madman
Super Moderator
Abstract: Although acne is a disease predominant in adolescence, it is being increasingly observed in adult life, including the menopausal period. The etiology of menopausal acne is multifactorial, with hormonal imbalance being the major culprit. There is a relative increase of androgens in the menopausal female that leads to clinical hyperandrogenism manifesting as acne, hirsutism and androgenetic alopecia. Other endocrine disorders including thyroid abnormalities, hyperprolactinemia and insulin resistance also play a role. Genetics, stress, dietary changes, lack of sleep and exercise and other lifestyle changes are implicated as trigger factors. Most menopausal women with isolated few acne lesions have normoandrogenic serum levels and do not require extensive investigations. However, baseline investigations including total testosterone are useful. Patients must also be evaluated for associated comorbidities such as obesity, diabetes, hypertension and dyslipidemia. A detailed history can help to exclude polycystic ovarian syndrome, late-onset congenital adrenal hyperplasia or medications as a cause of acne. The evaluation of menopausal acne and the approach to treatment depend on the severity of acne and associated features. In patients with mild acne without virilization, prolonged topical therapy is the mainstay of treatment. Though combined oral contraceptives are effective, they are relatively contraindicated in the postmenopausal period. Spironolactone is the first choice of therapy in the subset of patients that require oral anti-androgen therapy. Procedural treatment can be useful as it can also help in the treatment of associated acne scars and concomitant skin aging. It is also important to focus on lifestyle changes such as reducing stress, controlling obesity, having a healthy diet, exercise and proper skin care routine to reduce acne. The focus of this article is on the clinical presentation and management challenges of menopausal acne, which represents a special subtype of acne.
Conclusion
There is a plethora of skin changes in the menopausal period and now surprisingly acne is one of them, which was once considered as a disease of adolescence. The majority of adult and menopausal women with acne have persistent or relapsing acne from adolescence. Hormonal imbalance with relative hyperandrogenism is the major factor, while stress, genetic factors, cosmetics, dietary and lifestyle changes all play a role. Treatment is a challenge in clinical practice as most anti-acne products are designed for adolescent oily skins, with fewer products for sensitive mature skins in this age group. Prolonged topical therapy with judicious use of systemic therapy is the treatment of choice as acne tends to be more resistant, deep seated and prolonged in this subset. The use of a topical antibiotic as monotherapy should be avoided and combination therapy with benzoyl peroxide, topical retinoids, azelaic acid or salicylic acid is recommended as first-line treatment according to the patient’s skin and tolerability, including an oral agent if necessary. Spironolactone is the treatment of choice for patients requiring systemic antiandrogen therapy. The subset of patients who will require combined contraceptives should be selected with care to reduce the incidence of side effects. Procedural treatment can play a bigger role as it can also help in the treatment of acne scars and concomitant skin aging. However, detailed studies specifically evaluating prevalence, etiopathogenesis, presentation and management of this subset of women with menopausal acne are required to increase the evidence on which future treatment recommendations can be based.
Conclusion
There is a plethora of skin changes in the menopausal period and now surprisingly acne is one of them, which was once considered as a disease of adolescence. The majority of adult and menopausal women with acne have persistent or relapsing acne from adolescence. Hormonal imbalance with relative hyperandrogenism is the major factor, while stress, genetic factors, cosmetics, dietary and lifestyle changes all play a role. Treatment is a challenge in clinical practice as most anti-acne products are designed for adolescent oily skins, with fewer products for sensitive mature skins in this age group. Prolonged topical therapy with judicious use of systemic therapy is the treatment of choice as acne tends to be more resistant, deep seated and prolonged in this subset. The use of a topical antibiotic as monotherapy should be avoided and combination therapy with benzoyl peroxide, topical retinoids, azelaic acid or salicylic acid is recommended as first-line treatment according to the patient’s skin and tolerability, including an oral agent if necessary. Spironolactone is the treatment of choice for patients requiring systemic antiandrogen therapy. The subset of patients who will require combined contraceptives should be selected with care to reduce the incidence of side effects. Procedural treatment can play a bigger role as it can also help in the treatment of acne scars and concomitant skin aging. However, detailed studies specifically evaluating prevalence, etiopathogenesis, presentation and management of this subset of women with menopausal acne are required to increase the evidence on which future treatment recommendations can be based.
