Everything you need to know about adult acne

Like many people, I had acne as a teen—small pimples that dotted my nose like freckles. But as I’ve grown older, my blemishes have changed too; they’ve become bigger and relocated to my chin. They also seem to flare with increased stress. I’ve tried a long list of treatments, but the most effective has been one not even prescribed for my acne: birth control pills. When I’m on the Pill, my skin is clear. When I go off it (like I did in my 30s to get pregnant), the breakouts start up again. This pattern is how I came to understand that these flare-ups must be connected to my hormones.

I’m not alone. Studies have shown that more than half of women 25 and older suffer from hormone-induced breakouts, and up to 85 per cent say they get worse in the days before their periods. And we don’t get a reprieve at the end of menstruation either, as menopausal hormone changes can trigger acne too.

The primary culprit for these grown-up blemishes? DHT, the active form of testosterone. This androgen hormone is the one that “tells oil glands to make pore-clogging sebum,” explains dermatologist Joshua Zeichner, associate professor of dermatology at Mount Sinai Hospital in Manhattan. When women produce less estrogen before their periods—or as a result of menopause—DHT gains a disproportionate influence on the skin and can cause breakouts, explains David A. Ehrmann, an endocrinologist at UChicago Medicine.

As I’ve discovered, these adult hormonal breakouts tend to look different than the teenage variety. Rather than a smattering of pimples in the T zone, grown-up breakouts often “appear as red, angry pimples on the lower third of the face,” says Zeichner, who explains that the oil glands in that area may be more susceptible to DHT.

In addition, more women seem to be struggling with hormonal breakouts than in generations past. “When I started my practice 11 years ago, my acne patients were mainly teenagers or in their 20s,” says Naana Boakye, a dermatologist practising in New Jersey and author of Inside Out Beauty. “Now I’m seeing acne patients in their late 30s, 40s, and 50s.”

One reason for this spike may simply be that millennial and Gen X women are more apt to seek professional help. Another may be that many women in these two generations have been on birth control pills for the better part of their adult years, and coming off them to get pregnant—or because they’re menopausal—can suddenly give DHT newfound control.

A third possible cause for the increase is stress, which can trigger hormonal imbalance and exacerbate inflammatory skin conditions like acne. And we are more stressed than ever, especially because the past two years have felt like crisis after crisis.

The good news is, this uptick in adult acne has garnered greater demand for treatments—and the market is responding with lots of options. Topical prescription creams that bind to androgen hormone receptors in the oil glands, inhibiting their communication with pimple-causing DHT, have been well received. Similarly,  spironolactone, an oral prescription medication, blocks androgen receptors, reducing the influence of DHT on the skin. 

There is also, of course, the Pill, which, as I found, keeps skin clearer by maintaining higher estrogen levels. And most doctors do still endorse the use of tried-and-true topical acne fighters like salicylic acid, benzoyl peroxide, sulfur, and retinoids to alleviate hormonal breakouts—as long as the formulas are appropriate for grown-up skin.

“We don’t want to just kill the pimple; we want the products to work for an adult woman’s needs,” says Zeichner. That means seeking out formulas that deliver ingredients either in a slower, controlled-release system or as microparticles that go straight to big, angry pimples (rather than sitting on and irritating skin). Looking for products that contain these actives in lower doses is also a smart strategy, says Zeichner, who adds that studies have shown that 2.5 per cent benzoyl peroxide is as effective as higher concentrations.

Finally, Boakye believes that breakouts that begin internally can be controlled with healthier lifestyle choices too. “In my practice, we emphasise the importance of a plant-forward, low-glycemic diet, exercise, and sleep to fight acne,” she says. For her hormonal-acne patients, Boakye recommends lowering sugar intake and increasing exercise. High-glycemic foods like sugar, she explains, can increase a hormone that in turn increases androgens like DHT. And regular cardio exercise has been shown to reduce testosterone levels in women. For best results, aim for 2.5 hours of moderate or 90 minutes of intense exercise each week.