A study published in the Archives of Dermatology in 2004 showed 63% of acne-prone women experiencing premenstrual flares, with a 25% increase in total lesions.1 This probably comes as no surprise to the millions of women out there who experience a monthly flareup of their acne symptoms. Normally the increase in acne comes about 7-10 days before the onset of menstruation, and often subsides when menstruation begins. No one is sure exactly why this occurs, but it's safe to say that it has something to do with the intricate hormonal changes involved in the menstrual cycle.
When it comes to premenstrual acne, prevention is key. Because hormonally-induced acne can be hard to treat, there may be no way to completely combat it, but The Regimen does a fantastic job at turning a monthly scourge into a blip, or even eliminating it entirely. Birth control pills and androgen receptor blockers may also help with regulating hormones from the inside out.
Menopause: Any time people experience a change in hormones, they can see a breakout of acne. Even at menopause, some women will notice acne developing. Acne normally subsides once menopause has run its course.
Typically, women who suffer with acne may see a worsening of their condition in the first trimester of pregnancy. Even women who were previously clear sometimes see acne form during this time, both on the face and sometimes on the body as well. This is due to changes in hormone levels. Any time hormone fluctuations occur, acne can develop or worsen. Typically there is a respite during the second and third trimester, and often acne will subside considerably. Then, about three months after delivery, new mothers may see yet another occurrence of acne as their hormones return to pre-pregnant levels.1-2
Treatment options: First, talk to your doctor. The vast majority of acne treatments, both prescription and over-the-counter, have not been studied in pregnant or lactating mothers. Your doctor may have options for you that he/she considers safe for use during your pregnancy.
One option that is absolutely unsafe is Accutane. The active ingredient in Accutane, isotretinoin, is highly teratogenic (causes birth defects).3 It is absolutely vital that women who are pregnant or plan to become pregnant avoid isotretinoin.
Your baby: Yes, even babies can have acne. It is referred to as neonatal acne, and it normally subsides on its own.4 If your son or daughter show signs of acne as an infant, they may also suffer with acne as an adolescent. Be sure to have an open and honest talk with them if they start breaking out as a teenager and explain their options.
For many women, the right topical medications can keep acne at bay. Men and women do not differ significantly in terms of effective acne treatments, and appropriate application of topical treatment is often the best option.
Hormonal treatments are also an option. Doctors sometimes prescribe oral contraceptives (birth control pills), or androgen receptor blocker (most notably spironolactone and cyproterone acetate). Both oral contraceptives and androgen receptor blockers work internally to mediate the effects of male hormones, which are integral in the development of acne. Both options come with numerous side effects and should be carefully researched and then discussed with a trusted physician before coming to an educated decision on whether or not to embark on hormonal therapy.
As a last resort, for women with very severe, widespread, and deeply scarring acne, Accutane is also an option. However, because Accutane causes severe birth defects in the fetuses of pregnant women, and because of Accutane's other serious side effects, it should be entered into carefully. Before taking Accutane, make sure to have a serious heart-to-heart with your family and your doctor and become as educated as possible on the drug.
How do oral contraceptives (OCs) help with acne? As a general rule, OCs reduce androgens (male sex hormones) which are partly responsible for acne formation. Women with acne tend to have higher levels of androgens.1-5 More specifically:
Which work best? The FDA has approved only a select handful of birth control pills for patients with acne who also desire contraception. They include Ortho Tri-Cyclen, Estrostep, and Yaz. However, all birth control pills tend to produce 30%-60% reduction in acne lesions, and research remains inconclusive on which works best.3,6-11
What are the side effects? Side effects are common. Some of the more common include nausea, headache, breast tenderness, breakthrough bleeding, bloating, fatigue, irritability, mood changes, dizziness, weight gain, loss of libido, high blood pressure, and vaginal infections. Less common and more serious side effects include blood clots, heart problems (exacerbated by smoking), and possibly increased cancer risk.10,12 Talk to your doctor for more information.
Do antibiotics cause birth control pills to fail? While this is a largely held belief, and women have indeed become pregnant with the combination of birth control pills and antibiotics (tetracyclines), pregnancy rates were no higher than is seen from birth control pill failure alone. According to a 2010 overview article published in the International Journal of Women's Health, "Currently, there are no pharmacokinetic data or randomized controlled clinical trials supporting that oral antibiotics decrease the efficacy of oral contraceptives, with the notable exception of anti-tuberculosis drugs like rifampin."3
Androgen receptor blocker - hormonal therapy
What it is: Women who experience acne tend to have higher levels of androgens (male sex hormones). Spironolactone is an androgen receptor blocker. In other words, it prevents the cells of the body from interacting with androgens. Less androgens typically means less acne.1-3 Spironolactone is taken in pill form and can be used with other topical acne treatments, as well as in conjunction with birth control pills. It is especially effective when excessive hair growth (hirsutism) is present. Spironolactone is also used to treat this condition.4
Study results: Spironolactone has shown mixed results in several studies, both on its own and coupled with oral contraceptives. In a study published in 2009 in the Journal of the American Academy of Dermatology in 2008, 85% of women achieved very good results with a combination of spironolactone and an oral contraceptive with drospirenone.5 Another study published in the Journal of the European Academy of Dermatology and Venereology showed "clinically significant improvement" in 85.71% of subjects taking spironolactone alone.6 However, other studies have shown no significant decrease in acne symptoms when using spironolactone alone. Due to the small number of studies in this area, and their conflicting results, the authors of a meta-analysis in 2009, published in The Cochrane Library, conclude, "there [is] no evidence for the effectiveness of [spironolactone] for the treatment of acne vulgaris."3
Side effects: Side effects are common. Studies show upwards of 50% of women experiencing menstrual irregularities. Spironolactone may create breast tenderness, headache, or fatigue, and can also have a diuretic effect. In pregnant women, feminization of the male fetus is also possible.6 However, an 8-year study published in the Journal of Cutaneous Medical Surgery concluded, "...there were no cases of serious illness attributable to spironolactone use."7
Note: Asian women sometimes respond differently to hormonal treatment. However, a study of 116 Japanese women completed in 2006 showed that "...spironolactone is effective and safe for the treatment of acne in Asian females."8
Men: Spironolactone is usually reserved for use in females because gynecomastia (male breast growth) can occur in males who take the drug.
Androgen receptor blockers - hormonal therapy
What it is: Acne-prone women tend to have higher levels of androgens (male sex hormones). Cyproterone acetate is an anti-androgen, which helps suppress the male sex hormones testosterone and dihydrotestosterone (DHT). Less androgens typically means less acne.9 Cyproterone acetate is administered in pill form and also sometimes as a topical lotion. In both forms it has been shown to reduce sebum (skin oil) production. It can normally be used alongside other topical acne treatments. It is also used to treat polycystic ovary syndrome, excessive hair growth (hirsuitism), alopecia, and other diseases where androgen action is involved. Cyproterone acetate is a main ingredient in Diane-35 (cyproterone acetate plus ethinyl estradiol), a popular oral contraceptive in Europe and Canada.
Study results: The two studies performed thus far have shown 75%-90% of women experiencing an improvement in acne symptoms when taking cyproterone acetate alone.10-11 Another study found that women using Diane-35 saw a 58.8% decrease in total acne lesion count.12
Side effects: The most notable side effect is liver toxicity. In combination with oral contraceptives, there is an increased risk of blood clots. Osteoporosis is also a potential side effect with long-term use.
Note: Asian women sometimes respond differently to hormonal treatment. If you are of Asian descent, be sure to ask your doctor if he/she is aware of your particular circumstance before embarking on treatment.
Men: Cyproterone acetate is usually reserved for use in females because gynecomastia (male breast growth) and galactorrhea (milk production) may occur in males who take the drug.