November 8th 2019
How to deal with hormonal skin, whatever your life stage
April 8th 2018 / 0 comment
From puberty to menopause via pregnancy and periods, our skin always gives the hormonal game away. Consultant Dermatologist Dr Anjali Mahto explains how to manage flare-ups at any age
From the moment we hit puberty, our skin is at the mercy of our hormones. It’s the sex hormones, testosterone, oestrogen and to a lesser extent progesterone that make their presence felt in a pretty predictable way on our faces and bodies. Skin changes, especially acne, are nature’s favourite way of telling you you’re hormonal, and can have a huge impact on the way we feel.
No one knows this more than Consultant Dermatologist Dr Anjali Mahto, author of the Skincare Bible, who suffered from terrible acne which began in puberty and lasted two decades. "It’s the reason I became a dermatologist," she says.
She sees women in her clinics every day with hormonal skin conditions which can be highly distressing from the pregnancy pigmentation melasma, which can look like a moustache, to volcanic period spots and bright red menopausal rosacea.
Here, in an extract from The Skincare Bible, Dr Mahto gives you the hormonal skin lowdown and the best ways to treat it.
Consultant Dermatologist Dr Anjali Mahto
PUBERTY AND PERIODS
Hormonal havoc: acne
By far the commonest skin problem in puberty is acne. Androgen levels begin to rise in both boys and girls, acting on the skin’s oil or sebaceous glands to make them bigger and start producing more sebum. Around 85 per cent of teenagers will suffer from acne and it’s more common in boys. It can strike any area, where there is a high density of oil-producing glands such as the face, back and chest.
Teenagers with acne should be offered support as it is recognised that the condition can lead to altered body image and low self- esteem. There are good over-the-counter and prescription medications. Having myself suffered between the ages of 12 and 17 before finally receiving treatment that worked, starting university with clear skin was life-changing. I wish I’d received help sooner and been more open about how my skin made me feel.
Why do we get spots around our period?
Female hormones reach their lowest levels shortly before the onset of bleeding and so the level of testosterone becomes is relatively higher. This causes changes in the skin’s complexion that bring about acne. Fundamentally, all acne is hormonal, but in adult women it has often been reported – anecdotally – that it occurs more commonly on the lower half of the face, jawline, chin and neck. This is something I have noted in my clinics; however, the scientific evidence is inconclusive.
On a similar note, some observations have suggested that acne type also varies by age in women, with adults usually suffering from tender, inflammatory (cystic) spots. They also seem to have fewer numbers of blackheads or whiteheads compared to teenagers. Again, however, not all scientific studies confirmed this.
Hormonal havoc: stretch marks, rashes, pigmentation, itching, acne.
Acne in pregnancy affects nearly 50 per cent of women. Increased levels of progesterone, usually in the first trimester, are to blame. Those with a previous history of acne, are more likely to be affected but often things improve as pregnancy progresses. Managing it can be tricky, as most standard treatments should be avoided. It is always best to try and get your acne under control before pregnancy, but obviously, that is often easier said than done. Over-the-counter preparations using glycolic acid can be helpful. Topical prescription agents such as azelaic acid and oral antibiotics like erythromycin, cephalexin and azithromycin are considered safe. For the odd large spot, steroid injections directly into the spot can be considered. Light therapies are also likely to be safe.
Stretch marks develop not just due to the simple stretching of skin, but also because of pregnancy hormones. These cause a softening of the pelvic ligaments to allow for the delivery of the baby, but at the same time also soften skin fibres, which makes them more susceptible to stretching and tearing.
It’s often said that a younger age at pregnancy, family history of stretch marks and pregnancy weight gain are risk factors for stretch marks but these links have not been consistently reproducible in scientific studies.
Women can end up spending a small fortune during pregnancy on skincare. Sadly, the scientific evidence-based answer suggests that topical treatments will not prevent their development.
It is also not clear whether it is simply the action of massaging the skin (when rubbing the product in) that may help, more than the actual product. The best advice is to keep your skin well-moisturised but not fall into the trap of thinking that some magic (and no doubt expensive) cream will prevent stretch marks.
While treatments are unlikely to get rid of them entirely, appearance can be improved with retinoid-based creams, microneedling, radiofrequency devices and laser therapies.
Melasma or ‘pregnancy mask’
This skin discolouration can develop during pregnancy. Also called chloasma, it often affects the forehead, cheeks and upper lip. The upper lip area, in particular, can create much anxiety, as women feel it gives them the appearance of having a moustache. Hormonal changes that are thought to be responsible, in particular, fluctuations in oestrogen and melanocyte [pigment cell]-stimulating hormone (MSH). It can fade after delivery but can return during subsequent pregnancies. During pregnancy, wear sunscreen as sunlight can drive the melasma process. Most other recommended treatments should be avoided until the baby’s birth.
Pregnancy hormones, in particular, MSH, are thought to play a role in skin darkening of the areolas and nipples. Linear nigra, often known as the pregnancy line, can also develop. It gradually fades after pregnancy.
Temporary hair loss
Telogen effluvium is a temporary loss of hair from the scalp and is very common in the first three months after delivery. Skin and hair are closely linked and as this condition affects so many women (40 per cent) after pregnancy, it deserves a specific call-out. During pregnancy, higher levels of oestrogen and progesterone keep hairs in their growth phase (‘anagen’) and many women note their hair is thicker. After delivery, hormone levels change rapidly to normal and this ‘shock’ is thought to switch hairs from the growth to the shedding phase (‘telogen’), resulting in hair falling out. The good news is that, like most changes associated with pregnancy, this is temporary and settles over six to 12 months.
Itching without a rash
This is extremely common and is due to increased oestrogen levels. Stretching of the skin, particularly in the latter half of pregnancy, can also cause itching. Taking cool baths and showers can help. Avoid harsh soaps and detergents on the skin and use mild, fragrance-free cleansers. Keep the skin well hydrated and moisturized, and avoid getting too hot. An uncommon condition called cholestatic pruritus can cause intractable itching and is associated with raised bile salts and liver enzymes. If your itching is unbearable or stopping you from sleeping, discuss this with your GP or antenatal team as you may require a blood test to look for this condition.
Itchy hives or bumps known as PUPPP
A rash which can look like a mixture of hives and red bumps or patches on the skin that often start on the abdomen within stretch marks is known as pruritic urticated papules and plaques of pregnancy (PUPPP). It’s is a bit of a mouthful but is sometimes known by the slightly easier (but not much!) term ‘polymorphic eruption of pregnancy’. It is usually extremely itchy and most often affects a first pregnancy. It can be associated with rapid or extreme weight gain or multiple pregnancies such as twins.
PUPPP usually develops in the third trimester and settles a few weeks after delivery and while the condition is uncomfortable and the exact cause unknown, it will not harm the baby. Treatment requires emollient washes, antihistamines and prescription steroid creams or ointments to reduce inflammation.
In addition, pemphigoid gestationis is a rare condition that may be aggravated by raised oestrogen levels in pregnancy. It is an ‘auto-immune’ blistering disease – the mother’s immune system goes into a state of overdrive and starts producing antibodies which attack her own skin. Early input from a dermatologist is necessary as there is an increased risk of premature delivery. It’s treated with steroid creams/tablets plus antihistamines.
Hormonal havoc: acne, dryness, rosacea, skin thinning, loss of collagen.
Women are living longer and average female life expectancy in the UK is now nearly 83. This means there are far more women suffering with skin issues associated with the menopause for a much longer period.
As oestrogen levels fall from the mid-forties onwards (perimenopause), androgen levels become proportionately more dominant, which can drive oil gland activity and cause acne. Women may also start to notice dryness and red patches.
Once women reach the menopause the body goes into a relatively oestrogen-deficient state. Lack of oestrogen is the most common cause of post-menopausal skin issues. Common problems include:
A reduction in skin metabolism causes skin to function less effectively as a barrier resulting in increased water loss. This will leave the skin vulnerable to the elements. Alongside this, there is reduced oil and lipid production in the skin. These factors acting together promote dryness, so a rich, creamy moisturiser is key.
Post-menopause, women’s skin thickness decreases by 1.13 per cent per year due to falling collagen levels. In the first five years after menopause, collagen content is thought to decrease by 30 per cent. Collagen is needed for the skin’s support structure. Hormones and cumulative sun damage together promote wrinkles and sagging. Specific creams, injectable agents and laser treatments can counter these age-associated changes.
Increased skin fragility
As the skin thins with age, there is also loss of fat and connective tissue support around blood vessels which makes them more susceptible to injury. Oestrogen has a protective role in wound healing and reduced levels of this after menopause mean that the skin
Redness can occur due to hot flushes associated with the menopause. The skin condition rosacea can also develop leading to redness and sensitivity.
Supplements and medication
Oestrogen is what keeps our hair and skin youthful. Hormone replacement therapy (HRT) may help maintain skin elasticity, moisture and thickness. However, not everyone is suitable for, or wants to take, HRT, and this decision needs to be made after discussion with your doctor. Phyto-oestrogens (from plants) have gained popularity and a very similar chemical structure to oestrogen. They can be found in dietary supplements or foods such as soy, yam, tofu and linseed. There is a lack of robust clinical trials to show whether they cause a significant increase in collagen production or what their long-term safety profile looks like.
Use a retinoid-based product at night to boost collagen production. An antioxidant serum will limit potential damage to already fragile skin. Many women will need to moisturise with rich creams on a daily basis due to dryness.
Dr Anjali Mahto MBBCh BSc MRCP (Derm) is a UK-trained consultant dermatologist who has worked in both the NHS and private clinics. She began her career as a junior doctor before moving into dermatology after suffering acne for over a decade. Follow her on Twitter and Instagram.
An edited extract from The Skincare Bible - Your No-Nonsense Guide to Having Great Skin by Dr Anjali Mahto published by Penguin Life £14.99. Buy your copy here.