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November 2001
Adult Female Hormonal Acne
Acne in females may be influenced by
hormonal changes associated with menstruation, pregnancy, stress,
ovarian disease or endocrine imbalance. Most of the hormonal changes are
temporary. Sometimes they are caused by a condition that requires
medical treatment. When a female has acne that (1) appears for the first
time in adulthood or reappears in adulthood after clearing up earlier,
(2) is unresponsive to acne treatments, (3) gets worse during pregnancy
or menstruation, or (4) is associated with "masculine"
patterns of hair growth or hair loss, darkening of skin in armpits or
body folds, or central body obesity, she should be examined by a
dermatologist. Indications of hormonal imbalance may require examination
for adrenal, ovarian or pituitary abnormalities.
Hormones and Acne
The hormones that have the most influence
on acne are the androgens—so-called "male" hormones although
they are present in both males and females. The androgens are a
causative factor in acne because they have a stimulating effect on sebaceous
follicles where acne lesions have their origin.
Androgens tend to be present in
relatively large amounts during adolescence as the teenager matures. The
androgenic influence on sebaceous follicles is substantial at this time—a
reason that acne is often thought of as a "teenage condition."
As the body matures and androgen levels stabilize in adulthood, acne
clears in the majority of cases.
Hormones and Acne in the Adult Woman
Adult women can be unpleasantly surprised
when acne reappears in their 20s or 30s—or appears for the first time.
While the acne is often mild to moderate, it may not respond to
tried-and-true acne treatments that worked when the woman was a
teenager. The cause of this adult acne is probably a hormonal change.
The required treatment will be one that takes hormones into account.
This type of treatment cannot be purchased over-the-counter at the
pharmacy. It is a medical treatment prescribed by a dermatologist after
appropriate medical examination.
Typical examples of hormonal acne in
healthy adult women are:
Acne comes and goes during the menstrual
cycle as hormonal balances go through many changes in the body.
Acne "flares" during pregnancy
as the body’s hormonal balances shift to accommodate changing
physiologic needs. This photo illustrates acne flare during pregnancy:
A 23-year-old woman had a
flare of acne in the first trimester of pregnancy. The flare persisted
through the next two trimesters and after delivery.
(Photo used with
permission of the American Academy of Dermatology National Library of
Dermatologic Teaching Slides and the Sulzberger Institute for
Dermatologic Education)
Acne may be associated with chronic
emotional or physiologic stress. Stress may cause physiologic changes
that affect hormone production.
Acne in adult women may be associated
with other conditions that can indicate an underlying abnormality that
influences androgen levels:
Absence of periods or irregularity.
Excess facial hair (hirsutism) is a
"male pattern" of facial hair that may indicate an
overproduction of androgens.
Female pattern baldness (androgenic
alopecia) mimics male-pattern baldness in many respects and may indicate
excess androgen production. As seen in this photo, female pattern
baldness is usually on the central scalp:
Female pattern alopecia
(baldness)
(Photo used with
permission of the American Academy of Dermatology National Library of
Dermatologic Teaching Slides and the Sulzberger Institute for
Dermatologic Education)
A deepening "male type" voice,
or darkening skin in the armpits or body folds, may indicate excess
androgen levels.
Hyperandrogenism (excessive production of
androgens) can be a contributing factor to the development of acne in
any female whose acne is severe, sudden in onset, or associated with
hirsutism or irregular menstrual periods. A female with acne and any of
these symptoms of hyperandrogenism should be examined for the
possibility of an underlying disease of the adrenal glands, ovaries or
pituitary gland. Diabetes can also affect hormonal balance.
Treatment of Hormonal Acne in the
Healthy Female
Hormonal acne in a healthy female can be
effectively treated by a dermatologist. An underlying disease of
ovaries, adrenals or pituitary, or diabetes, should be treated by an
appropriate specialist physician.
A variety of treatments are available for
hormonal acne in the healthy female. The dermatologist selects the
treatment best suited to the needs of the patient, based upon the
patient’s medical history and examination. Treatment options include:
Oral contraceptive pills are estrogen-progestin
combinations formulated to alter the female hormone pattern. Because of
their effects in altering androgen production, low-dose oral
contraceptives have been prescribed by dermatologists for many years in
the treatment of hormonal acne. The Food and Drug Administration
recently approved an oral contraceptive specifically for the treatment
of mild to moderate hormonal acne. Oral contraceptives can be taken for
extended periods of time to control hormonal acne if the woman has no
plans to become pregnant. Side effects of low-dose oral contraceptives
can include nausea, weight gain, menstrual spotting and breast
tenderness.
Oral corticosteroids are
anti-inflammatory drugs that belong to a class of drugs produced by the
adrenal glands. When adrenal glands are overactive in producing
androgens, oral corticosteroids such as prednisone and dexamethasone can
be prescribed to suppress androgen production. Oral corticosteroids are
also prescribed to suppress inflammation in severe acne. Side effects of
oral corticosteroids can include weight gain and bone thinning.
Antiandrogens are a class of drugs that
(1) reduce androgen production in ovaries and adrenal glands, and (2)
block androgen reception by cells in sebaceous follicles. Reduction of
excess androgen and reduction of androgen available in the sebaceous
follicle are anti-acne effects. Antiandrogens used in the treatment of
hormonal acne include spironolactone and, less commonly, flutamide. Side
effects of irregular menstruation and breast tenderness may be eased by
taking the drug together with an oral contraceptive.
References
AAD Press Release "Women and Acne:
The Hormonal Connection (March 3, 2001)
Strauss JS et al. Diseases of the
sebaceous glands. In: Freedberg IM et al (Eds.). Fitzpatrick’s
Dermatology in General Medicine, 5th ed. New York:
McGraw-hill; 1999:769-784.
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