Menopause and Acne: Everything You Need To Know

Unfortunately, the menace of acne is not confined to the hormonally turbulent years of adolescence. Many women in their forties and fifties are disturbed to discover a sprinkling of facial blemishes as they enter menopause. Much like adolescence, menopause is characterized by a tumult of hormonal changes. Hot flashes, night sweats, and weight gain are but a few of its unwelcome gifts. But acne? Really? That has to be the final blow.

Although more serious chronic illnesses take center stage, acne represents an undisputed quality of life issue. Its daily embarrassment can significantly interfere with the enjoyment of life in general. Women are cautioned not to panic. There is hope. New medical treatments do exist which can effectively control or suppress those unattractive breakouts.

So What Exactly Is Acne?

Let’s start at the beginning… Acne results when the oil (sebum) produced by the hair follicle becomes trapped below a collection of dead skin cells. A normally friendly component of facial skin flora, Propionibacterium acnes, simply cannot resist the delectable sebum and sets up residence in the engorged skin follicle. Until recently, this set of events was believed to explain acne pathogenesis.

Over the last several years, however, studies have shown that patients with acne are under increased cutaneous and systemic oxidative stress. 1 2

Free radicals are continuously formed in the human body, but an efficient oxidative defense system normally contains these destructive oxygen species. In patients with acne, the normal antioxidant defense system appears to be impaired which allows these oxidative free radicals to trigger pronounced inflammation.

Why Are Menopausal Women Plagued By Acne?

Hormones! According to Dr. Wilma F. Bergfeld, Professor of Dermatology at the Cleveland Clinic Foundation and former President of the American Academy of Dermatology, “An adult woman with acne without a teenage history of acne should be looked at closely for hormonal irregularities. That said, I often look at hormones, particularly for cases of inflammatory acne, because there are likely to be increased circulating androgens. We have learned that older women can have elevated androgens episodically released by the ovaries, a fact that was not appreciated in the past.” 3

Clearly, the hormonal disturbances that mark adolescence and perimenopause contribute significantly to the development of acne. Both at puberty and during perimenopause, a relative predominance of androgens (male sex hormones) is responsible. Menopause is characterized by a steady decline in the production of estrogen by the ovaries with essentially no change in the release of androgens. Androgens stimulate sebum production. Androgens may are also responsible for deepening of the voice and the appearance of facial hair. 4

Just How Bad Can Acne Get During Menopause?

Perimenopausal acne behaves differently than teenage acne. The acne lesions tend to be deeper. Blackheads, whiteheads, papules and pustules are few, but there are more small, hard, tender cysts. 5 Severe cystic acne, however, is rare.

What Parts of the Body Are Affected By Menopausal Acne?

Unlike adolescent acne, perimenopausal acne is less likely to involve the T-zone area of the face and more likely to affect the chin, jaw, mouth and upper neck. The chest and upper back can also show lesions. 6

What Is the Difference Between Rosacea and Acne?

It is extremely important to distinguish acne vulgaris from rosacea. The two conditions can easily be confused. Rosacea is characterized by malar (cheeks) and nasal redness. Lesions include papules (small pimples) and telanglectasias (broken superficial blood vessels). Rosacea can also cause dryness and irritation of the eyes. Women with fair complexions are at greater risk for rosacea.

According to Dr. Hilary Baldwin, associate professor of dermatology at SUNY Downstate Medical Center, Brooklyn, New York, “Effective management of the redness associated with rosacea is difficult. Often, laser treatments are necessary to ablate the blood vessels. The acneiform lesions are best controlled with long-term topical or oral antibiotics.

The antibiotics act as anti-inflammatory agents, so there is no issue of resistance, and they are safer than traditional anti-inflammatory drugs. Tetracycline and erythromycin are the preferred antibiotic treatments. Topical retinoids are contraindicated in patients with rosacea in whom facial redness is prominent, as these drugs increase blood flow to the face.

Topical steroids are also contraindicated for rosacea because long-term use causes an increase in vascular size, which will lead to a worsening of the redness. Topical steroids can also cause steroid acne that may take longer than six months to overcome. This said, a low oral dose (10-20 mg) of steroids for 2 days prior to an important event, such as a wedding, can work wonders, and there are no side effects.” 7

Can Acne Occur After Menopause?

Acne after menopause can also occur. The relative predominance of androgens over estrogens is to blame. However, acne after menopause can potentially indicate a more serious medical condition. According to the American Academy of Dermatology, post-menopausal women who get acne should be screened for a possible ovarian or adrenal tumor. Such tumors have been known to secrete sex hormones which may cause acne. The American Diabetes Association notes that diabetics can suffer from skin conditions which resemble acne.

What Is the Treatment of Acne After Menopause?

Treatment of acne that occurs after menopause is much like the treatment of menopausal acne and may include combination oral contraceptives (estrogen and progesterone), hormone replacement therapy, and anti-androgen medications.

What About Acne After Surgical Menopause?

What is surgical menopause? Surgical menopause occurs following the surgical removal of a women’s ovaries (an “oophorectomy”). Because the ovaries are responsible for the production of estrogens, their sudden absence will result in a precipitous drop in a women’s estrogen levels. Because the interruption of estrogen production is so abrupt, menopausal symptoms including acne are likely to be even more prominent than during natural menopause. The potential benefits versus risks of hormone replacement therapy should be thoroughly discussed with the treating doctor.

What About Acne During Testosterone Treatment?

Many menopausal women complain of low sexual interest. Testosterone is often cautiously prescribed to increase libido. Unfortunately, among the negative side effects of testosterone supplements is the possible development of acne.

How Is Menopausal Acne Treated?

Perimenopausal acne can be more resistant to treatment than adolescent acne. It may take several weeks before treatment takes effect. 8 Management of menopausal acne makes use of topical and systemic therapies.

Topical therapies are typically the first choice in mild to moderate acne. They include:

  • retinoids
  • antibiotics
  • benzoyl peroxide
  • dapsone
  • azaleic acid

Retinoids are vitamin A derivatives. They act to open up pores which aids in preventing pimples and improves absorption of other topical medications. Retinoids increase collagen synthesis which helps eradicate fine wrinkles. Unfortunately, however, these agents have a strong drying effect on the skin which may not be well tolerated in older patients. 9 Adapalene is a third generation retinoid which has less of this drying effect and may be better tolerated. 10

Topical antibiotics are used to treat acne because they have both antimicrobial and antiinflammatory properties.

Clindamycin, erythromycin, metronidazole or dapsone 11 (a sulfur compound) are available in topical preparations. Because of concerns with regard to antibiotic resistance of P. acnes, 12 topical antibiotics should not be used alone. Recent studies show that dapsone increases the effectiveness of topical retinoids. 13

Benzoyl peroxide is a cleansing agent which suppresses bacterial growth, keratin overproduction and inflammation. Unfortunately, its harsh drying effect may be poorly tolerated by older skin.

Azaleic acid belongs to a class of compounds called dicarboxylic acids. It also has bactericidal properties.

Combinations of antimicrobials (benzoyl peroxide or topical antibiotics) with retinoids are available, well tolerated, and most studies demonstrate increased efficacy compared to the use of monotherapy. 14

Light therapy has been shown to reduce bacterial colonization by P. acnes and reduce sebum production. 15 Self-administration of “blue light” therapy has also been shown to reduce acne severity. 16

Systemic therapies (oral medications) are typically reserved for more severe cases of acne and include:

    • oral antibiotics
    • hormonal therapies
      • combination oral contraceptives
      • Hormone Replacement Therapy
      • anti-androgen agents
  • retinoids

Oral antibiotics are indicated for acne that has an inflammatory component. Concerns over the possible development of resistant bacteria has led to the development of specific guidelines to decrease this risk. 17

Hormonal therapies are commonly used to treat acne of all severities in adult women. These therapies decrease sebum production.

Oral contraceptive pills (OCPs) are available as progesterone alone or combined estrogen/progesterone pills. Only combined OCPs should be used to treat acne because synthetic progestins have androgenic activity.

Hormone Replacement Therapy

In the past, hormone replacement therapy (HRT) was a treatment of choice for menopausal symptoms, with the added benefit of preventing osteoporosis. However, a recent large study, known as the Women’s Health Initiative (WHI), has significantly impacted the way that HRT is viewed by the medical and lay communities. The results of the WHI showed that, compared to placebo, the administration of estrogen and progestin to postmenopausal women resulted in an increased risk of heart attack, stroke, blood clots, and breast cancer. The study also showed that, compared with placebo, the administration of estrogen to postmenopausal women resulted in an increased risk of stroke and blood clots. 18

Thus, cardiovascular risk factors must be carefully considered when prescribing OCPs and HRT. These treatments are contraindicated in women with a history of stroke, venous thromboembolism, myocardial infarction or uncontrolled hypertension. In addition, women over the age of 35 years who smoke are not candidates for OCPs due to the increased risk of stroke and coronary artery disease. 19

Androgen-blocking medications can be effective when used alone or in combination with other anti-acne medications. Spironolactone, a potassium-sparing diuretic, is an example of an androgen-blocker. Combining androgen blocking agents with OCPs improves the efficacy of treatment. 20

Isotretinoin (first marketed as Accutane) is another option for perimenopausal acne. 21 Dose-related negative side effects include dry lips and mouth, nosebleeds or thinning of hair.

Are There Any Natural Remedies For Menopausal Acne?

Whole soy foods such as tofu, soymilk, edamame, soy nuts or tempeh, are good sources of isoflavones which are compounds that help balance hormone levels and have some estrogen activity. The safety and efficacy of isoflavone supplements have not yet been established. Substances called lignins contained in flaxseed are thought to be important modulators of hormone metabolism. One to two tablespoons per day of ground fresh flaxseed are recommended. Dong quai (Angelica sinensis) is also believed to enhance the natural balance of female hormones. It has no estrogenic activity. This herb should be avoided if a woman is experiencing heavy bleeding. 22

The topical use of certain plant extracts has been shown to suppress inflammation, bacterial growth, and sebum production. Studies show potential beneficial effects of topical green tea, 23 tea tree oil, 24 and basil extract. 25

Is There An Acne Diet?

A recent study 26 has identified a connection between diet and acne. High glycemic load foods and dairy products have been associated with increased acne severity. The glycemic index is a ranking of carbohydrate-rich foods based on the speed with which they raise blood sugar levels. Foods with higher glycemic index values increase blood sugar levels much more rapidly than do foods with lower glycemic index values. No scientific evidence exists to support the belief that chocolate and greasy foods cause acne.

Notes:

  1. Sahib, A.S., Al-Anbari, H.H., Raghif, A.R. (2013). Oxidative stress in acne vulgaris: an important therapeutic target. J Mol Pathophysiol. 2(1): 27-31 doi: 10.5455/jmp.20130127102901
  2. Bowe, W.P., Patel, N., Logan, A.C. (2012). Acne Vulgaris: The Role of Oxidative Stress and the Potential Therapeutic Value of Local and Systemic Antioxidants. J Drugs Derm 11: 6: 742-47.
  3. Meisler, J.D. (2003). Toward Optimal Health: The Experts Discuss Facial Skin and Related Concerns in Women. Medscape. Accessed 26 March 2014. http://www.medscape.com/viewarticle/461568
  4. Howard, Diana. (n.d.) How does menopause affect the skin? International Dermal Institute. Accessed 25 March 2014. http://dermalinstitute.com/us/library/12_article_How_Does_Menopause_Affect_the_Skin_.html
  5. Irwin, B. (2014). Menopause and your skin. Accessed 27 March 2014. http://www.skintour.com/particular-interests/menopause-and-your-skin
  6. Irwin, B. (2014). Menopause and your skin. Accessed 27 March 2014. http://www.skintour.com/particular-interests/menopause-and-your-skin
  7. Meisler, J.D. (2003). Toward Optimal Health: The Experts Discuss Facial Skin and Related Concerns in Women. Medscape. Accessed 26 March 2014. http://www.medscape.com/viewarticle/461568
  8. Goulden, V., Clark, S.M., Cunliffe, W.J. (1997). Post-adolescent acne: a review of clinical features. Br J Dermatol. 136:66–70.
  9. Addor, F.A., Schalka, S. (2010). Acne in adult women: epidemiological, diagnostic and therapeutic aspects. An Bras Dermatol. 85: 789–95.
  10. Puizina-Ivic, N., Miric, L., Carija, A., Karlica, D., Marasovic, D. (2010). Modern approach to topical treatment of aging skin. Coll Antropol. 34:1145–53.
  11. Clindamycin, erythromycin, metronidazole
  12. Patel, M., Bowe, W.P., Heughebaert, C., Shalita, A.R. (2010). The development of antimicrobial resistance due to the antibiotic treatment of acne vulgaris: a review. J Drugs Dermatol. 9:655–64.
  13. Tanghetti, E, Dhawan, S, Green, L, Ling, M, Downie, J, et al. (2011). Clinical evidence for the role of a topical anti-inflammatory agent in comedonal acne: findings from a randomized study of dapsone gel 5 % in combination with tazarotene cream 0.1 % in patients with acne vulgaris. J Drugs Dermatol. 10:783–92.
  14. Pazoki-Toroudi, H, Nilforoushzadeh, MA, Ajam,i M, Jaffary, F, Aboutaleb, N, et al. (2011). Combination of azelaic acid 5 % and clindamycin 2 % for the treatment of acne vulgaris. Cutan Ocul Toxicol. 30:286–91.
  15. Haedersdal, M, Togsverd-Bo, K,Wulf, HC. (2008). Evidence-based review of lasers, light sources and photodynamic therapy in the treatment of acne vulgaris. J Eur Acad Dermatol Venereol. 22:267–78.
  16. Gold, M. H., Andriessen, A., Biron, J., Andriessen, H. (2009). Clinical Efficacy of Self-applied Blue Light Therapy for Mild-to-Moderate Facial Acne. J Clin Aesthet Dermatol.
  17. Simpson, RC, Grindlay, DJ,Williams, HC. (2011). What’s new in acne? An analysis of systematic reviews and clinically significant trials published in 2010-11. Clin Exp Dermatol.
  18. Women’s Health Initiative. (2010). Accessed 26 March 2014. http://www.nhlbi.nih.gov/whi/
  19. Haider, A, Shaw, JC. (2004). Treatment of acne vulgaris. JAMA.292:726–35.
  20. Shaw, JC. (2000).  Low-dose adjunctive spironolactone in the treatment of acne in women: a retrospective analysis of 85 consecutively treated patients. J Am Acad Dermatol. 43:498–502.
  21. Rademaker, M. (2013). Isotretinoin: dose, duration and relapse.What does 30 years of usage tell us? Australas J Dermatol. 54:157–62.
  22. Weil, A. (2014). Perimenopause. Accessed 27 March 2014. http://www.drweil.com/drw/u/ART03145/Perimenopause.html
  23. Sharquie, KE, Al-Turfi, IA, Al-Shimary, WM.(2006).  Treatment of acne vulgaris with 2 % topical tea lotion. Saudi Medical Journal. 27:83–5.
  24. Enshaieh, S, Jooya, A, Siadat, AH, Iraji, F. (2007). The efficacy of 5 % topical tea tree oil gel in mild to moderate acne vulgaris: A randomized, double-blind placebo-controlled study. Indian Journal of Dermatology, Venereology and Leprology. 73:22–5.
  25. Orafidiya, LO, Agbani, EO, Oyedele, AO, Babalola, OO, Onayemi, O. (2002). Preliminary clinical tests on topical preparations of Ocimum gratissimum linn leaf essential oil for the treatment of acne vulgaris. Clinical Drug Investigation. 22:313–9.
  26. Burris, J., Rietkirk, W., Woolf, K. (2013). Acne: The Role of Medical Nutrition Therapy. Journal of the Academy of Nutrition and Dietetics 113; 3.

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