Written by Dr. Laura Lenihan, Skin Expert, GP & Aesthetic Doctor at Dr. Laura Clinic, Galway and Dr. Kate Gilmore, Dr. Laura Clinic, Galway
Dr Laura Lenihan
Dr Kate Gilmore
Acne
Acne is typically viewed as a disease of adolescence, however this common generalisation can contribute to stigma experienced by those who suffer from adult acne – broadly defined as persistent or new lesions at the age of 25 or older. Acne has been linked to a number of debilitating psychological symptoms, despite often being dismissed by clinicians as a minor condition. Many patients report increased levels of anxiety and depression, and an overall decreased quality of life that does not correlate necessarily with severity of disease.
Hormonal acne can be particularly difficult to treat as it is often approached by patients and clinicians with the same methods used to treat adolescent acne. To understand why it requires an alternative approach, it is important to first understand the pathophysiology of the disease.
Pathogenesis
Acne is a disease of the pilosebaceous unit, or the pore. The pathogenesis of acne is broadly considered to consist of four elements: hyperkeratinization of pilosebaceous follicles, followed by excess sebum production (worsened by hormones), c. acnes colonisation and inflammation. C. acnes, a bacteria found in pilosebaceous follicles, has been shown to induce an inflammatory response which promotes follicular rupture. By promoting sebaceous gland growth and secretory activity, androgens contribute to acne formation. Androgen levels also don’t have to be abnormal, or high, but rather the androgen receptors in the pores respond inappropriately to normal levels of hormones. Within the realm of female adult acne, androgens play a major role. Hyperandrogenism, such as PCOS is an important factor to be aware of and clinicians should be advised to look out for signs of PCOS such as hirsutism and irregular periods. If a patient has signs of hyperandrogenism and late onset acne then they should be further evaluated for an underlying endocrine disorder such as PCOS with their GP.
Contributing factors
We do know that there can be a variety of contributing factors but how much of a role they have to play is very much still up for debate. These include genetics, diet (mainly high GI foods like dairy products and chocolate), environmental factors, stress and occlusive cosmetics.
Clinical presentation
With female adult acne, there are 2 subtypes now recognised. Persistent adult acne, which is defined as acne that persists beyond adolescence and into adulthood and accounts for 80% of cases in female adult patients. And late onset acne, acne that begins after the age of 25.
Hormonal acne is often concentrated along the lower face (typical U pattern versus T pattern associated with teenage acne), with a typical pattern presenting around the jawline extending down to the neck. It can often present concurrently on the chest and back. Lesions are more often of the papulopustular or nodular kind. In practice, there do not tend to be a lot of open or closed comedones (blackheads and whiteheads) in adult female acne, which can sometimes make diagnosis difficult and can lead to missed opportunities to treat.
Other common presentations would be patients experiencing acne for the first time since their adolescence after discontinuing birth control pills, patients who are perimenopausal, and patients who experience the worst flare ups during their periods. Pregnant patients can also present with flare ups.
Treatment
Hormonal acne can be particularly challenging for patients as it is seemingly resistant to conventional first or second line acne treatments. Often a patient will present having tried numerous forms of topical treatments which proved effective in their youth are now doing very little to combat their symptoms.
When it comes to treatment, it’s important to remember the pathogenesis and ensure that we treat all four of the major issues. Treatment can be challenging as it can have a chronic course (13-16 years for some or longer) and there can be high rates of failure and often numerous choices for the clinical. As important as treatment is, maintenance and prevention is key and so treatment should be considered for a much longer period of time. For us here in clinic, we cannot stress the importance of skincare in the treatment of adult onset acne, as it is required to alleviate lots of the issues causing acne in the first place. While medications work, tretinoin being the gold standard and working across all 4 issues, there is lots that we can do with skincare as well, using ingredients that reduce keratinisation of pores, to help decrease sebum and inflammation. WIth adult women, there are significantly higher rates of treatment failure, 80% of women will fail multiple courses of systemic antibiotics and up to 3040% of women will fail roaccutane.
Le’ts take a look at some of the treatment options
Given the role that androgens play, it’s clear that medications that affect androgen levels will have an important role in the treatment of female adult acne. This means the combined oral contraceptive pill (COCP) and spironolactone will be saviours for most patients.
The COCP works with oestrogen increasing levels of sex hormone binding globulin (SHBG), which binds with excess free androgens stopping them affecting sebum levels. The COCP works well for acne lesions focused around the jaw and chin area, or if there is a history of flaring that coincides with menstrual cycles. It’s a great option for women who also need contraception. There are however a number of contraindications to the use of the COCP including, increased BMI, smoking, pregnancy, and hypertension. The GP or prescriber should advise patients of the same.
Spironolactone works by blocking the androgen receptors in the pilosebaceous unit. This results in shrinking of the sebaceous glands and a reduction in sebum production. Spironolactone is an excellent choice for patients who have tried hormonal therapies with varying results and do not wish to use isotretinoin. As spironolactone is a diuretic, it is important to advise patients to keep well hydrated by consuming the recommended 2L of fluid a day. The American Academy of Dermatology states that spironolactone can be used in patients under the age of 40 without any medical issues, without testing U+E. In any patients with a medical history they should be checked pre treatment, after initiation and with any dose changes.
Isotretinoin (brand name Roaccutane) is a Vitamin A derivative. It is the gold standard for severe and recalcitrant acne. It works by shrinking overactive oil glands and it has also been shown to reduce c. acnes in the skin.
For many patients, isotretinoin is a life changing drug, but it is not without its pitfalls. Patients will need to be counselled about numerous side effects, including dry, cracked skin – especially in mucous membranes. Over the counter lip balms with ceramides and saline nasal sprays can help to soothe these symptoms. Dry, inflamed eyes and eyelids can also be treated with various over the counter drops and gels.
Routine monitoring of liver function tests, serum cholesterol and triglycerides and regular pregnancy tests are necessary for the duration of treatment. There has been much discourse surrounding isotretinoin and its effects on mood, and it has long been associated with depression and increased risk of suicidality. Despite persistent studies, there is still little evidence to support this. Patients should be aware that they should contact their GP immediately if they notice any mood changes.
Both spironolactone and isotretinoin pose teratogenic risks so it is important to ensure that patients are informed of these risks before starting the medication. The patient will need to be on adequate birth control. For isotretinoin two forms of contraception are recommended, with one being a barrier method. Long acting reversible contraceptives such as the coil should be considered.
Topical treatments
There are a lot of topical treatment options for acne, many of which can be very successful. However some are better for younger age groups than others. Topical treatment is also ESSENTIAL for maintenance and prevention of further lesions and should be initiated alongside any oral therapy.
Topical Tretinoin (retinoic acid) is considered the gold standard for topical therapy in acne.
It should be used over adapalene (differin) in older patients. All patients with acne can benefit from topical retinoid treatment, which are an important part of maintenance therapy. For example, in the case of severe hormonal acne which has been treated with isotretinoin, daily application of topical tretinoin can play a vital role in maintaining treatment responses following the discontinuation of isotretinoin. Tretinoin also has the advantage of significant anti-aging benefits, including increasing cell turnover, increasing collagen synthesis therefore reducing fine lines and wrinkles, and evening skin tone by decreasing pigmentation. This makes it a fantastic option in older age groups looking for anti ageing benefits as well.
Azelaic acid (Rx Skinoren) can be prescribed by clinicians but also can be found in many over the counter products. Azelaic acid is usually tolerated very well by patients, and reduces c. acnes on the skin while also decreasing keratin production and offsetting the effects of post-inflammatory hyperpigmentation. It is both an anti inflammatory and anti bacterial agent and can be used with good effect in acne. In clinic we would prescribe skinoren in the AM and tretinoin in the PM for acne treatment and maintenance. This is considered to be the gold standard among dermatologists worldwide. It is also safe to use in pregnancy and breastfeeding and so a good option for women who may otherwise struggle.
Topical antibiotics have not been found to have the best efficacy in hormonal acne. Furthermore, sustained topical antibiotic use can confer antibiotic resistance, especially when used by itself. Benzoyl peroxide, although a mainstay in adolescent acne, has been shown to be less effective in the treatment of hormonal acne. Topical retinoids are preferable. Emphasising to patients that establishing a consistent skincare routine is the hallmark of maintaining results. If patients are using topical acne treatments that are drying or have side effects then for the most part their skincare routine should be nourishing. Look out for gentle cleansers used both AM and PM. There is no need to clean the skin more than twice per day. Ingredients such as salicylic acid can be used to decrease oil levels and unclog pores. Niacinamide is a potent anti-inflammatory agent that also works to control sebum levels and is found in a number of cosmetic products. Alphahydroxy-acids such as glycolic acid or lactic acid can be used to work on texture, reducing blockage of pores. Looking out for a non comedogenic moisturiser and SPF are also key.
Another important element of treatment is ensuring that the patient is aware of the timeline of treatment. Often breakouts can worsen in the first few months of treatment, especially with the use of topical treatments such as tretinoin. Patients should 100% be informed of the risk of purging, as many will quit therapy thinking it isn’t working. Results take a minimum of 8 – 12 weeks and often longer for more severe cases.
Two new advancements in acne therapy include the recent approvals of both the AviClear laser and clascoterone 1% topical cream. Both have shown promise in the area of hormonal acne.
Although clascoterone is not yet licensed in Ireland or the UK, its initial clinical data is promising. It acts as an androgen receptor blocker. It is a novel treatment, the first topical anti-hormonal treatment on the market. It will be especially beneficial for patients who cannot tolerate the side effects of systemic androgen receptor blockers. It is not expected that clascoterone will be a substitute for all other therapies, but that it will be a very beneficial adjunct to current treatments. Early studies suggest it has a possible role in reducing the dosage of and even hastening the discontinuation of oral therapy. With already limited options for treating hormonal acne, this new addition to the physician’s arsenal is a very exciting one.
The AviClear laser from Cutera is a 1762nm wavelength laser which is the first device of its kind to be cleared by the FDA. The advent of machines such as the AviClear which target sebaceous glands without damaging surrounding skin could also spell a new era for acne treatment, providing an option for patients who are pregnant or who cannot tolerate certain oral or topical treatments. Initial studies have suggested that the AviClear could be as efficacious as isotretinoin at the two year post treatment mark. As the device is extremely new, having been approved in March 2022, further research will be needed to cement its status as a viable alternative to isotretinoin.
Menopausal skin
Menopause officially begins one year after your final period however many women will start to notice changes in their skin long before this while going through perimenopause. During perimenopause the body’s production of oestrogen and progesterone, the two hormones made by the ovaries, varies greatly giving symptoms such as hot flushes etc. High levels of oestrogen seen in younger women help to keep the skin healthy and plump by stimulating the production of collagen, glycosaminoglycans and natural oils. Collagen is the primary protein in skin, but also nails, hair muscles and bone. As you age and oestrogen levels drop, we see a decrease in the production of collagen, which means the skin becomes more susceptible to dryness and fragility. By the time a woman is postmenopausal her oestrogen production has stopped. So how does this affect skin? From dryness to rashes, menopause has many different effects on women’s skin.
The main complaints that patients will mention include: general ageing of the skin such as wrinkles and a reduction in elasticity, skin dryness and itching, acne (menopausal breakouts are quite common), increased skin sensitivity, redness associated with hot flashes, facial hair, hair thinning, as well as changes to the skin around the genital area which is highly susceptible to changes in oestrogen.
While we know the effects of oestrogen on lots of body systems, including cardiovascular; the effects it has on the skin are less well understood. We do know that it prevents a decrease in skin collagen production. From the age of 25 we lose about 1% of our collagen a year but in the first five years after menopause we lose a further 30% which can have significant changes on our skin. Oestrogen is also known to maintain stratum corneum barrier function, it increases hydration levels by increasing glycosaminoglycans and hyaluronic acid in the skin and also has an effect on elastin fibres. By removing oestrogen this can have a deleterious effect on our skin showing as dryness, thinning skin, loss of elasticity and loss of collagen. The overall effect is an increased rate of ageing. Menopause can also have an effect on the hair of both your face and scalp.
Although hormonal therapy (HRT) remains the gold standard for treating many of the physical symptoms of menopause, there is no evidence that it helps with age-related skin changes in patients who are postmenopausal. Some studies have shown however an increase in sebum levels in postmenopausal women receiving HRT so watch this space.
Skin issues at menopause
Fine lines & wrinkles
WIth that reduction in collagen fine lines & wrinkles appear where we never had them before. They can increase substantially after menopause.
How to fix them?
SPF should be used daily to prevent further damage occurring ideally alongside a potent antioxidant serum in the AM such as L-Ascorbic Acid to negate the effects of UV damage on the skin. Retinoids (prescription retinoic acid or over the counter retinol) are great for stimulating collagen production and increasing cell turnover. Some people advocate for taking vitamin C supplements also as it is an essential precursor to the formulation of collagen.
Age spots / pigmentation
During menopause, skin becomes even more susceptible to UV damage. Concurrently, UV damage that has already accumulated below the surface of the skin can rise to the skin’s surface, causing hyperpigmentation. Many patients complain of worsening “sun spots” at the onset of menopause. Skin cancer and precancerous skin growths can also become more common. Remember UV damage is cumulative.
How to fix it?
It is vital to counsel patients on the importance of sun protection. SPF 50 should be worn daily, and patients should avoid direct sunlight as much as possible. Conservative measures such as wearing wide brimmed hats and protective clothing, staying in the shade and avoiding being outside for too long during peak sun hours in the summer months can all aid in preventing further damage and pigmentation. If a patient is worried about any spots then they should have them assessed by a GP or dermatologist and do regular self skin exams.
Other ingredients mentioned below will help with pigmentation. Alpha hydroxy acids such as lactic acid and glycolic acid will shed away dead skin cells that have extra pigment in them. Retinoids help to reduce pigmentation by blocking tyrosinase. Vitamin C and other antioxidants help to reduce the deleterious effects of UV rays on the skin. If the pigmentation is bad, we can use prescription skin bleaching products such as hydroquinone, which must be used under medical supervision.
Dry Skin
During menopause, the stratum corneum weakens and there is an increase in water loss from the skin. As oestrogen levels drop, the skin produces less sebum, hyaluronic acid and ceramides, which are all essential in keeping the skin barrier intact and preventing transepidermal water loss (TEWL).
How to fix it?
Using moisturisers containing ceramides, shea butter, fatty acids, hyaluronic acid and squalane that help to maintain the integrity of the skin barrier and keep water in, and bacteria and pollutants out. Switch to a gentle cleanser that won’t strip dry skin of its essential oils. We prefer a cream cleanser for menopausal skin rather than a foaming one.
Sensitive skin
With the onset of menopausal symptoms, many patients complain of increased sensitivity. As we age, our skin’s pH changes which can lead to increased sensitivity to products which may have previously suited our skin.
How to fix it?
The most important thing is to use gentle products and see a cosmetic doctor if there is any irritation. Using pH balanced cleanser and moisturisers can also help and avoid irritating ingredients such as glycolic acid while you improve the overall structure and function of skin.
Dullness
As we age, the rate at which we turn our cells over decreases leading to dullness (old cells that don’t reflect the light as well). Dry skin can also look lacklustre.
How to fix it?
We need to exfoliate dead dull skin cells. Using a gentle exfoliant such as lactic acid, or glycolic acid if no sensitivity and this can give immediate improvements in the look of dry dull menopausal skin. Retinoids also are an essential part of treating perimenopausal skin. They increase cell turnover revealing a brighter radiant complexion.
Acne
One of the most frustrating effects for women of menopausal skin is acne. They feel that this should be left in their teenage years. But unfortunately for some it can be quite severe, despite dry skin.
How to fix it?
A salicylic acid face wash can help clear pores alongside a retinoid – ideally prescription as the gold standard in acne treatment. Other treatment options that can help
We discussed above the significant decrease in collagen during those first five years post menopause. In clinic an innovative way to combat this is collagen induction therapy. One such example of this is micro needling in which a device stamps thin needles into numbed skin. This stimulates wound healing and creates new micro channels in the dermis. This process induces the formation of new collagen.
Another example is radiofrequency microneedling which induces longer term dermal remodelling by creating micro injuries at the level of the dermis, setting off the wound healing cascade. Insulated needles release radiofrequency currents upon reaching the dermis, creating thermal zones which trigger neo elastogenesis and neocollagenesis. The depth of the needle can be adjusted accordingly to target different layers of the dermis. Radiofrequency microneedling is considered superior to microneedling alone, as it reaches a deeper layer of the skin and has less downtime.
Hormonal acne, menopausal skin and stretch marks are just a few of the many dermatological issues that healthcare professionals encounter in the community. Long waiting lists for tertiary care and the classification of the vast majority of these conditions as non-urgent can result in many patients suffering for years with symptoms that could be easily alleviated with the right treatment plan. The advent of more specialised, focused primary care and continuous reeducation about the treatment modalities for these common presentations is crucial for ensuring an optimal patient experience. By factoring in the latest clinical guidelines and tailoring our approach to fit each unique presentation, we can not only ensure that our patients are visibly healthier, but that they reap the vast psychosocial benefits that come with clear, healthy skin.
