Treatment of Hormonal Acne

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The treatment of hormonal acne

What can be done for female adult acne? The good news is that plenty can be done!

Adult acne will usually respond to acne treatments used for teenage acne including medicated creams, gels and oral antibiotics.

If you have more severe acne, if your acne fails to respond to topical therapy or if you can't tolerate topical treatment, there are other alternatives. The combined oral contraceptive pill, plus or minus anti-androgens such as spironolactone, may help achieve longer-term acne control.

Checking hormone levels

Most adult females with acne have relatively normal levels of androgens (testosterone) and only about 10 per cent will have abnormally high levels of androgens - including females with polycystic ovarian syndrome.

The regularity of your menstrual cycle is one of the best ways to assess how well regulated your hormones are. If your period is as regular as clockwork (28-day cycle), an abnormality in your hormone levels is unlikely.

You should consider checking with your doctor about possible hormonal abnormalities if you have acne accompanied by any of the following:

Abnormal menstrual cycle, such as a significant variation in the time to your period or in its duration


Extremely oily skin, excessive facial or body hair growth, or thinning or loss of scalp hair


Failure of your acne to improve well with treatment


Darkening of skin on the side of your neck and armpits or


A male rather than female pattern of fat distribution - in other words, more fat on your torso or belly rather than on your hips


Obesity and insulin resistance

A useful treatment for females with hormonal acne and insulin resistance or high insulin levels is a low dose of metformin, a drug normally used for diabetes. This treatment has many advantages. It not only reduces androgen levels and improves acne but also normalises insulin levels and helps with weight loss and the prevention of diabetes.

Patience is required because the beneficial effects of metformin take time. If used on its own, it can take three to six months before an improvement in acne is seen. This improvement is likely to continue for more than a year. Moreover, metformin's beneficial effects on weight and metabolism, plus its ability to delay or prevent diseases such as diabetes and bowel cancer, can be life-long.

For rapid acne control, metformin is best used in combination with other acne treatments such as topical creams and lotions during the first three to six months.

'Low androgenic' combined oral contraceptive pills (including Loette and Microgynon 20) normally have beneficial skin effects in females with acne. These can include a reduction in the oiliness of skin and pore size (starting after one cycle), fewer pimples less often (this may take three cycles to start but improvements continue for up to six to nine cycles), and a reduction in excessive body hair (after three or more cycles). These beneficial effects are often lost or greatly reduced when taken by females who are overweight or obese.

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Combined oral contraceptives

The heartening news is that no matter how mild or severe your acne, the combined oral contraceptive can often be effective.

The combined oral contraceptive regulates the menstrual cycle and has direct and indirect anti-androgenic actions, which can help in controlling acne.

As with any medication, combined oral contraceptives have varying benefits and side effects.

For more severe and difficult to control acne, combined oral contraceptives containing the progesterone cyproterone acetate have the best proven benefits in female hormonal acne.

However, it is important to know they carry a slightly higher risk of some side effects including venous thrombosis (e.g. deep vein thrombosis) and embolism (e.g. blood clots that travel through the veins and through the heart).

The oral contraceptive pill also has a number of medical benefits such as reducing the risk of uterine or endometrial cancers.

If you have mild to moderate acne, you may want to opt for other combined oral contraceptives which also have proven benefits in hormonal acne but have a low risk profile.

Combined oral contraceptives (Loette, Microgynon 20ED) that contain low doses of oestrogen and levonorgestrel (100mg) have a low side effect risk, including a lesser risk of venous thrombosis. However, breakthrough bleeding is a more frequent side effect of such lower dose pills.

Common side effects of combined oral contraceptives include mood changes, nausea, weight gain, menstrual spotting and breast tenderness. If you smoke or have high blood pressure, you increase your risk of important side effects such as blood clots and strokes.

Combined oral contraceptives have a slow onset of action so your doctor may suggest a combination of a combined oral contraceptive and other acne therapies, such as a topical retinoid, during the first 3-6 months to improve acne control.

Other combined oral contraceptive pills with proven benefits include those containing Cyproterone acetate (Brenda 35ED, Diane 35ED, Estelle 35ED, Juliet 35ED). Those containing drospirenone (Yasmin), desorgestrel (Marvelon) and gestodene (Femoden and Minulet) are also of proven benefit.

It is generally wise to steer clear of progesterone-only contraceptive pills - also known as minipills - as they are likely to worsen acne. Similarly, contraceptive implants can make acne worse.

Spironolactone

An advantage of spironolactone is that you are likely to see benefits sooner than with a combined oral contraceptive.

You may notice a reduction in skin oils after the first month. By the end of the second month, your acne should begin to improve and continue to do so for another few months.

There can be side effects such as irregular or heavy periods and breast tenderness but these are eased or prevented if you also take a combined oral contraceptive. Spironolactone is taken daily at doses of 50-100mg for acne.