The Dermatologist's Guide to Treating Menopausal Acne

As if the hot flashes and mood swings weren't enough, add "constant breakouts" to the list of menopausal symptoms. The root cause should come as no surprise; it all comes back to good old-fashioned hormonal changes. And these hormonal changes can cause acne not only during menopause, but also before and after. In other words, it can be something you're dealing with for years to come. But the good news (and don't worry, there is some!) is that, with the right approach and treatment plan, there are ways that you can help keep menopausal acne in check.

Ahead, Ife J. Rodney, MD, a board-certified dermatologist and founder of Eternal Dermatology in Fulton, MD, and Jessie Cheung, MD, a dermatologist in Willowbrook, IL, explain everything you need to know about what sets menopausal acne apart from other types of breakouts—and what you can do to clear your skin.

What Is Menopausal Acne?

Simply put, it's a type of hormonal acne. "Hormonal changes are one of the biggest reasons for acne, and there's no bigger time of hormonal change in a woman's life than menopause," says Rodney. (More on the specific difference between these hormonal changes and those that trigger other types of acne in a moment.) The condition is somewhat of a misnomer, given that it occurs not only during menopause but also during perimenopause. "Perimenopause is the transition period that leads up to menopause, usually happening two to eight years earlier. Since the average age of menopause is 51, it’s not uncommon for women in their early 40s to experience menopausal acne," Rodney explains. Cheung agrees, noting that initial hormonal changes may not be enough to stop your period fully, but they are enough to make your skin (and emotions, for that matter) go haywire. Adding insult to injury, it can then extend even into postmenopause, sometimes well into a woman's 50s, adds Rodney.

Like other types of hormonal acne, the defining characteristic is deep, tender bumps or cysts, mainly around the mouth, chin, and jawline. (This, in contrast to regular acne, looks like blackheads, whiteheads, and pus-filled bumps on oily areas of the face, like the T-zone.) Another tell-tale sign that you're dealing with menopausal acne? "It often manifests along with excess facial hair, especially on the chin and upper lip," says Cheung. Again, this goes back to those hormones.

Causes and Prevention of Menopausal Acne

Ultimately, the only cause here is hormonal changes, but let's unpack that a bit further.

• Decreased estrogen Levels of estrogen, the so-called female hormone, plummet rapidly during menopause, throwing off the delicate balance of androgens, most specifically testosterone. "As estrogen levels fall, the relative increase of testosterone results in oily skin and clogged pores," explains Cheung. (That spike of testosterone also causes increased facial hair growth and is why this type of acne shows up on the lower face, as it seems that this is where more androgen receptors live, she adds.) Estrogen and testosterone are the same key hormones at play when acne pops up at other times, for example, during puberty and early adulthood. But during those periods, it's more of a function of either an increase of both, or the two fluctuating and not remaining stable, rather than this drastic drop in estrogen. It's also worth noting that decreased estrogen impacts the skin in other ways as well (but more on that to come). Attempting to level off these hormonal imbalances—as much as possible—is ultimately the best way to both prevent and treat menopausal acne.
• Stress As any woman who has experienced or is experiencing menopause will quickly tell you, it's a stressful time. Unfortunately, this becomes a double-edged sword: "Stress due to the many other changes happening within the body also contributes to acne," Rodney says. Along with impacting hormone levels in general, stress increases cortisol in the body, the aptly-dubbed stress hormone. It wreaks havoc on the skin in many ways, triggering breakouts through increased oil production being just one of them. While it's obviously easier said than done, attempting to reduce stress as much as possible during, before, and after menopause is paramount.

Treatment

Unlike the topical approach often favored for other types of acne, treating menopausal acne requires an "inside out" approach. "The most effective treatments focus on correcting the hormonal imbalance," says Rodney. Both dermatologists say spironolactone, an oral medication first used to treat high blood pressure, is one of the most often used. It gets right to the root of the issue, an anti-androgen medication that blocks the androgen receptors in the skin, helping to prevent both acne and excess facial hair growth, says Cheung. While it's often used to treat adult acne for women in their 20s and 30s, it's even a better option in an older patient population, she adds. Spironolactone may cause birth defects in pregnant women, and that's obviously not a concern during menopause.

Oral contraceptive pills can also help with regulating hormone levels, but these should only be used when prescribed by your gynecologist, as there are potential side effects in menopausal women, cautions Rodney. Similarly, it's worth pointing out that, while hormone replacement therapy, or HRT, is often used to treat other issues associated with menopause (such as osteoporosis, hot flashes, and vaginal dryness), it may actually exacerbate hormonal acne due to the synthetic hormone progestin, she says.

From a topical standpoint, many of the same tried-and-true, acne-fighting ingredients (like benzoyl peroxide and retinoids) can play an important role in combatting menopausal acne—but with one important caveat. That major drop in estrogen also affects the dermal matrix of the skin, in short, leaving your skin drier and more reactive, explains Cheung. What does that mean when it comes to creating an effective anti-acne routine? She says to be wary of another common acne-fighter, salicylic acid, as it can make your dry skin even drier. And as far as the other topical ingredients go, seek out gentle formulas, ideally ones that use time-released versions of the actives to help minimize the likelihood of increased dryness and irritation.

At the end of the day, "the changes that happen with drops in estrogen around the time of menopause are inevitable, but hormonal acne doesn't have to be," says Rodney.