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Dermatologist guide to Acne treatments for women, including Hormonal Acne

Updated: Oct 28, 2022



 

Disclaimer: The information in this article is not meant as specific individual medical advice. Please consult your dermatologist or other medical professional about your skin or medical condition.

 

Acne affects as many as 12% of all adult women.


When acne is persistent, it can cause permanent scarring and poor self-esteem.


Some women experience symptoms of depression and anxiety because of having severe acne.



What type of acne do you have?


How acne is treated depends large on the type of acne she has.


As you know, acne is characterized by having blackheads, whiteheads and red painful pimples, usually on the face and sometimes over the upper body.


Some women mainly have blackheads and whiteheads (comedones). This type of acne is called comedonal acne.


Other women have multiple red zits, pus bumps or pimples (inflammatory lesions). This type of acne is called inflammatory acne.


Many women experience worsening or breaking out of acne lesions monthly, or around their menstrual cycle. This type of break-outs are related to her body’s androgen (testosterone, DHEA) levels, and is commonly termed hormonal acne.


When acne is severe, a woman can have multiple large painful nodules and cysts on the face, or upper body. Sometimes these large acne lesions can cause thick and raised scars, called keloid scars. This type of severe acne is called nodulocystic acne.


In reality, many women experience a mix of these different types of acne, and treatment is selected accordingly.



What causes acne?


To understand how the different treatment works, you first want to understand what causes acne.


Acne is caused by plugging of pores by thickening of the skin, debris and oil production. This causes blackheads and whiteheads (comedones).


In addition, a bacterium, called Proprioniacterium acnes (P acne), grows in acne lesions and causes inflammation. This causes red bumps, zits, pimples or pus bumps (inflammatory lesions).


There are also genetic factors that determines the number and size of the acne lesions, the amount of inflammation that happens and how our body makes androgens.


There is increasing evidence that suggest that food rich in carbohydrates (high glycemic index diets) may be associated with acne. In some small studies, people who follow a diet with low carbohydrate load experienced improvement in acne severity.


There are also some studies that show that consuming cow’s milk, especially skim milk, may increase the risk of developing acne.


Lastly, certain contraceptives, hormonal treatments and replacements that contain testosterone and progesterone can also cause acne lesions to form.



Treatment for blackheads and whiteheads


The two main treatments for blackheads and whiteheads in comedonal acne are:

  • Topical retinoids

  • Topical salicylic acid


Topical retinoids


Topical retinoids are the first-line treatment for blackheads and whiteheads (comedones) in comedonal acne.


Topical retinoids are derived from vitamin A.


Retinoids work by breaking up blackheads and whiteheads and reduce plugging of pores. They also reduce inflammation.


There are three main topical retinoids available - tretinoin (Retin-A®), adapalene (Differin®) and tazarotene (Tazorac®).


Topical adapalene 0.1% is sold over-the-counter in the United States.


The other two retinoids, as well as the higher strength adapalene 0.3%, are only available as a prescription.


Most retinoid products, especially tretinoin, are best applied in the evening. This is because sun exposure can sometimes deactivate the active ingredient.


Retinoids can cause dryness, peeling, irritation and redness of the skin. These effects increase with the strength of the treatment. If this happen, using a lower concentration option or applying the treatment less frequency can help.


Retinoids can also increase sun sensitivity, so it is important to take sun protective actions to reduce the risk of sunburn.


Retinoids are not recommended to be used during pregnancy because of the risk of possibly causing birth defects.


Salicylic acid


Salicylic acid can be helpful for reducing small whiteheads and blackheads. Hence, it is useful for women with mild comedonal acne.


This treatment is available over the counter in strengths between 0.5% to 2%. Salicylic acid is frequently included in acne cleansers.


Dryness, redness or skin peeling may occur when using salicylic acid. This is especially so if you are already using another topical treatment, like a retinoid or benzoyl peroxide, which can also cause skin dryness or irritation.



Treatment for red zits (or pimples) in Inflammatory Acne


The type of treatment used for inflammatory acne depends largely on how severe the acne is.


When inflammation is mild and there are fewer zits, topical treatments are usually used first.


The most commonly used topical treatments for mild inflammatory acne are:

o Benzoyl peroxide

o Topical antibiotics, such as clindamycin and erythromycin

o Azelaic acid

o Topical dapsone



Benzoyl peroxide


Benzoyl peroxide is an antibacterial treatment that kills the P acnes bacteria. [1] By doing this, it reduces inflammation.


In the United States, benzoyl peroxide is sold over-the-counter as topical wash, foam, cream and gel. The strengths available range from 2.5% to 10%.


These treatments are usually meant to be used about once a day to the areas where there are inflammatory lesions.


Improvement can normally be seen by a month of use, with maximum improvement around 2 to 3 months of use.


Continued use of benzoyl peroxide is usually required to maintain the improvement.


Benzoyl peroxide can sometimes cause drying of the skin and skin irritation. The chance for skin irritation is higher at higher concentrations. If you have sensitive skin, you may wish to use the lower concentration (2.5%) wash-off products.


It can also cause staining and bleaching of clothing.


Benzoyl peroxide is also effective in prevention of bacterial resistance and is recommend to be used in combination with topical antibiotics, which we will discuss next.



Topical antibiotics


Topical antibiotics reduces inflammation in acne through its anti-bacterial effect on P acnes.


Currently, clindamycin 1% is the preferred topical antibiotic.[2]


This is available as a prescription treatment, in the form of a lotion, gel or solution.


It is rated pregnancy category B, which means it is considered to be safe for use during pregnancy.


There are rare reports of inflammation of the colon (called Clostridium difficile-related colitis) but the risk appears to be low.



Topical erythromycin 2% is an alternative topical antibiotic. It is also available as a cream, gel or lotion, as well as combined with benzoyl peroxide.


This is usually prescribed when a person is not able to tolerate topical clindamycin.



Topical antibiotics are usually applied once or twice a day to the inflammatory lesions.


Topical antibiotics are usually used in combination with benzoyl peroxide to reduce antibiotic resistance.


People allergic or sensitive to topical antibiotics may experience skin irritation.



Azelaic acid


Azelaic acid (Fiancee®) is a naturally occurring dicarboxylic acid found in cereal grains. It has both anti-bacterial and anti-inflammatory effects in acne.[3]


It is also helpful for lightening skin discoloration caused by acne.


Azelaic acid is a mild treatment and usually does not cause skin irritation, and is better tolerated by people with sensitive skin.


Azelaic acid is available only as a prescription, and is usually used about once to twice a day.


This is also rated pregnancy category B and is thought to be safe for use during pregnancy.



Dapsone


Topical dapsone (Aczone®) gel is also helpful for reducing inflammation in acne.[4]


It also appears to be more beneficial to adult women (than men when compared).[5]


Topical dapsone is available only as a prescription treatment. It is usually applied about once a day.


It is not recommended to use both dapsone and benzoyl peroxide at the same time because it can cause brown discoloration of the skin, although this can be washed off.



Oral antibiotics


Oral antibiotics are often used for women who has more severe inflammatory acne or has acne that requires more rapid control.


There are several oral antibiotics that may be prescribed in this situation.


Oral doxycycline and oral minocycline, which belong to the tetracycline class of antibiotics, are considered the first line treatment for more severe acne.


In addition to killing bacteria, these antibiotics have an additional action of decreasing inflammation in acne.


Doxycycline is also available at a sub anti-bacterial dose of 40mg daily.


Doxycycline can cause sun sensitivity and stomach upset.


Minocycline may sometimes cause ringing in the ears, dizziness and discoloration of the skin and teeth.


Rarely, autoimmune symptoms and increased brain pressure may occur with these antibiotics.


Both doxycycline and minocycline should not be used during pregnancy or nursing.



Oral erythromycin can also be used to treat acne, but is used less often due to risk of antibiotic resistance.


Erythromycin is most commonly used when oral doxycycline and minocycline cannot be used, such as during pregnancy.


Erythromycin can cause stomach upset, nausea or diarrhea.



Oral sulfamethoxazole-trimethoprim (Bactrim) is another common antibiotic used when acne does not respond to doxycycline or minocycline.


Bactrim may also cause sun sensitivity and stomach upset. Rarely, severe allergic reaction and decreased blood cell counts may occur.



Oral amoxicillin may also be used to treat acne during pregnancy or when there are no other options available due to side effects or allergies.



Oral antibiotics are usually used in combination with a topical retinoid and benzoyl peroxide.


The use of oral antibiotics is ideally limited to 3 to 4 months. Sometimes these antibiotics are used for longer durations because a patient needs it for acne control.


In addition, oral antibiotics can increase the risk of vaginal yeast infections caused by Candida.



Intralesional steroid injection


Injecting triamcinolone acetonide, a corticosteroid, directly into acne lesions is commonly used to treat individual painful larger inflammatory lesions.[6]


This is usually used to treat up to a few acne lesions at a time.


Rapid reduction in pain and size of the injected lesions can be expected.


Rare side effects including lightening or thinning of the skin around the injection site may occur.



Treatment for Hormonal Acne


Some women experience breakouts or worsening of their acne due to how their body may be producing androgens (testosterone, DHEA).


Some women may have an underlying condition called polycystic ovarian syndrome which can cause raised androgen levels.


In this situation, combined oral contraceptives or spironolactone can be helpful.


These treatments work by decreasing the effect on androgens on the body.


These treatments are typically used for several months, and sometimes years, to control acne.


These treatments should not be used during pregnancy.



Combined oral contraceptives


Combined oral contraceptives, containing both estrogen and progesterone, are effective in treating hormonal acne in women who also desire contraception.


These work by decreasing the production of androgens (like testosterone and DHEA) and their effect on causing acne lesions to form.


In the United States, there are currently 4 oral contraceptives that are approved by the FDA for treatment of acne. These are Orthro Tri-Cyclen®, Estrostep Fe®, Beyaz® and Yaz®.


The improvement in acne may not be appreciated for the first few months of treatment.


There are side effects associated with combined oral contraceptive use that you may want to be aware of.


Combined oral contraceptive use is associated with an increased risk of heart disease, stroke, blood clots and breast cancer.


Hence, contraceptives are not recommended in women who are at risk of developing breast cancer, heart disease, stroke, liver disease or blood clots.


Combined oral contraceptives should be used under the direction of a provider who specializes in women’s health, such as a gynecologist.



Spironolactone


Spironolactone is another prescription medication that is useful for treating women with hormonal acne.[7]


It decreases the production and activity of testosterone, which decreases acne severity and oil (sebum) production in women.


Spironolactone is an overall well tolerated treatment.


Some common side effects are increase urine production because it is a mild diuretic, irregular menstrual cycles, breast tenderness and headache.


It can be used in combination with an oral contraceptive to regulate menses and prevent pregnancy.


Rarely, spironolactone can raise potassium levels in the body (hyperkalemia), usually in people with kidney disease, or taking certain other medications.


Processed foods or supplements rich in potassium is not recommended for use when taking spironolactone.



Treatment of severe Nodulocystic Acne


Oral Isotretinoin


Oral isotretinoin is the main treatment option for women with nodulocystic acne, where large nodules and cysts develops on the face or upper body.


In addition, oral isotretinoin is also used to treat less severe acne that is not responding to other forms of treatment.


Oral isotretinoin is a treatment derived from vitamin A.


It works by decreases oil (sebum) production, reducing inflammation and can also improve scarring.


Oral isotretinoin is usually started at a dose of 0.5mg/kg/day and increased to 1.0mg/kg/day.


The treatment continues until a cumulative dose of target dose has been reached, which usually takes about 6 months for most patients to complete.


This dosing regimen has been to found to be associated with a lower acne relapse rate. [8][9]


Oral isotretinoin is best taken with food to improve its absorption.


The main risk of using oral isotretinoin is that it will cause severe birth defects if consumed during pregnancy


As a result, in the United States, enrollment in iPledge is required by both men and women who take this medication.


iPledge is a program that is mandated by the FDA to decrease fetal exposure to isotretinoin.


iPledge requires all women to abstain from sex or use 2 contraceptive methods during and until 30 days after completing isotretinoin treatment.


In addition, iPledge also requires women to have monthly pregnancy tests starting 30 days before treatment, until 30 days after completing treatment.


Women who take oral isotretinoin can expect to experience severe dryness of their skin, lips and nasal mucosa.


Occasionally, some women may experience joint pain, muscle ache, headache or blurred night vision.


Blood tests are usually performed regularly during the treatment period to monitor for raised cholesterol and fat (triglyceride) levels and raised liver enzymes.


There have been situations where people taking isotretinoin experience delayed wound healing and keloid scar formation. As a result, it is recommended that procedures including dermabrasion or laser treatments are delayed for 6 to 12 months.


Changes in mood, including depression, have been reported in people taking oral isotretinoin. According to the American Academy of Dermatology, acne treatment guidelines, “many studies have shown no evidence of depression from isotretinoin”.


However, given the prevalence of depression and anxiety in the general population, women who are taking isotretinoin should monitor for these symptoms closely, and inform their prescribing provider if they develop.


There are has been various studies to determine if oral isotretinoin use is associated with or causes inflammatory bowel disease such as Crohn’s disease or ulcerative colitis.


The American Academy of Dermatology states that the ‘current evidence is insufficient to provide either an association or causal relationship between isotretinoin use and inflammatory bowel disease.’[10]





I hope you have found this article on the treatment of acne in women helpful for making your medical decisions when you meet your dermatologist.




[1] Fulton Jr., J.E. Farzad-Bakshandeh A. Bradley S. Studies on the mechanism of action to topical benzoyl peroxide and vitamin A acid in acne vulgaris. J Cutan Pathol. 1974; 1: 191-200 [2] Becker L.E. Bergstresser P.R. Whiting D.A. et al. Topical clindamycin therapy for acne vulgaris. A cooperative clinical study. Arch Dermatol. 1981; 117: 482-485 [3] Cunliffe W.J. Holland K.T. Clinical and laboratory studies on treatment with 20% azelaic acid cream for acne. Acta Derm Venereol Suppl (Stockh). 1989; 143: 31-34 [4] Draelos Z.D. Carter E. Maloney J.M. et al. Two randomized studies demonstrate the efficacy and safety of dapsone gel, 5% for the treatment of acne vulgaris. J Am Acad Dermatol. 2007; 56: 439.e1-439.e10 [5] Tanghetti E. Harper J.C. Oefelein M.G. The efficacy and tolerability of dapsone 5% gel in female vs male patients with facial acne vulgaris: gender as a clinically relevant outcome variable. J Drugs Dermatol. 2012; 11: 1417-1421 [6] Levine R.M. Rasmussen J.E. Intralesional corticosteroids in the treatment of nodulocystic acne. Arch Dermatol. 1983; 119: 480-481 [7] Goodfellow A. Alaghband-Zadeh J. Carter G. et al. Oral spironolactone improves acne vulgaris and reduces sebum excretion. Br J Dermatol. 1984; 111: 209-214 [8] Strauss J.S. Rapini R.P. Shalita A.R. et al. Isotretinoin therapy for acne: results of a multicenter dose-response study. J Am Acad Dermatol. 1984; 10: 490-496 [9] Lehucher-Ceyrac D.de La Salmoniere P. Chastang C. Morel P. Predictive factors for failure of isotretinoin treatment in acne patients: results from a cohort of 237 patients. Dermatology. 1999; 198: 278-283 [10] American Academy of Dermatology website. Position statement on isotretinoin. Available at: https://www.aad.org/Forms/Policies/Uploads/PS/PS-Isotretinoin.pdf. Accessed January 6, 2016.

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