As if mood swings, hot flashes, and low libido weren’t enough, another unfortunate symptom of menopause can be adult acne. As with most symptoms related to life cycles, midlife acne is hormone-driven. Hormones are powerful messengers, and when they’re out of balance, the results can be evident throughout the whole body.
The causal relationship between menopause and acne can be explained by these hormones. The delicate balance between estrogen, progesterone, and testosterone is disrupted as women enter perimenopause in their late 30s or early 40s. Skin is made up of several layers, and the dermis - the thickest layer - is sensitive to the decrease in these hormones that occurs with age.
Menopausal 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. 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 tends to be the product of hormonally-induced oil excess and sticky skin cells (keratinocytes) plugging up the pores. Because of this abundant oil, younger skin can tolerate the drying side effects of popular, topical acne medications and harsh techniques like blackhead extraction. What worked well in our teens included improved diet, hygiene, and over-the-counter treatments, but those things aren’t necessarily going to help at this stage.
In the 20s and 30s, many women are introduced to the challenges of hormonal fluctuations from contraceptives, pregnancy, breastfeeding, and the stresses of balancing work and home life. At that age, skin is less oily and starts becoming 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.
For many women entering perimenopause, it is common to notice early signs of sun damage that manifest as sunspots and fine lines. As a woman moves through 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.
Estrogen’s Critical Role in Your Skin
Each hormone has its own special receptor or landing pad throughout the body. Hormones are only effective if they find their correct landing pad. The estrogen receptors in the skin play a role in many factors that determine how skin looks and feels:
Sebum production- Sebum is an oily, waxy substance produced by the body's sebaceous glands. Sebum is necessary to coat, moisturize, and protect the skin. A decrease in estrogen can lead to less sebum production; this allows the skin to become thinner, resulting in sagging and volume loss, especially on the face.
Maintaining elastin - Elastin is what helps skin bounce back. As estrogen decreases, so does elastin, which can manifest as skin losing its elasticity and beginning to sag.
Moisturizing - Estrogen and testosterone help keep skin moisturized. With the decline in both of these hormones, the resulting dryness makes wrinkles appear more prominent.
These changes happen slowly over time, but after menopause, skin and facial structure undergo more rapid changes, including thinner lips, deeper wrinkles, and a sagging jawline3.
Correcting the underlying hormone imbalances can prevent these from becoming permanent.
Preventing Adult Acne
Regardless of your acne history, be it adolescent, chronic, or new, there are a number of ways to successfully prevent menopausal, hormonal acne:
Manage fluctuating hormone levels with Hormone Replacement Therapy (HRT). Imbalances in hormones (especially estrogen and progesterone) can lead to breakouts.
Women experience fluctuating hormones at different stages:Alongside menstruation
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, 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.
Treating 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. The following are treatment approaches that individually or in combination may work for you:
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 facial 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 from facial blemishes.
Factors to Consider with Treatment
While the use of HRT (especially progesterone) may be helpful, taking too much progesterone can have the opposite effect - worse acne. That’s why it’s important to work with aging specialists that know how to tailor treatment to your specific needs.
Another consideration is that with age, skin becomes increasingly sensitive to scents and color added to products, as well as cleansers that are too harsh. This is due to the loss of estrogen which leads to thinner, drier skin that is more intolerant of topical medications.
An example of this intolerance can be observed with the use of topical retinoids, vitamin A derivatives. **Retinoids are very effective for acne and anti-aging, but they have a tendency to cause irritation. There are some over-the-counter forms of retinoids, but because of the potential to worsen the skin if not used properly, it’s safer to use tretinoin that is available only by prescription.
Custom compounding - something Winona pharmacies do - allows for microencapsulation and the addition of ingredients like hyaluronic acid to minimize dryness and irritation. Microencapsulation is a process where tiny particles of a product are surrounded by a coating to make small capsules that can be readily absorbed.
Conclusion
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 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 menopause and acne, reach out to Winona today, and we’ll be happy to help you find the treatment that is right for you.
