Sometimes, acne is a sign of an underlying medical condition. Once the medical condition is diagnosed and treated, the acne often clears.
Some of the Most Common Adult Acne Questions:
It’s important to understand that acne varies in severity based on age, sex, and hormone levels. Treatment will depend on the individual. Thus, 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 for all patients. One thing that is a common thread is that treatment goals will include prevention and resolution of acne and the scars that sometimes result.
What about my current acne scars? What is the cause?
Picking or popping acne is strongly discouraged due to the risk of infection and scarring. 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 jawline, earlobes from piercing, shoulders, and chests. Types of acne scars can include:
hyper- or hypopigmentation (coloration) of the area where the acne was (post-inflammatory),
pitting or “ice-pick” scars,
thin (atrophic) scars,
thick (hypertrophic) scars, and
Keloids (thick raised scar). Persons of color are at higher risk for the formation of keloids, but they can occur in any skin type.
How do I treat the 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:
Stay out of the sun. If suffering from skin discoloration after acne has resolved, stay out of the sun.
Lifestyle changes can be very successful in decreasing adult acne:
The stress hormone ‘cortisol’ is so important for skin health and overall well-being. Daily walks, meditation, yoga, and self-care practice are essential.
An anti-inflammatory diet rich in antioxidants and limiting refined sugars will improve skin appearance and decrease breakouts.
Hormone replacement therapy (HRT) available both in a combination of progesterone with estrogen or without is an effective option. HRT can help normalize the levels of hormones to calm down the acne flare-ups. Just like in puberty, the changes of hormones are causing our skin to revolt. We know that teenage girls are often put on hormonal birth control to try to relieve acne. Just like that treatment, 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 (wheat and barley). Prescription-strength azelaic acid 15% and 20% formulations are expensive (unlikely to be covered by insurance), but OTC azelaic acid 10% 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 is also 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 hormone replacement therapy (HRT) treatment, niacinamide can be a beneficial addition to acne treatment and can benefit acne, rosacea, hyperpigmentation, and ultraviolet-induced skin damage.
Retinoids (the vitamin A family) help with acne, anti-aging, and hyper-pigmentation but 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**(more below).
Spironolactone is an option for individuals intolerant of retinoids or with more pronounced hormonal acne. Low-dose spironolactone can be used at a lower dose to take advantage of 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 in darker skin types. Prescription hydroquinone 4% is readily available and may be custom compounded in concentrations as high as 18% with other active ingredients or 20% without. It cannot be used chronically due to risk or paradoxical hyperpigmentation (ochronosis) and scheduled breaks should be planned every 12-16 weeks.
Topical vitamin C can have some positive 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? While they may advertise “acne facials,” many are left wondering if they really help. Facials certainly can help improve the appearance of the 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.
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Are there other options for treating acne scars?
For darker skin types prone to hyperpigmentation (too much color causing scars), short-term prescription steroids may be used to decrease inflammation but should be closely monitored due to the potential risk of skin thinning and worsening of acne.
Microneedling, chemical peels, dermabrasion, ablative and non-ablative lasers.
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.
**Careful with the Retinoids
When beginning a retinoid regimen, use a small amount the size of a pea. 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 the top. Don’t forget your sun protection, as all retinoids can increase sun sensitivity and result in easier burning.
Winona encourages women to embrace their new, more mature skin and to treat it well. While acne can be a particularly surprising symptom of aging and decreasing hormones for adults, many acne treatments can help you today. If you are worried about acne scars and looking for acne scar treatments, be careful and seek out the assistance of a licensed, board-certified, dermatologist if you want to try some of the more aggressive approaches.
“This article is for informational purposes only and does not constitute medical advice. The information contained herein is not a substitute for professional medical advice. Always talk to your doctor about the risks and benefits of any treatment.”