Treatment of Adult Acne in Women: Spotlight on "Hormonal" Treatments

While acne is often thought of as a skin condition that affects teenagers, in many cases it either starts in or persists into adult life.  This is more common in women, in whom it is estimated that 50% of women in their 20s, 25% of women in their 30s, and 12% in their 40s still experience acne.  Adult acne may have different features than acne in teenagers and younger women, and in some cases it requires its own approach to treatment.

How Does Adult Acne in Women Differ from Teenage Acne?

Our hormones play an important role in the development of all types of acne.  Hormones known as androgens, which are found in both men and women, act on our oil glands to produce sebum, a key step in the development of acne.  Hormones influence acne at all ages, and they appear to play an especially prominent role in what is known as hormonal pattern acne in adult women. While some women will have acne with classic features, others will develop a pattern that tends to have the following characteristics:

  • tends to be mild to moderate in severity
  • consists of inflamed pimples that are often deep (nodules and cysts)
  • is more likely to occur on the chin, jawline and around the mouth
  • frequently gets worse (flares) with the menstrual cycle, often in the week prior to the period

Do Adult Women with Acne have Abnormal Hormone Levels?

Usually not.  Most adult women with acne will have normal hormone levels.  It is thought that perhaps the oil glands in these women are more sensitive to the effects of hormones (androgens).  In a small percentage of cases, acne can be a manifestation of a hormonal imbalance such as polycystic ovarian syndrome (PCOS); your dermatologist can determine whether you should be evaluated for this.

What are the Treatment Options for Adult Acne?

Many cases of adult acne are treated in similar ways to acne in teenagers.  Types of treatments that may be used for all types of acne include:

  • Topical medications
  • Laser and light-based treatments 
  • Chemical Peels
  • Oral antibiotics 
  • Hormonal therapies
  • Isotretinoin 

All of these treatments have a role in treating acne, and an in-depth discussion of all of them is beyond the scope of this post.  Much of the time, more than one treatment is combined in order to achieve the best results.  A board-certified dermatologist can review these options with you and determine which is the best approach in your particular situation.  Therapies are usually tailored to the specific type of acne someone has, an individual's preferences, and other considerations such as any medical conditions an individual has that may affect treatment.  

Hormonal Treatment of Adult Acne in Women:

While there are many worthwhile treatments for this problem, therapies known as "hormonal treatments" play an important role in the treatment of adult acne in women.  These medications work by lessening the effect that certain hormones have on the skin, either by decreasing their levels in the body, or by preventing them from acting on the oil glands.  There are two types of hormonal treatments that are most commonly used in acne: combined oral contraceptives (birth control pills that contain both an estrogen and a progestin), and spironolactone.  It should be noted that these medications are used exclusively in females and are not used in men with acne.

1. Combined Oral Contraceptives (Birth Control Pills)

Birth control pills can be very helpful for treating the hormonal component of acne in both teenagers and adults.   They primarily work by lowering the levels of certain hormones in the body that activate sebum production and contribute to acne. Only those birth control pills that contain both an estrogen and a progestin (the two main types of female hormones) are used in acne; progestin-only forms of birth control are not used (these can actually make acne worse).  

Several types of birth control pills have been found to be effective in the treatment of acne, and your doctor can help you select one that is likely to work.  Three have been approved specifically for this purpose by the FDA, and two have been approved by Health Canada.  In addition to the birth control pills that are commonly used, in Canada (and in Europe), a combination hormonal pill that contains a hormone blocker known as cyproterone acetate is approved for the treatment of moderate or severe acne.  

In several large randomized controlled trials, birth control pills reduced the number of pimples (inflammatory acne lesions) among those who took them by an average of 50 - 60%, and people who took the medications were significantly more likely to have skin that was rated as "clear" or "almost clear" than people who received a placebo (sugar pill). Birth control pills are not without side effects, and your doctor must carefully evaluate whether one of these treatments is right for you. Rare, but serious health problems such as leg clots or strokes (among other side effects) can occur with the use of these medications, and because of this not everyone is a good candidate for their use.  

2. Spironolactone

Spironolactone is a medication that is used in acne primarily because of its ability to block both the action of androgens (it also lowers their levels). It was originally used to treat high blood pressure, and it has been used off-label to treat acne for over thirty years.  About 60% of people who take spironolactone at appropriate doses experience improvement in their acne, and many dermatologists find this medication to be very valuable in treating adult women with this condition.

Spironolactone is generally well-tolerated but, like any medication, it has the potential to lead to side effects.  The most common of these are breast tenderness and irregular periods (a more detailed list can be found here).  It can cause birth defects if taken when pregnant, and so is often used in conjunction with birth control pills. 

What's the Bottom Line?

  • Adult acne is common in women

  • Some women develop a "hormonal acne pattern" , in which their acne is more likely to be cystic, involve the lower part of the face and fluctuate in severity with their cycle

  • Hormonal therapies such as birth control pills and spironolactone have been shown to be beneficial in a significant proportion of women with adult acne

  • All medications have potential side effects.  The risks and benefits of any acne treatment should be discussed with your doctor

There are many effective ways to treat adult acne.  A board-certified dermatologist can review your options and help you select a treatment plan that is right for you.  

 

References:

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Knaggs HE, Wood EJ, Rizer RL, et al.  Post-adolescent acne.  Int J Cosmet Sci 2004; 26: 129-138.

Koltun W, Lucky AW, Thiboutot D, et al.  Efficacy and safety of 3 mg drospirenone/20 mcg ethinyl estradiol oral contraceptive administered in 24/4 regimen in the treatment of acne vulgaris: a randomized, double-blind, placebo-controlled trial.  Contraception 2008; 77: 249-256.

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Redmond GP, Olson WH, Lippman JS, et al. Norgestimate and ethinyl stradiol in the treatment of acne vulgaris: a randomized, placebo-controlled trial. Obstet Gynecol. 1997;89:615–622.

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Shaw JC.  Low-dose adjunctive spironolactone in the treatment of acne in women: a retrospective analysis of 85 consecutively treated patients.  J Am Acad Dermatol 2000; 43: 498-502.

van Vloten WA, van Haselen CW, van Zuuren EJ, et al. The effect of two combined oral contraceptives containing either drospirenone or cyproterone acetate on acne and seborrhea. Cutis. 2002;69(4):2–15.

 

Michelle Levy

Dr. Michelle Levy is a board-certified dermatologist specializing in medical and aesthetic dermatology. A graduate of the University of Toronto's Faculty of Medicine, Dr. Levy provides a full spectrum of dermatologic services in Toronto, Canada. Education: M.D., University of Toronto, 1999 Residency in Dermatology, University of Toronto, 1999-2004 Employment History: Self-employed, North York, Ontario, 2005-Present Medcan. Consultant Dermatologist. 2007-Present