As many of us are aware, acne is very common and presents in various subtypes. Hormonally induced acne, one of the more common subtypes of acne, is, unfortunately, both under-recognized and under-treated.
Generally, hormonally induced acne
is characterized by deeper sometimes tender pimples
occurring on the jawline, chin, forehead, and trunk of female acne patients. Typically this acne
subtype flares reliably in relationship (before, often) to one’s menstrual cycle (but not always). Menstrual cycles may be regular or irregular. Importantly, if one’s menstrual cycles are irregular, in conjunction with acne
and hirsutism (excess hair growth), one should consider evaluation by an endocrinologist or gynecologist for polycystic ovarian syndrome
(PCOS) or other disorder.
Who is at risk for hormonally induced acne?
In my experience I divide hormonally induced acne into the following typical presentations:
1) Teens with significant acne flaring during the week before your menstrual cycle
2) Young women (age ’20s-’30s), often with no history of teenage acne, with a rather abrupt onset of deeper tender pimples
sometimes occurring several years before or after menopause
as well), women in the 40’s or 50’s with tender deeper pimples
generally occurring on the chin, jawline, and neck.
5) Women of all ages who recently (2-3 months prior to the onset of acne) switched birth control to include one of the following progesterones: norethindrone, levonorgestrel, etonorgesterel, among others.
How to treat hormonally induced acne
Treatment of hormonally induced acne can be a bit of a challenge. Topical treatment generally is insufficient to improve hormonal acne, although mild hormonal acne may be improved by clindamycin, azelaic acid, niacinamide, dapsone, or other antimicrobials/anti-inflammatories. Coordinating with one’s primary care physician, dermatologist, pediatrician, and/or gynecologist is crucial, as optimizing the selection of a low-androgenicity oral contraceptive can make a huge difference in the treatment of hormonal acne. The optimal progesterone for hormonal acne includes desogestrel, norgestimate, and drospirenone. Lastly, spironolactone, a diuretic often employed in the off-label treatment of hormonal acne, may be used as monotherapy or in combination with an oral contraceptive.
The final comment to make about hormonally induced acne is regarding the use of isotretinoin. Now, I love isotretinoin as much as the next dermatologist, however one must recognize its limitations as well. Although hormonal acne will improve during an isotretinoin course of therapy, it will generally recur after the treatment has completed. As a result, before female patients commence a course of isotretinoin, it is often sensible to optimize hormonal acne treatment to determine if the isotretinoin course is actually necessary.