Unless you've managed to make it through life with some kind of pimple- and zit-resistant chip the rest of us lack, acne and periods are often inextricably linked.
We know the hormonal changes associated with periods make acne more or less likely, but when? And why? Is getting acne during ovulation a thing, or is it more common just before your period?
It can be hard to know which of the four menstrual phases puts us most at risk for zits and how to hack our self-care and product regimens to nip them in the bud. So we asked five skin experts to break down the four different menstrual cycles, how they effect our hormonally vulnerable complexions, and how to cope.
Keep reading to learn how to track (and treat) acne throughout your menstrual cycle.
How Your Period Affects Your Skin
You already know your menstrual cycle influences your skin to some extent, but did you know your cycle puts your hormone levels in flux on on a day-to-day basis? Believe it, says Hadley King, MD, FAAD, a New York City–based dermatologist.
"The average menstrual cycle is 28 days and each of these days is different hormonally," King says. But overall, she says, "estrogen is the dominant hormone during the first half of the cycle and progesterone is the dominant hormone during the second half."
Estrogen actually improves acne and is responsible for making skin look generally fabulous, King explains. Progesterone, on the other hand, worsens acne by increasing your skin's output of sebum, or oil. Testosterone is another hormone that jacks up sebum production; when levels of both progesterone and testosterone are high, these are ideal conditions for hormonal acne to explode.
How to Track Changes During Your Menstrual Cycle
To find out whether hormones are the culprit in your breakouts, it's important to break down the menstrual cycle. Try noting when, exactly, your breakouts tend to occur relative to the phases of your 28-day cycle.
"If you notice that your acne flares correlate with your cycle, then hormonal treatment options are likely to be helpful," King suggests.
Menstruation is technically considered the "first" phase of our cycles from a hormonal perspective. But Jennifer Herrmann, MD, FAAD, a dermatologist who practices in Beverly Hills, California, says it’s easiest to begin decoding breakouts starting with the follicular phase. During this phase, which lasts seven to 10 days, estrogen is the hormone in charge, preparing the lining of your uterus for implantation.
"Right before ovulation, estrogen is at its peak and your skin looks sensational," says Loretta Ciraldo, MD, FAAD, Miami-based dermatologist and founder of Dr. Loretta skincare. "During this time, moisture levels are high, pores appear smaller, and the increase in collagen and elastin is working wonders."
In other words, the follicular phase when skin usually has peak clarity and radiance.
There's a lot happening, hormone-wise, during the ovulation phase, which lasts three to five days. First, there's a rise in follicle-stimulating hormone, followed by a rise in luteinizing hormone, which stimulates the follicle to release an egg. Estrogen continues to increase during this phase and testosterone also begins to climb.
According to King, progesterone starts to rise before ovulation and continues rising after ovulation is complete. "The mid-cycle rise in progesterone stimulates increased production of sebum," she notes. So while skin oiliness and acne can occur during ovulation, they're usually more common in the next phase, the luteal phase.
The luteal phase lasts 10 to 14 days, and for people with hormonal acne, it's a doozy. Your body basically reaches its boiling point, as far as all skin-provoking hormones are concerned.
"During the luteal phase, estrogen levels drop and progesterone levels rise," says Joyce Imahiyerobo-Ip, MD, FAAD, dermatologist and chief executive officer of Vibrant Dermatology and Skin Bar in Dedham, Massachusetts. "Furthermore, testosterone-to-estrogen ratios are also elevated during this phase. These elevations in progesterone and testosterone result in clogging of pores and increased oil production, which contribute to more whiteheads and more inflamed cysts."
"Progesterone is the major negative player during the first part of this phase, as it causes the skin to swell while also increasing oil (sebum) production," Herrmann adds. "This, in combination with slightly higher body temperatures, creates a perfect environment for P. acnes, the major bacterial culprit of acne, to flourish, thus leading to breakouts."
The luteal phase can wreak other skin havoc besides pimples. "Toward the end of this phase, as both estrogen and progesterone plummet, the skin can become dull and splotchy without the hydrating and barrier support functions of estrogen at play," Herrmann says. "Prostaglandins are also higher during this time, which can create more skin sensitivity—best not to wax or tweeze!"
The menstrual phase lasts three to seven days and is when hormone levels decline quickly to their lowest levels. (There's always a silver lining, folks!)
According to Herrmann, the simultaneous drop in acne-causing hormones helps breakouts improve after the chaotic, frat-party-like conditions of the luteal phase. However, she warns, skin can become dry and dull toward the end of our periods until estrogen kicks up a notch during the follicular phase.
How Do You Know If Your Acne Is Hormonal?
Luteal-phase breakouts can be one indication you have hormonal acne; another indication is where on your face acne tends to manifest.
"Hormonal adult acne typically forms on the lower part of the face," reports Ronald Moy, MD, FAAD, a dermatologist and facial plastic surgeon who practices alongside Herrmann in Beverly Hills. "Classically, this includes the bottom of the cheeks and around the jawline." Hormonal acne can include blackheads, whiteheads and cysts, he says.
King agrees. "If your acne correlates with your menstrual cycle, and it tends to include inflammatory acne lesions in the beard distribution"—the chin, upper neck, lower lip, and preauricular area in front of your ears—"then these findings are consistent with hormonal acne," she says.
Suspiciously located pimples aren't always indicators of hormonal breakouts, Ciraldo warns. For example, when patients come to her complaining of hormonal chin acne, she says they have "at least an 80 percent improvement rate" when they switch to "more skin-friendly hair care" products and start using standard topical medications for acne. Nevertheless, an experienced dermatologist can help you troubleshoot your skin issues, and properly diagnose and treat your acne.
If in addition to hormonal acne you have symptoms like excessive facial or body hair, weight gain, or irregular or infrequent periods, you may require additional testing. In that case, book an appointment with a healthcare provider ASAP.
How to Treat Hormonal Acne
Although we have only a little control over the inner workings of our hormones (more on that in a minute), we can strategically adapt our skin and medication regimens to compensate for hormonal changes. There are a plethora of prescription options to help manage menstrual breakouts, especially if those breakouts are moderate to severe and not improved by over-the-counter acne treatments.
Ciraldo says she prefers to start with topical prescriptions for any acne patients, including those with hormonal breakouts, before turning to the big guns—oral medications. "I try to leave oral medications as a last resort in the treatment of acne," she says.
For hormonal acne, derms can prescribe topical options like tretinoin (aka Retin-A), a retinoid, which helps unclog pores and increase cell turnover; dapsone (aka Aczone), a powerful antibacterial and anti-inflammatory medication originally used to treat leprosy; and the antibiotic clindamycin, which reduces acne-causing bacteria in the skin.
King says topical meds don't always get hormonal acne in check. "Topical products can still be helpful for treating acne of any cause, but they are not specifically targeting the cause of hormonal acne and therefore may not be as effective as oral medications that are specifically addressing hormonal causes," she explains.
But there's one recent exception to that rule, which King calls "a very exciting development" for hormonal acne treatment: clascoterone.
"Clascoterone (brand name Winlevi) is a new topical drug that has anti-androgen and anti-inflammatory properties," she says. Anti-androgen medications work by suppressing production of androgens, like testosterone, or blocking androgen receptors in the body. Clascoterone blocks testosterone from binding to androgen receptors in the skin, preventing skin from becoming excessively oily and inflamed.
"[Clascoterone] is therefore the first topical drug for decreasing sebum production and should be ideal for hormonal acne," she advises.
BTW, make sure to use topical meds for hormonal acne regularly, not just during problematic phases of your cycle. "The most effective approach to control acne is to maintain consistency with dealing with acne-prone skin instead of changing products for different phases of your menstrual cycle," Ciraldo says.
Birth control is a common treatment for those seeking relief from persistent blemishes. "Oral contraceptive pills containing ethinyl estradiol plus either the progestin norgestimate, norethindrone acetate, or drospirenone are also FDA approved to improve hormonal acne," Moy explains. "One should avoid contraceptive pills for acne that contain androgenic progestins (i.e., norgestrel and levonorgestrel) because they can actually exacerbate breakouts."
The Pill isn't your only birth control option for preventing pimples. King says other combined hormonal contraceptives—like transdermal patches and vaginal rings—containing estrogen and progesterone "are often helpful for decreasing sebum and acne."
When topical meds don't do the trick for hormonal acne, oral drugs can be prescribed to kick acne to the curb, stopping it before it starts.
One of those meds is spironolactone, also sold under the brand names Aldactone and CaroSpir. Spironolactone is an anti-androgen medication to treat high blood pressure, but it's also a low-key miracle for treating hormonal acne in women. (Although it's perfectly safe for most adult women, spironolactone causes breast growth in men and boys.)
"In my practice, strong oral medications such as spironolactone are used as an adjunct for severe hormonal acne that is non-responsive to topicals," Imahiyerobo-Ip says. "For women who have severe hormonal acne, medications such as spironolactone block the effects of testosterone on the skin."
Shop the Best Skincare Products for Hormonal Acne
In addition to managing lifestyle factors like reducing stress, loading up on sleep, and eating a healthy diet, taking your skincare game up a notch with proven acne-fighting ingredients is the first line of defense against hormonal breakouts. Try these dermatologist-recommended skincare picks for acne.
Over-the-counter cleansers, lotions and treatment creams with benzoyl peroxide are awesome options for treating acne of any type, King says.
"Benzoyl peroxide is an organic acid in the peroxide family that has been used to treat acne for more than 60 years," King says. "Benzoyl peroxide is helpful for treating acne because it not only kills bacteria that contribute to acne but also helps to prevent and clear out clogged pores." She recommends the affordable AcneFree Oil-Free Acne Cleanser, which contains 2.5 percent benzoyl peroxide.
The beta hydroxy acid salicylic acid is another ingredient to look for on skincare labels. Herrmann recommends dutifully removing any makeup at night and reaching for a cleanser with salicylic acid, especially during the luteal phase. "This can help lift thick sebum and dead skin cells that lead to clogging," she explains.
Imahiyerobo-Ip also recommends treating mild hormonal acne with a salicylic acid cleanser—specifically, her fave St. Ives Acne Control Tea Tree Daily Cleanser. "I love this product because it combines the pore-cleansing properties of salicylic acid with the anti-inflammatory benefits of tea tree oil," she says. "This is a great product for [people] who experience a mild increase in whiteheads and small cysts right before their period."
Over-the-counter retinoids—including retinol, the gold-standard anti-aging ingredient—are also smart buys. "Retinol helps acne and also is beneficial if a woman has hyperpigmentation or acne scarring," Ciraldo says. "I like to start Concentrated Firming Serum with 0.5 percent retinol on all but my sensitive-skinned acne patients."
And don't forget about adapalene, a potent acne fighter that until recently was available only by prescription. "Adapalene is a third-generation retinoid with proven efficacy and tolerability for the treatment of acne," King says. "It has been studied in numerous clinical trials that have demonstrated high efficacy and a lower risk of skin irritation." She suggests picking up AcneFree Adapalene Gel, only $7.
Mayo Clinic Proceedings. "Male Gynecomastia." August 2009.