Hormonal Acne: Why It Happens And How To Treat It
YOU DON'T HAVE TO BE A TEENAGER TO GET ACNE.
I can't tell you how many patients come in sheepishly confessing to me that they have acne, thinking they're the only one with zits that don't know how to use TikTok. Once I tell them that they're my third patient of the day in their 30’s/ 40’s/ 50’s /60’s with acne, there's an audible sigh of relief.
Acne is incredibly common beyond the teen years, but it doesn't get as much PR.
One survey study (Collier, 2007) showed that 50% of women in their 20s still have acne, 35% of those in their 30s, 26% of women in their 40s, and 15% over 50. You are definitely not alone.
HOW DO I KNOW IF I HAVE HORMONAL ACNE?
Image: Dermnetnz.org
Hormonal acne looks like:
Painful deep-seated, nodular or cystic acne
Lesions on the chin and jawline, as well as on the neck, chest and back
Hormonal acne is different from run of the mill acne in that it tends to be more stubborn and difficult to treat with topical treatments, both over-the-counter and prescription (more on treatment below).
For women in their 20’s & 30’s, this typically shows up around the time of menstruation (what a joy!) or pregnancy.
For women closer to menopause, as estrogen levels fall, androgens take the driver's seat & can lead to breakouts (I know, it's unfair, hot flashes & zits?!).
Image: VA.gov
WHAT CAUSES HORMONAL ACNE?
Just because you've gotten past puberty, doesn't mean your hormones won't cause trouble.
Most acne in adulthood is primarily driven by fluctuations in your hormone balance and overactivity of specific androgens like testosterone and dihydrotestosterone (DHT).
These circulating hormones, as well as hormones produced within the sebaceous glands, signal to the androgen receptors in the basal layer of your sebaceous glands and follicles to produce more sebum/oil. Increased sebum is one of the major drivers of acne formation.
Estrogen plays a role in reducing sebum production, which is why certain types of oral contraceptives can be used for treatment. They are thought to oppose the local effects of androgens, as well as inhibit gonadal production of androgens. Estrogens may also play a role in regulating genes that reduce sebaceous gland growth and lipid production.
Especially in menopause, reduction of estrogen paired with unchecked activity of androgens is a recipe for adult acne.
HOW CAN I TREAT HORMONAL ACNE?
In my clinical experience, topical over the counter products, including benzoyl peroxide and salicylic acid, don’t tend to help much. Because this is a systemic problem, it's more effective to treat it from the inside out with oral medications.
Your friendly neighborhood dermatologist has very effective prescription medications in their toolbox to help with stubborn, hormonal acne.
SPIRONOLACTONE
This is one of my first-line medications to treat hormonal acne because it has specific anti-androgen activity. Although traditionally it is a blood pressure medication, it blocks the DHT receptor in your sebaceous gland and shuts off sebum production. It is generally very well tolerated with minimal side effects, although it’s not a permanent fix. Once you stop taking it, the acne will recur.
One retrospective study (Grandi, 2017) showed that 86% of patients improved while taking this medication.
For more information on this medication, click here.
ORAL CONTRACEPTIVE PILLS (OCP)
Those containing ethinyl estradiol and its esters can be effective for some people. They are combined with low androgenic progestins, such as norgestimate and levonorgestrel.
Ortho Tri-Cyclen, Estrostep, Yaz, and Beyaz are all FDA-approved in the treatment of acne.
“Is one better than the others?”
Why, yes! There was a study (Lortscher, 2016) that found OCPs containing drospirenone (found in Yaz) were most effective at clearing up acne.
Not all birth control is created equal. If you notice an increase of acne breakouts once starting one, you may want to speak with your provider about switching. Depot injections, implants, and hormonal intrauterine devices may also cause increased breakouts.
ISOTRETINOIN
If you want a permanent solution, this is it. Isotretinoin, formerly known as Accutane, is the closest thing we have to a cure for acne.
It doesn’t specifically target the hormones, but amongst other things, it shrinks the sebaceous gland, thus getting rid of one of the main drivers of acne.
Typically, you take the medication for a few months and once your skin is clear, the medication is stopped and you pretty much stay clear. The downside is that for women of childbearing potential, you have to get monthly pregnancy tests and enroll in a special monitoring program.
TOPICAL RETINOIDS
Although systemic medications are more effective in general, it doesn’t mean you shouldn’t also be tackling the problem from the outside. Consistent long-term use of a topical retinoid can help maintain clearance, as well as help wean you off systemic medications.
This works great in addition to a consistent topical regimen (see below for a sample regimen).
DO I NEED SPECIAL PRODUCTS FOR HORMONAL ACNE?
Nope! I've recently noticed advertising for products targeted at hormonal acne & unfortunately, it's all just marketing. There are no over-the-counter (OTC) products with mechanisms of action that specifically address hormonal acne, so don't fall for it!
Retinoids, AHAs, salicylic acid & benzoyl peroxide are all great treatments for acne in general, but often OTC products are unable to adequately treat cystic hormonal acne alone.
One special consideration to keep in mind is that the skin becomes drier and less able to retain water as we age and during menopause. If you are in that stage, I recommend using cleansers and moisturizers that are super hydrating, especially since many acne medications are also drying.
For more on supplements, check out this post.
DO SUPPLEMENTS WORK IN HORMONAL ACNE?
Nope nope nope. The supplement industry is big business, but there is no strong data to support the claim that these vitamins will improve your acne.
There is some data investigating the use of oral zinc supplementation in acne, but it’s not conclusive.
Bottom line: save your money.
SAMPLE OVER THE COUNTER REGIMEN FOR HORMONAL ACNE
Optimizing a topical regimen is an important adjunct in treating hormonal acne, in addition to any systemic medications you may be taking. Here is a sample regimen that can help keep you clear and acne-free!
A.M. Regimen
WASH — I recommend a salicylic acid wash, as it is less drying than benzoyl peroxide. I like the Neutrogena Oil-Free Acne Wash.
TREAT — Prescription topical acne medication, like Aczone, is great for the morning. If you don’t have access to that, an azelaic acid product, like the one from Paula’s Choice, is a good alternative
MOISTURIZE — Always important to moisturize, since many acne medications can be quite drying. CeraVe AM Facial Moisturizing Lotion is a great option. Don’t forget your sunscreen!
P.M. Regimen
WASH — If you aren’t too irritated, you can use your salicylic acid wash again. However, if you are noticing some dryness, wash instead with a gentle cleanser, like CeraVe Hydrating Facial Cleanser.
TREAT — This is the most critical step - a retinoid!! If you are seeing a dermatologist, you should definitely be using a prescription retinoid, like tretinoin. If not, adapalene is a good one to start with and is available over the counter. Check out my guide (link) to using retinoids if you are just starting out.
MOISTURIZE — Retinoids tend to be quite drying and irritating, so I recommend using a thicker moisturizer in the evening. I use Cetaphil Moisturizing Cream and love it. It’s the only thing that keeps my skin feeling moist for the whole day.
ONCE A WEEK
Using a higher concentration glycolic acid peel (10-20%) once a week is great adjunct and will give you a glow like no other. My guide to chemical peels will help walk you through how to use it.
I love the Pixi Glow Peel Pads, but there are also other great options here.
If you’re plagued by hormonal acne, see your friendly local board-certified dermatologist for a personalized treatment regimen.
ADULT ACNE IS REAL. You are not alone and there are great treatments that can help.
References
Collier CN, Harper JC, Cafardi JA, et al. The Prevalence of Acne in Adults 20 Years and Older. J Am Acad Dermatol. 2008;58(1):56-9.
Grandhi R, Alikhan A. Spironolactone for the Treatment of Acne: A 4-Year Retrospective Study. Dermatology. 2017;233(2-3):141-144.
Lortscher D, Admani S, Satur N, Eichenfield LF. Hormonal Contraceptives and Acne: A Retrospective Analysis of 2147 Patients. J Drugs Dermatol. 2016 Jun 1;15(6):670-4.
Thompson KG, Kim N. Dietary supplements in dermatology: A review of the evidence for zinc, biotin, vitamin D, nicotinamide, and Polypodium. J Am Acad Dermatol. 2021 Apr; 84(4):1042-1050.