An increase in androgens, especially testosterone, can lead to breakouts of acne caused by hormonal fluctuations. Despite being called "hormonal acne," these breakouts can occur in adults of any age, but are particularly common during menstruation and menopause.

What is hormonal acne?

Hormonal acne is a type of acne caused by changes in hormone levels, particularly an increase in androgens like testosterone. It can affect adults at any stage of life, not just during puberty. In addition to hormonal imbalances, other underlying medical conditions may also contribute to the development of acne in adults.

Symptoms of hormonal acne

Hormonal acne typically appears on the nose, chin, and forehead during puberty. However, in adults, it may appear on the lower parts of the face, such as the jawline and lower cheeks.

Comedones, which are either whiteheads or blackheads, can also appear with acne. Blackheads, also known as open comedones, are open at the surface of the skin and appear black due to sebum interacting with the air. Whiteheads, also known as closed comedones, are closed under the skin surface and appear white on top. Touching or picking at comedones can cause the follicle wall to rupture, leading to the spread of sebum and bacteria, resulting in inflammation. Pustules are the first signs of inflammatory acne. Other types of acne include papules, small raised red bumps due to inflammation or infection of the hair follicles, nodules, similar to papules but larger, denser, and more painful, and cysts, large lumps under the skin filled with pus, which can be painful and tender.

Causes of hormonal acne

Acne can be triggered by conditions that affect hormone levels such as puberty, menstruation, menopause, polycystic ovary syndrome, and increased levels of androgens. It is estimated that around 50% of women between the ages of 20 and 29 and 25% of women between the ages of 40 and 49 experience acne.

A rise in testosterone levels can cause excessive secretion of sebum from the skin's glands, leading to an infection of the hair follicles by the bacteria Cutibacterium acnes, which can result in hormonal acne.

Fluctuations in the levels of sex hormones, including progesterone, during the menstrual cycle may also contribute to acne before the period. Progesterone levels rise during the middle of the cycle, which can also raise body temperature and worsen sweating, leading to clogged pores and breakouts.

Testosterone can cause acne as well. A rise in testosterone levels stimulates more sebum production, which clogs the skin pores. The infection of these clogged pores by acne-causing bacteria can result in pimples.

During menopause, hormonal fluctuations can also cause acne. Some people may develop acne around menopause due to a normal level of androgen but reduced levels of estrogen, leading to an increase in sebum production and flare-ups. In some cases, hormone replacement therapy (HRT) may also trigger acne.

Severity of acne

Scientists have developed several grading systems to evaluate the severity of acne. One such system is the Global Acne Grading System (GAGS), which classifies acne as mild, moderate, severe, or very severe. To determine your acne severity according to GAGS, you will need to calculate the local acne score for each affected area on your body.

This is done by multiplying the location factor by the grade of the most severe lesion in that location. The location factor is based on the body part affected, with higher values given to areas such as the chest and upper back. The grade of the most severe lesion ranges from comedone (1) to nodule (4).

The global score is the sum of all the local scores. For example, if you have papules on both cheeks and comedones on the chin, the global score would be (2 x 2) + (2 x 2) + (1 x 1) = 9.

According to GAGS, the acne severity is:

Mild: 1-18

Moderate: 19-30

Severe: 31-38

Very severe: more than 39

This system can be used to evaluate the severity of the acne and to track the progress of the treatment.

Hormonal acne treatments

Treatment options for hormonal acne vary depending on the severity of the condition. Over-the-counter treatments may not be effective for moderate to severe cases, and a healthcare provider may recommend oral medications to help balance hormones and clear the skin. These include oral contraceptives and anti-androgen drugs.

1. Oral contraceptives can help to normalize testosterone production, which can lead to an improvement in acne. However, these medications should only be prescribed by a healthcare provider after discussing the risks and benefits.

2. Anti-androgen drugs reduce the production of the androgen hormone, which can lead to an excessive production of sebum and acne. These drugs should only be taken under the guidance of a healthcare provider.

3. Retinoids, which are derivatives of Vitamin A, can be used to treat mild hormonal acne. They are available over-the-counter in gel, lotion, or cream form, or can be prescribed by a dermatologist. Sunscreen should be used daily while using topical retinoids as they increase the risk of sunburn.

4. Some natural remedies such as tea tree oil may be effective in treating mild hormonal acne, however, research on the efficacy of these treatments is limited. It's important to consult with your healthcare provider before using these types of treatments, to verify whether they will interact with any medications you may be taking.

Tips for people struggling with acne

To help clear or prevent the worsening of acne, the following self-care tips can be useful:

• Gently wash your face no more than twice a day, especially after heavy sweating.
• Use mild cleansers or soaps and lukewarm water, avoid hot water.
• Avoid using exfoliating products or harsh scrubs.
• Don’t rub, pick, or scrape your pimples, as this can cause inflammation.
• If you use makeup, try to find options that are labeled as non-comedogenic.
• Avoid staying in humid environments, as they can lead to sweating.
• It's important to note that excessive washing and scrubbing can actually worsen acne by removing too much oil from your skin, which causes irritation and leads to an increase in oil production.

The takeaway

Hormonal acne is caused by changes in hormone levels, particularly an increase in testosterone. This can lead to increased sebum production from the sebaceous glands, which when combined with dirt, bacteria, and dead skin cells can clog pores and cause acne.

During puberty, hormonal acne is commonly found on the T-zone, which includes the nose, forehead, and chin. Similarly, during menopause, fluctuations in hormones can also lead to acne.

Treatment options for hormonal acne include topical products, oral contraceptives, or anti-androgen drugs, that can be prescribed by a healthcare provider.