Hormonal Acne in Women

by James Channing Shaw, MD

It is common for women to get acne in their 20s or 30s for the first time. The cause usually centers around hormonal issues.

A common scenario is the woman who gets acne within a year of stopping birth control pills. Women often take birth control pills for years in their teens or early 20s, and their acne is controlled. When they stop taking birth control pills, hormones return to having fluctuations that lead to acne.

Another cause comes from irregular ovarian activity that causes hormone fluctuations. These women often have irregular periods or acne that gets worse a week before each period. Any woman can have this problem, and at its worst, it is part of polycystic ovarian syndrome. There are other diseases that lead to hormonal acne, but fortunately they are rare.

The hormone that causes acne is the male hormone testosterone and its metabolites. Women produce testosterone in small quantities, but several conditions lead to increased testosterone effect. An increase in body weight, for example, shifts hormones toward more testosterone effect. Ovaries or adrenal glands can spontaneously overproduce male type hormones. Stress causes acne mainly through overproduction of hormones by adrenal glands.

This photograph shows a typical woman with moderately severe hormonal acne. Women with adult hormonal acne commonly have pre-menstrual worsening, and involvement of the lower face and jaw-line. Their acne is usually larger red pimples instead of blackheads on the forehead. Increased oiliness on the face is common. Some women have unwanted hair growth on the face. Irregular menstrual periods are common as well.

Standard topical acne treatments can be effective in women with adult acne, but most need hormonal treatments for optimal control. Even Accutane® is less effective in women with hormonal acne. The best treatments for adult women are birth control pills and spironolactone.

Birth control pills not only provide a steady state of hormones, they reduce overall testosterone effect through a protein called SHBG (sex hormone binding globulin). The net effect (in addition to not ovulating, i.e. prevention of pregnancy) is less stimulation of the oil glands and facial hair follicles. Many women can achieve complete control of their acne with birth control pills alone. Health risks from birth control pills are fortunately very low, but certain women have higher risks of blood clots, and full discussion with the prescribing doctor is essential. Brands of birth control pills differ by country, and some are marketed for acne.

Spironolactone is an oral drug that blocks the receptor for testosterone and prevents hormonal stimulation of acne. This drug is mainly used as a diuretic in older patients. The acne benefit was discovered as a side effect years ago. Spironolactone is well tolerated by itself, with a 40 year track record of safety in young women, but works best when given together with birth control pills. Side effects include menstrual irregularities when it is given alone.

This photograph is the patient above after a year of combination hormonal treatment. Her acne is much improved and the hair on her lip has reduced. Many women achieve excellent control within a few months with hormonal treatments, but ongoing treatment is necessary in most cases. It is important to find a doctor who is familiar with the use of these drugs for purposes of monitoring.

Finally, two recent developments in acne: 1) Cosmetics have been shown not to aggravate or cause acne in most cases. 2) Dietary influences of a western diet high in carbohydrates and dairy products may worsen acne through complex hormonal mechanisms, so a reduction in carbs and milk products may be beneficial.