Acne is popularly considered a skin condition that affects only teenagers. However; nearly 17 million Americans are known to suffer from acne of which over 50% sufferers are women aged 25 and older. In majority of these, the patients are suffering from hormonal acne.
What is the correlation between hormones and acne?
Hormones are known to play an important role in development of acne. In fact: hormonal acne starts in the adrenarche phase- the period at onset of puberty when the adrenal glands start secreting androgenic hormones. These hormones lead to over-secretion of sebum in the sebaceous glands leading to clogged pores. Whiteheads and blackheads are hence seen in the T-zone region of the face in many teenagers.
In girls, at the onset of puberty, ovaries produce estrogen as well as androgens like testosterone. Testosterone further increases sebum production. As a result, inflammatory hormonal acne is very common during this period. This is characterized by papules and pustules, mainly on the chin, forehead and cheeks where the sebaceous glands are highly concentrated.
Acne in adult women and the menstrual cycle
In adult women, hormonal acne tends to be concentrated on the lower region of the face such as lower jaw line, chin, cheeks or neck. Additionally, these lesions are also more painful and inflammatory or cystic in nature. This is again due to hormonal stimulation which results in increased sensitivity of the sebaceous glands. Moreover, hormonal acne flare-ups are closely related to the menstrual cycle. In majority of adult women suffering from hormonal acne, the flare-ups are greater around the pre-menstrual phase, though some women also experience acne mid-cycle or during ovulation.
Stress, birth control pills and other factors also stimulate the adrenal glands to release more androgens.
Diagnosing hormonal acne
Not all kinds of acne are related to hormones. Hence, dermatologists must take the complete menstrual history when acne is present in adult women. One must ascertain whether one’s periods are regular and whether the acne is indeed related to the menstrual cycle.
Hormonal workup is necessary when the patient has acne along with abnormal hair growth on the chin. Obesity, infertility, irregular periods and scalp alopecia are also indicative of complete hormonal workup as all these are signs of virilization (development of male physical characteristics owing to excess androgen production).
Hormonal workup involves testing free testosterone and adrenal hormone dehydroepiandrosterone sulfate (DHEAS) levels. If these are elevated, the abnormality is usually due to gynecological and adrenal abnormalities.
More extensive hormonal workups may be needed in some cases to check the ratio of FSH to LH. FSH is Follicle stimulating hormone and LH is Luteinizing hormone. If the ratio of FSH to LH is more than 3:1, there is a possibility of the patient having ovarian cysts. Before performing these tests, patients must stop taking oral contraceptives and other hormone therapies at least 1 month in advance.
Experts say that in majority of the cases, all the above tests end up with normal results since most women with a tendency of hormonal acne have localized sensitivity to hormones at the sebaceous glands.
Why is hormonal acne difficult to treat?
Hormonal acne is difficult to treat owing to the myths surrounding the condition. Women often try to self-treat it and it is years before they seek professional help. During this period they try everything from toothpastes, to tea tree oil to harsh over the counter products to dry up the acne. Many also scrub their skin excessively, thinking that dirt is causing the acne.
Hormones in women are constantly changing: from puberty, to adulthood, to pregnancy to menopause. The effects of these changes are not the same and they affect each woman differently. For example, pregnancy hormones in some women actually clear up the complexion, while in others, it leads to acne. Treating hormonal acne in pregnancy stage is also difficult since there are very limited acne therapies that don’t affect the fetus. Topical medicines are the only solution and conservative treatment is the best option.
Treating hormonal acne
If you are suffering from hormonal acne, it is important that you visit a dermatologist to seek the right treatment for it. Many modern medicines including contraceptive pills with estrogen can help decrease the free circulating testosterone to reduce hormonal output causing the acne. Several of these also effectively suppress FSH and LH levels. Apart from such systemic medicines, topical retinoids and antimicrobials as well as antibiotics may be prescribed to treat hormonal acne flare-ups.