Hormonal acne can be very embarrassing, but what do we know about it ? Here are the best articles from the net I have read concerning hormonal acne, causes, effects, and treatment. Various points of view are exposed, and may help you to make yours :
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.
Hormonal acne is thought to result from the interplay of:
*sex hormones, such as progesterones, oestrogens and testosterone
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).
*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.
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
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.
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.
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.
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
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
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 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.
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.
FEMALE ACNE AND HORMONES
Acne is Extremely Common
If someone has acne which is enough to bother her, it is best not to just wait to “grow out of it.” One her first visit, one of my patients said to me recently, “I’m 63 and I’ve been waiting for my acne to go away since I was 18. Though acne, fortunately, rarely lasts this long, it is still common in the thirties and forties. If you are bothered by acne, it is reasonable to seek medical help for it.
Acne is one of those conditions about which insensitive jokes are still made. Yet research has shown that acne lowers self-esteem and is extremely stressful. One study has shown that unemployment rates are higher in both women and men with acne, showing that people with acne are discriminated against. Though our society has been learning not to discriminate against people who are physically challenged, no one speaks up for the miseries of acne.
Acne and Polycystic Ovary Syndrome (PCOS)
Acne, the Teenage Years and Beyond
When acne is more severe it should be regarded as a pressing medical problem, because permanent scarring may result. A few acne scars may not show, but an accumulation of scars over time can cause considerable damage to the complexion. If acne is enough to cause distress, it is best to get it treated promptly to minimize scarring.
Hormonal Testing for Acne
Treating the Hormonal Cause of Acne
I’ll return to hormonal acne treatment shortly but want to review the standard measures first.
Skin Care for Acne
Anyone with a tendency to acne should only apply non-comedogenic preparations to their skin. “Comedone” is the medical term for whiteheads and blackheads so “non-comedogenic” simply means not causing breakouts. Non-comedogenic products will not feel greasy if rubbed between the fingers.
A soap-free skin cleanser, such as Purpose®, or a soap that is only slightly drying such as Clinique® for dry skin, is best. Soaps with perfume or high moisturizer content may cause problems. Astringents contain alcohol which dries the skin. Although use of an astringent may make the skin feel less oily immediately after use, it will not stop the increased oil production involved in acne and may irritate the skin. Abrasive preparations also are best avoided.
Some women with acne notice that it gets better after sun exposure. This is not a good way to control acne for two reasons. Firstly, long term sun exposure greatly increases the risk of skin cancer (including melanoma). Secondly, though the skin dries up initially after sun exposure there may be a rebound later, when oiliness actually increases. Sunbathing may therefore exacerbate acne in the long run. Use of a non-comedogenic sun screen lotion that has a Sun Protection Factor (SPF) of at least 15 is recommended. If you are in the water, it will need to be reapplied frequently, whatever it says on the package.
Another important aspect of skin care for people with acne is the use of moisturizers. Dry skin is particularly common in people who live in a northern climate. While women with acne usually have oily skin, when acne is treated, the skin often gets dryer. Some women have oiliness in some facial areas and dryness in others. Many will benefit from the use of a moisturizer, but of course it should be non-comedogenic. There are hundreds of moisturizers on the market, many of which are not really effective. Two good ones are Vaseline Intensive Care Extra Strength (not made from Vaseline which should not be put on the skin), and Mi Fine Skin. The latter was developed by a Cleveland dermatologist, Beno Michel, MD and is the best in my experience. It can be ordered by telephone (1-800-SKIN-066 or on-line www.mifineskin.com). I have no commercial interest in this product but my wife and I use it and have ceased to have dry skin problems.
While acne is not caused by poor hygiene, a good routine can help it. For mild acne, regular use of a skin cleanser at least twice a day, and a daily application of over the counter preparation with benzoyl peroxide, will produce some improvement. But if a regular skin care routine does not help enough, a visit to a physician experienced with acne is the next step.
Non-Prescription Acne Treatments
There are many other OTC acne remedies, not all of which are effective. Some contain ingredients that can irritate the skin or even make things worse. I suggest using a product which contains benzoyl peroxide without a lot of additional ingredients.
Standard Prescription Acne Treatments
Two oral contraceptives (OCs ) have been approved at this time (11/01) for treatment of acne in women who want to be on the pill. These are OrthoTriCyclen® and Estrostep®. (I was involved in the research for both and have lectured and consulted for both companies.) The number of pimples are reduced by about 50%, on average. This is a significant improvement.
However, the pill does not give adequate clearing for all women with acne. For a woman whose skin is still broken out despite use of one of these OCs, or who does not want to take an OC, there are other ways to prevent hormones from triggering it. OCs can be combined with the other acne treatments described above or with other hormonal treatments as described below.
Hormonal Treatment of Acne
Oral contraceptives can be part of the treatment because they lower free testosterone. The addition of medications which block testosterone can dramatically clear the skin. Spironolactone (Aldactone®) is usually quite effective. Though often used with an OC, spironolactone can also be used by itself. Spironolactone was originally developed as a blood pressure medication. It blocks aldosterone, a blood pressure-raising hormone. Because testosterone is chemically similar to this hormone, it is also blocked by spironolactone.
Finasteride, sometimes useful for other testosterone problems in women, probably will not help acne and there is serious worry about its safety in pregnancy. This is discussed in detail in the section on treatment of unwanted hair. [Hormones and Unwanted Hair] Although birth defects have not been reported with use of spironolactone to my knowledge, they are theoretically possible since it blocks testosterone, so it is important not to get pregnant while taking this medication also.
A new OC, Yasmin® contains drospirenone, a close cousin of spironolactone, as its form of progesterone. It is not labeled for acne in the United States at this time and is equivalent to a rather low dose of spironolactone. Dose is definitely important with spironolactone; low doses are less effective.
Acne and Extra Hair
The sebaceous glands respond immediately to testosterone and so acne usually appears fairly soon after levels go up. The hair follicle however may take months or years to respond so increases in hair growth generally appear at a somewhat later age than acne. Not everyone follows this pattern however.
What Causes Acne?
The first event leading to acne is stimulation of the sebaceous (oil making) glands by testosterone. Next, the pores plug up and trap the oil inside. Bacteria grow in the trapped oil, causing the production of irritating chemicals. Finally the body’s immune system comes into play. There is both good and bad news about this immune response. While it fights the bacteria, it also causes the redness, swelling, pus-like fluid and later scarring which make acne so unsightly.
Many women notice that their acne is worse in the week before their period. The exact reason for this common pattern is not known, but obviously it is related to hormonal changes during the cycle, perhaps a rise in testosterone at midcycle.
Other Oily Face Conditions
A Final Note
Hope these articles bring you good informations about hormonal acne and help you.