Raise your hand if you’ve ever had your day ruined by a new pimple that sprouted up over night. If you can’t relate to that feeling, consider yourself lucky! I will never forget waking with a huge pimple on my chin the morning of my wedding. Most people consider acne a problem during puberty when teenage hormones are rapidly changing. Unfortunately, acne can follow us into adulthood or even occur for the first time as an adult. More often than not this occurs in females in their mid to late 20’s and is what we categorize as hormonal acne.
Hormonal acne occurs due to fluctuations in androgen hormones throughout the menstrual cycle that stimulate production of sebum/oil glands in the skin. Overproduction of sebum leads to accumulation of dead skin cells that block pores, resulting in comedonal acne (AKA white and black heads). Increasing colonization of acne forming bacteria prompts an immune response and inflammation in the skin that results in an inflamed papule or nodule (AKA a pimple or cyst). Patients will typically recognize flares of acne at certain points of their cycle, usually right before or during menses. These hormonal changes can also occur during pregnancy, prior to menopause, or as a side effect of certain hormone therapies as well. Severe hormonal acne presenting with other symptoms (irregular periods or hair growth, infertility, obesity, insulin dysregulation or diabetes, etc.) may be due to an underlying endocrinological disease such as polycystic ovarian syndrome (PCOS) or malignancy.
Managing hormonal acne is challenging for patients and medical providers. This type of acne may be more resistant to traditional treatments as it has a tendency to relapse despite courses of aggressive medication like accutane. Studies on hormonal acne demonstrate significant psychological impacts on patients, including negative influence on quality of life and symptoms of anxiety and depression.
Treatment depends on the severity of acne and patient preference. In my experience, successful acne treatment plans incorporate my medical recommendations with a regimen that the patient is comfortable with. The most common obstacle to treating acne is lack of compliance to medications. This is understandable considering how slow and unpleasant the process may be. It can take 4-6 weeks to adjust to topical acne medications with side effects including skin irritation, redness, and dryness. Acne “purging” is also common during the first 1-2 months of treatment, meaning that acne may actually get worse before it gets better. Typically, we start to see improvements in acne after 2-3 months of consistent treatment. As with many medical conditions, there is no “one size fits all” for treating acne and this timeline can vary, especially for hormonal acne. If adequate improvement is not occurring we may need to adjust or add medications, which prolongs our timeline to improvement even more.
As you can see, treating acne is a slow process that requires patience, consistency, and perseverance. Due to the challenges in treating hormonal acne in particular and the significant psychosocial burdens it imposes on patients, there has been increasing research expanding on this topic. Stay tuned for another blog post that goes more in depth on how we treat hormonal acne medically and through lifestyle changes!