For something that’s so common, acne can be very mysterious. According to the American Academy of Dermatology, “The majority of women with acne have normal androgen levels.” You’ll often hear that elevated levels of androgens (the “male hormones”) are what lead to adult hormonal acne or premenstrual flare-ups, but that’s not always the case.
Hormonal Acne: the Basics
Hormonal acne is characteristically along the jawline and on the chin and neck, sometimes also the chest and back — in general, places that men tend to grow hair but women do not. Estrogen, for a couple of different reasons, may help guard against acne; thus, when hormones fluctuate and estrogen levels dip, acne may ensue. But that sounds simple, and acne is not simple.
For women, androgens are produced in three places: the ovaries, the adrenal glands and the skin itself. Somewhere along the way, your body may be either overproducing or overreacting to androgens. And if this is the case, your acne may be resistant to treatment.
Menstrual Acne Flare-ups
Nearly half of all women experience acne flare-ups during the week preceding their period. While hormonal acne typically begins around age 20–25, it can strike at any age, and is most persistent in women over the age of 30. So what’s going on?
In the second half of the cycle, when estrogen drops, progesterone takes over to prepare the body for pregnancy. Progesterone can cause acne for a couple of reasons: Along with androgens, it encourages the production of sebum (oil). And in addition to breast tenderness and bloating, it can cause the skin to swell — think nice tight pores, glowing skin and … acne.
When you become pregnant, your hormones go full throttle. Acne can be a side effect of this surge, especially in the first trimester. If you’ve been using an acne medication and discover you are pregnant, don’t panic: for the acne treatments that are known to cause birth defects like isotretinoin (commonly known as Accutane) or spironolactone (an androgen-receptor blocker), you will either be required to take birth control while on it or made well aware before you get your prescription.
Consult your doctor before any treatment, but the following are considered to be OK during pregnancy:
- topical antibacterials
- benzoyl peroxide
- clindamycin and erythromycin
- azelaic acid
- salicylic acid (in small topical doses)
Experts recommend avoiding the following during pregnancy:
- topical retinoids
- oral antibiotics
- oral tetracyclines
- hormone therapies (including all of the ones discussed below)
PCOS (Polycystic Ovary Syndrome) and Acne
PCOS is a hormonal disorder that is the most common cause of infertility. Elevated androgen levels disrupt the normal process of egg maturation and ovulation. Tiny fluid-filled sacs called follicles or cysts fail to break open and instead collect from cycle to cycle. Acne is just one common symptom. Others include irregular menstrual cycles, hirsutism (excessive body or facial hair) and weight gain. PCOS is thought to be genetic and may also be related to insulin resistance. Treatment consists of managing the symptoms including the hormonal therapies discussed below, especially spironolactone since it can address both hirsutism and acne.
Acne is not a symptom of menopause, but it’s not unusual either. In perimenopause, hormones are still fluctuating and there may even be estrogen highs. But in menopause, the ovaries stop producing estrogen but continue producing androgens (testosterone). Some of the testosterone may be converted back into estrogen, but it will not match the levels you had before.
Hormone replacement therapy (HRT) may help stop acne since you are reintroducing estrogen into the system, but it may actually also cause acne. Besides estrogen, HRTs can include progesterone and sometimes testosterone, both of which can lead to acne. This doesn’t mean they will, just that they can. If acne pops up in menopause and you’re not a good candidate for HRT, you may consider trying standard acne treatments, like ones that contain benzoyl peroxide or retinoids or even an anti-androgen like spironolactone (see below).
Birth Control (The Pill) for Treating Acne
Oral contraceptives suppress the production of androgens in the ovaries. Even if your androgen levels are normal but your acne is still unresponsive to other treatments, the pill may help. The key is that there’s a blend of estrogen and progesterone, not just progesterone alone, which as mentioned above, can actually worsen acne.
There are a few that the FDA has approved for treating acne, including Ortho Tri-Cyclen®, Estrostep® and YAZ®, but other formulations can work just as well. NuvaRing® and the patch function much the same as the pill and should work the same as oral contraceptives for acne. Depo-Provera®, the birth control shot, is progestin-only (no estrogen), so it won’t help treat acne and could actually make it worse. IUDs (like progestin-only Mirena® and Skyla® or copper-based Paragard®) are made to kill sperm and do not function the right way or contain the balance of hormones needed to treat acne Often women will think that their birth control is causing their acne, when in reality, they’ve just switched to something that is not giving them the same acne benefits.
Anti-Androgens (Spironolactone) for Treating Acne
Spironolactone (brand name Aldactone®) has been a miracle for some acne sufferers. Known as a “water pill” (a potassium-sparing diuretic) its purpose is to treat hypertension and congestive heart failure, but it has long been used off-label for acne because of its ability to function as an androgen-receptor blocker. As discussed earlier, androgens are produced in several places, including the skin itself. Spironolactone blocks the effect of androgens on the sebaceous glands. It’s often prescribed in conjunction with oral contraceptives, both for effect and because it’s a hormonal therapy and should not be taken while pregnant.
Even though “water pill” sounds harmless enough, you may have to have your potassium levels monitored closely while on it and there are several side effects to consider, such as frequent urination and irregular periods.
Corticosteroids for Treating Acne
Unlike the other hormonal acne treatments, corticosteroids are used short-term for immediate relief of severe acne. Small doses of corticosteroids, like prednisone, may curb inflammation and suppress the androgens produced by the adrenal glands. They will probably be used in combination with another treatment that’s meant for long-term control of acne. As far as side effects, some acne sufferers have found that corticosteroids actually aggravate their acne. It’s still debated in the medical community whether or not to use them for this reason.
It’s good to keep in mind that acne has a genetic component. Hormonal acne therapies will be used for treatment-resistant acne and will often be used in combination with each other or in conjunction with more common treatments. And while everyone with acne wants immediate results, long-term hormonal therapies can take longer to kick in than traditional therapies, so stay patient!