PracticalDermatology

Along with general aging-related changes in skin appearance and texture, women experience dermatologic changes throughout the lifespan that are closely tied to the hormonal changes of each reproductive stage and beyond. These ever-shifting fluctuations warrant a highly personalized approach to address the specific skincare needs of women at every age.

Whether the challenges are androgens sparking heightened sebum production, pregnancy producing a radiant glow with alterations in skin pigmentation, or perimenopause/menopause causing skin thinning and reduced elasticity due to declining estrogen, a comprehensive approach to women’s skin care is warranted.

“The dynamic influence of hormones on women’s skin at different life stages is a fascinating journey to explore,” said Hope Mitchell, MD, founder and CEO at Mitchell Dermatology in Perrysburg and Fremont, OH, in an interview with Practical Dermatology. “Understanding and addressing these nuanced shifts empower us to provide tailored care, ensuring that our patients traverse each life stage with skin health and confidence.”

According to Mary Lupo, MD, owner of Lupo Center for Aesthetic and General Dermatology and adjunct professor of dermatology at Tulane University School of Medicine in New Orleans, LA, the main contributors to hormonal skin changes are cortisol, estrogen, progesterone, DHEA, and testosterone. Increased testosterone and DHEA in women, which can result from polycystic ovarian syndrome or excess testosterone in hormone replacement therapy (HRT) after menopause, can cause hirsutism, acne, and androgenetic alopecia.^1,2

“Cortisol is the stress hormone that can affect patients at any age – it causes a change in the oil balance of our skin and cellular turnover and that can lead to acne,” Dr. Lupo told Practical Dermatology. “In general, estrogen makes skin more supple and does not cause acne, while progesterone, when in excess relative to estrogen, can cause acne pre-menopause.”

Hormonal Effects of Menstruation and Menopause

Hormonal fluctuations across each stage of the menstrual cycle can impact skin and scalp health, and the extent of these effects varies across patients.³

“During the luteal phase (from ovulation to menstruation) less estrogen is produced, and progesterone increases the activity of the sebaceous glands,” Elizabeth Houshmand, MD, owner of HoushmandMD Dermatology and Wellness in Dallas, TX, told Practical Dermatology. “The higher levels of progesterone are responsible for oilier skin and acne on the chin and jawline, especially during the premenstrual days.”

In the days before menstruation begins, the scalp becomes more sensitive and produces more sebum. During the menstruation phase, both estrogen and progesterone levels decrease, and skin can become drier, less oily, and more sensitive. During perimenopause (the transition to menopause which usually occurs by the mid-40s but can also occur in the mid-to-late 30s), periods become irregular and lighter as estrogen levels decline. At this point, patients often start to experience skin manifestations of menopause, including erythema, acne, the appearance or acceleration of inflammatory skin disorders, an increase in pore size and fine lines, and moisture imbalances.^2,4

Estrogen receptor expression has been shown to be reduced following menopause as estrogen levels continue to decrease, resulting in additional cutaneous changes.⁵ At this stage, patients may notice changes such as easy bruising and delayed healing due skin thinning; evidence suggests that skin thickness decreases by 1.13% per postmenopausal year and that collagen decreases by up to 30% during the first 5 years of menopause and 2% per year thereafter.^6,7

“Interestingly, this decrease in skin collagen content parallels the reduction in bone mass seen in post-menopausal women,” Dr. Mitchell noted.6 “Furthermore, estrogen accelerates wound healing by promoting the repair of damaged epithelial cells and reducing local inflammation, so perimenopausal and menopausal women may experience delays in wound healing and the appearance of unwanted and perceived unattractive scars.”

Other skin changes during menopause may include rough textured skin due to reduced cellular turnover, decreased firmness and elasticity, dry skin, wrinkles, prominence of nasolabial folds, increased skin sensitivity, facial hair, and hyperpigmentation, and an increased risk for skin cancer.⁴

“I think it is important to recognize and share and normalize these findings, so patients know they are not alone,” Dr. Houshmand added.

Women’s Skin Care Across the Age Groups

Dr. Houshmand noted the importance of customizing skincare recommendations to each patient’s skin type, age, and stage of life, and she emphasized that skin care is just one component of optimizing skin health.

“There are several universal lifestyle recommendations – like eating a healthy diet, sleeping well, and avoiding alcohol and smoking – which help support skin health at any age,” she said, noting that each of these factors can have interactive effects that influence skin health throughout the lifespan. She also highlighted research indicating high glycemic index diets may affect hormones and skin, stress levels, and sleep quality.^8,9 However, further randomized controlled trials are needed to clarify these effects.

“It is also critical to conduct an appropriate physical exam and bloodwork to monitor levels of thyroid hormones, vitamin D3, and iron,” Dr. Houshmand said. “I can’t stress enough that skin and hair health is entirely dependent on one’s overall health and wellness.”

According to Dr. Lupo, providers should be sure to ask about issues that may indicate hormonal origins of skin problems: For example, does acne flare at a certain point in their period? Are there other issues like glucose intolerance? Is there a history of estrogen-sensitive breast cancer?

“We look for signs of hormonal imbalance like facial hair and scalp hair loss” to further inform the patient’s treatment plan.

“It is always important to protect the lipid skin barrier with gentle cleansing, avoid harsh scrubs, and remember that dehydration from water loss can cause inflammation and an irritant rash,” Dr. Lupo noted. For teens and young adults, oil-free hydrators tend to be the optimal fit, while aging skin warrants more emollient moisturizers.

Women’s Skin Care Needs at Each Hormonal Stage

Teen Years: In the teen years, patients typically need non-comedogenic cleansers that effectively manage excess oil without causing further irritation.

“Introduce topical treatments containing salicylic acid or benzoyl peroxide to target acne at its source, educate teens on the importance of consistent sun protection since certain acne medications can increase UV sensitivity, and stress the value of establishing a simple yet effective and consistent skincare routine early on,” Dr. Mitchell advised.

Menstrual Cycle: Skincare needs may vary across the different stages of the menstrual cycle, which “we usually don’t take into account when applying the same product throughout the whole month,” Dr. Houshmand said. During the luteal phase, she recommends using a cleanser with ingredients like salicylic acid, glycolic acid, or benzoyl peroxide to help control excess sebum and keep skin as clear as possible, as well as thermal spring water and hyaluronic acid to improve skin hydration.

“During the menstruation phase, I recommend more gentle hydrating cleansers without actives using mild, non-irritant products with ingredients such as thermal water, calendula, centella asiatica, and probiotic topicals, which are all gentle and soothing for the skin,” she added.

Pregnancy: In pregnancy, expectant mothers often experience a range of hormonal changes that impact the skin. “For these patients, simplicity is key,” Dr. Mitchell stated. She suggests that providers recommend pregnancy-safe skincare products that address pigmentation concerns with ingredients such as glycolic acid and vitamin C, sunscreens with physical blockers to counter the increased risk of melasma during pregnancy, and hydrating moisturizers to accommodate the skin’s changing needs and maintain elasticity.¹⁰

Perimenopause and Menopause: To optimize women’s skin care during perimenopause and menopause, understanding estrogen’s role in skin health is essential.6 “Estrogen receptors in skin allow estrogen to bring moisture into the skin by stimulating hyaluronic acid production; promote wound healing; and stimulate fibroblasts to produce collagen, helping to preserve thickness and elasticity of the skin,” according to Dr. Mitchell.

“Because hormonal shifts associated with perimenopause and menopause bring about changes such as dryness, skin thinning, and reduced elasticity, providers should prioritize hydration by recommending products containing hyaluronic acid and ceramides and incorporating retinoids into the skincare routine to stimulate collagen production and counteract the effects of thinning skin,” she suggested.

Dr. Mitchell also talks to her patients about topical estrogen and HRT and refers them to providers with expertise in those areas when appropriate.¹¹ To further address collagen loss, she recommends adding vitamin C (a cofactor in collagen production) to the skin care regimen as well.

“Antioxidant-rich formulations can also play a role in minimizing oxidative stress and supporting overall skin health,” she said. Additionally, she urged practitioners to reinforce the importance of sun protection to patients in perimenopause or menopause, as aging skin becomes more susceptible to environmental damage and discoloration.

“In essence, tailoring skincare recommendations to the specific concerns and changes associated with each life stage ensures that patients receive personalized care, addressing not only immediate dermatological needs but also fostering long-term skin health,” she added.

Improvements in Research Needed

Dr. Mitchell highlighted the ongoing need for targeted, comprehensive research to elucidate the nuances of women’s skin health across the life stages and diverse demographics.

“Fostering an inclusive approach to skincare research that considers the diversity of all patients is imperative for ensuring equitable and effective care for all women,” she emphasized. “Continued efforts to bridge the gap in dermatological research, focusing on women-specific concerns like hormonal fluctuations, will enable us to refine treatment strategies and develop innovative solutions.”

Among other remaining research gaps in this area, Dr. Lupo cited the need for research to explore the development of safe contraception methods that do not exacerbate acne like many currently available methods.

“Hormone-based intrauterine devices, for example, are notorious for triggering acne because the progesterone is too high for many patients,” she said.

Additionally, Dr. Mitchell said there is a need for studies investigating the impact of environmental factors such as pollution and climate variations on women’s skin, as well as the influence of stress and mental health on skin conditions, to provide valuable insights for tailored skincare recommendations and a more holistic approach to patient care.

“As clinicians and researchers, our commitment to advancing knowledge in these areas will undoubtedly elevate the standard of care we provide to our female patients throughout their lifespans,” she said. –by Tori Rodriguez

Disclosures
Each of the experts interviewed for this article reported no relevant financial disclosures.

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