ACNE IN AN ADULT WOMAN

Why talk specifically about acne in women?

• Acne is much more common in young women than in young men.
• A woman's hormonal cycle affects her acne.
• Hormonal approaches (e.g. spironolactone) can be helpful in women.
• A woman's birth control method can affect her acne.
• A woman can become pregnant, and she may breastfeed.

Does adult female acne differ from teenage acne?

Yes. The adult woman with acne tends to have primarily inflammatory lesions (pimples) and few visible comedones (blackheads and whiteheads). The distribution is typically along the jawline and chin (as opposed to the teenage pattern of acne uniformly distributed on the face).

What are signs of hyperandrogenism in a woman?

• Menstrual disturbances
• Impaired fertility
• Hirsutism (excessive, dark hair growth in typically male areas)
• PCOS (polycystic ovary syndrome)

Hyperandrogenism can aggravate acne. Full hormonal workup should be considered in patient who shows signs of hyperandrogenism.

What birth control measures can aggravate acne?

• Progestin only mini-pills, e.g. Camila, Errin, Heather, Incassia, Jencycla, and Nora-Be.
• Depo-Provera injections
• Subdermal implants, e.g. Nexplanon
• Hormonal IUDs, e.g. Mirena, Skyla. 
  

Some progestins are chemically similar to testosterone and can increase androgen activity, leading to increased oil production, which can contribute to acne.  For example, a woman is 2.5 times more likely to develop acne if she receives a hormonal IUD as compared to a Copper IUD.

What birth control measures can improve acne?

• The estrogen in combined birth control pills (containing both estrogen and progestin) helps to lower androgen levels in the body, which can reduce oil production and improve acne. Examples of combined birth control pills that can help with acne include Yaz, Yasmin, Alesse, and others. 
• BCPs that contain drospirenone.

What BCPs contain drospirenone?

Drospirenone has anti-androgenic properties and can block the effects of androgens, reducing acne lesions, inflammation, and oil production. BCPs that contain drospirenone include:

• Yaz and Yasmin: These are combination birth control pills containing drospirenone, a progestin, and ethinyl estradiol, an estrogen.
• Beyaz: This BCP also contains drospirenone and ethinyl estradiol, but it also includes levomefolate calcium, a folic acid supplement.
• Slynd: This is a progestin-only contraceptive pill (POP) containing drospirenone.
• Other brands: Gianvi, Jasmiel, and Nikki

What BCPs are FDA-approved for acne?

• Yaz is a brand-name drug that contains the active drugs drospirenone and ethinyl estradiol. This active drug combination is also available as a generic medication.
• Estrostep Fe contains 2 hormones: norethindrone (a progestin) and ethinyl estradiol (an estrogen). There is a small amount of iron (ferrous fumarate) in each of the 7 inactive tablets taken during the fourth week. The inactive pills do not contain any hormones.
• Ortho Tri-Cyclen contains norgestimate and ethinyl estradiol

Even though a BCP is not FDA-approved for acne, it may still be beneficial for reasons noted above. It just may be that the drug company did not go through the formal process to get FDA approval.

Treatment

The usual conventional approaches to acne work well: benzoyl peroxide, a topical retinoid, oral antibiotics, and isotretinoin. In those women who relapse after a course of isotretinoin or who have signs of hyperandrogenism (e.g. PCOS, hirsuitism), hormonal workup and therapy is most helpful. The following are often used in adult woman with acne in addition to conventional therapy:

• Spironolactone e.g. 100 mg/day can be excellent. It is usually combined with a BCP and topical therapy (see below).
• BCPs: Either those that are FDA-approved for acne (Yaz, Estrostep Fe, Ortho Tri-Cyclen), or dospirenone-containing birth control pills (e.g., Yasmin, Yasminelle, Yaz, Beyaz, Ocella, Zarah, Daylette, and Angeliq)
• Azeleic Acid 15% gel or 20% cream BID can be helpful in women with acne. It has been shown to reduce both inflammatory and comedonal lesions, plus may reduce PIH. It may be favorably combined twice a day with spironolactone.

Spironolactone

Spironolactone is a heart-medication that can be very effective in the treatment of acne in adult women. Important points about spironolactone include:

• Spironolactone is a pill taken once a day, usually 100 mg/day.
• It takes about 6-9 months to have its full effect. Be patient.
• Spironolactone is thought to improve acne by blocking the production of male hormones including testosterone and DHEAS, thereby decreasing oil production by 50 to 80%.
• Spironolactone is a mild diuretic (it can make you pee).
• Spironolactone is a mild anti-hypertensive. If you have baseline low blood pressure, it could make you lightheaded.
• Spironolactone can cause breakthrough bleeding in a small percentage of patients. This is one of the reasons it is usually combined with a birth control pill beneficial for acne.
• Do not take the antibiotic trimethoprim-sulfamethoxazole with spironolactone as this can increase the risk of hyperkalemia.
• In pregnancy, it can feminize the male fetus. So if you get pregnant, stop the spironolactone.
• Spironolacone is okay for lactating women.

Picture

Acne in a young adult woman is very common (in contrast to men for whom the acne usually remits by age 20). Note the predominance of pimples and lack of blackheads.

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