Aarti Patel, ND

ABSTRACT

This case study explores menopausal acne in a 55-year-old female with severe skin barrier damage from a history of using medical-grade prescription, as well as over-the-counter acne topicals, along with a more recent history of supplementing with bio-identical testosterone injections for menopausal symptoms. 

The case article explores menopausal acne and its contributing factors for women who have been experiencing chronic breakouts since the onset of their early teenage years. Factors will include skin barrier damage from harsh acne-fighting ingredients found in either prescription or over-the-counter products containing skin actives; hormone imbalances such as adrenal fatigue and/or estrogen dominance; a relative increase in androgens along with a more pronounced reduction of female hormones (including estrogen and progesterone); poor sleep due to menopausal hot flashes and its impact on the skin barrier; and the potential contribution of bioidentical hormone therapies involving androgens.

What is Menopausal Acne?

While the term ‘menopausal acne’ is not always classified separately, the American Academy of Dermatology¹ defines a related term, ‘adult acne,’ as breakouts that occur at ages thirty and older. The term ‘menopausal acne’- commonly used in academic articles, healthcare culture, and on social media and blogs- would be considered a subset of that age group. The Academy further explains that among these ages, menopausal acne is the most prevalent form of acne.  

Menopause has historically been regarded as a reproductive phase during which acne is expected to resolve for women who experience it, and it was assumed to be a non-relevant clinical topic for those with no prior experience. However, a 2006 survey² revealed that the prevalence of acne in women aged 50 and over was 15.3%, indicating that more than 10% of women in this age group continue to experience acne, challenging the assumption that menopausal women are free of this condition. 

Khunger and Mehrotra² report that hormone imbalances, such as the relative increase of androgens during menopause compared to the more rapidly declining female hormones like estrogen and progesterone, significantly contribute to menopausal acne. The rise in androgens, such as testosterone, can overstimulate hair follicles and the sebaceous glands within them, producing skin oils (sebum). This can result in clogged pores and acne. 

We must also consider a few underlying factors that affect menopausal acne, which are harder to detect and operate on a mind-body level. These factors include the mental pursuit of anti-aging; skin dysmorphia linked to social media or other prevalent physical ideals; and increased self-consciousness regarding appearance and aging skin among menopausal women. These elements can significantly impact the skin’s long-term ability to heal and maintain an intact barrier to prevent future acne. How does this work?

Menopausal women may turn to quick-fix methods to improve their complexions rapidly, but these approaches can disrupt the skin’s natural ability to renew, heal, detoxify, and balance oils. Quick-fix methods may include potent, moisture-stripping acne skincare routines, extraction techniques using esthetic tools, skin picking while looking in the mirror, excessive or prolonged use of pharmaceuticals and harsh acne medications, and heavy application of makeup that can clog pores and exacerbate acne. These methods, whether used alone or in combination, can create vulnerability in the skin barrier for menopausal women, which tends to worsen over time. 

This damage to the skin barrier occurs at a time when women’s maturing menopausal skin is already challenged by hormone deficiencies, unbalanced hormones and oils, a reduction in collagen and elastin within skin cells, and increased transepidermal water loss (TEWL) compared to what women typically experience in their 20s, 30s, and 40s. 

It appears that, on the surface, there are many similarities between teenage acne and menopausal acne; however, there are also significant differences beneath the skin worth noting. 

Both occurring during a phase of natural hormone fluctuations, menopausal and teen acne can manifest as inflammatory and non-inflammatory lesions, including whiteheads, blackheads, large pustules, and even cysts, which have often been regarded as a symptom exclusive to teenagers.² The facial regions affected overlap with those in teenagers as well, comprising what is known as the “beard” distribution along the lower cheeks, jawline, the submental space between the chin and neck, and the distal part of the throat.²   

When menopausal women seek treatment for their acne, they are often prescribed the same prescription-grade topicals offered to teenagers, as well as potent over-the-counter acne skincare products, or both. However, the skin characteristics of a teenage girl are vastly different from those of a menopausal woman. 

These contrasting characteristics include abundant collagen and elastin in the skin of teenagers, significantly lower transepidermal water loss (TEWL) and increased natural moisture retention within skin cells, rising hormone levels that support skin tone and strength, and a more resilient skin barrier typical of young age. Using potent topical treatments, young skin can recover more quickly if the skin barrier is damaged. 

When a medication, such as prescription retinoids that can be drying or customized skincare formulas that combine topical hydroxy acids, topical antibiotics, and benzoyl peroxide at various dosages, impairs the skin barrier of a menopausal woman, new therapies with a similarly suppressive or harshly eradicative approach to treatment are often prescribed. 

Patients are often advised to apply multiple potentially harsh or damaging products or ingredients simultaneously on their skin. This approach causes the skin barrier to lose its integrity, healthy oils, and moisture levels, leading to increased susceptibility to acne, slower healing, and more significant scarring over time. 

Menopausal women can benefit from a naturopathic approach to acne treatment that employs internal measures to support the health of the organs, nourishing the skin and providing gentle, nourishing, yet effective topical skin care. Providers specializing in hormone balancing for women should exercise caution when prescribing bio-identical androgens, as they can increase the incidence of acne. Additionally, providers can collaborate with their patients on stress management and adrenal health, treatment for hot flashes and sleep disruption, immune and gut health, androgen excess, and estrogen dominance to offer a well-rounded approach to treating menopausal acne. 

CASE PRESENTATION

S //

A 55-year-old female CW with a decades-long history of previously diagnosed hormonal and cystic acne presents with severe skin barrier damage and a worsening of her acne symptoms. 

CW went through menopause three years ago, after which her acne worsened instead of improving as she had expected. An eight-step topical skincare routine, prescribed by a clinical provider fourteen years ago, had improved her complexion for several years. However, it may have contributed to excess skin dryness over the past six months, particularly on the bilateral cheeks, chin, and nose. The dry skin exacerbated her acne symptoms, leading to redness, sensitivities, and increased wrinkles. Her skincare routine included multiple active ingredients used simultaneously, such as a high-dose topical antibiotic, mandelic acid, salicylic acid, glycolic acid, and antiseptic components.

The patient was also receiving a 1.5 mg estradiol injection once a week from a different provider, a 0.75 mg testosterone injection weekly, and a 200 mg progesterone capsule each night. Other medications included a prescription stimulant for ADHD symptoms and an over-the-counter allergy medication. No family history of acne or any other chronic skin conditions was reported. 

Supplements she was already taking included omega-3 fatty acids and magnesium. CW engaged in low-to-moderate intensity workouts four days a week for 30-40 minutes per session, combining cardiovascular exercise with light resistance training. She shared her history of high stress levels related to a previous divorce years ago and changes in her position at work. She felt that stress played a significant role in acne flare-ups, which tended to vary in frequency. 

Hormonal changes leading to occasional hot flashes disrupted CW’s sleep, further increasing her stress levels for the following day. At times, her energy could be notably low throughout the day. The patient sometimes experienced migraines due to chronic stress and also reported having cold hands and feet. 

O// 

The facial skin appeared red and crepey in all areas except beneath the eyes, with two cystic bumps on the chin and multiple regions of post-inflammatory erythema (PIE) and post-inflammatory hyperpigmentation (PIH). The PIE and PIH scarring seemed slow to heal, and the skin surrounding these areas did not regain its tone, moisture, or luminosity.

Hormones were assessed using a comprehensive salivary panel that included eight analytes: estradiol, progesterone, testosterone, DHEA, and four cortisol readings (morning, noon, evening, and night). Results indicated moderate (or phase 2) adrenal fatigue, characterized by low cortisol levels in the morning, noon, and night. DHEA was low, testosterone was on the upper end of normal, and estrogen was within range. CW’s progesterone was moderately low, and the progesterone-to-estrogen ratio was severely low, which indicates estrogen dominance. 

A// 

The patient was diagnosed with menopausal acne, a conclusion drawn from the presenting symptoms and CW’s history of acne dating back to high school. Rosacea was considered for differential diagnosis because of the redness visible on the skin. However, the cystic bumps and slow-healing distinct spots of post-inflammatory erythema (PIE) and post-inflammatory hyperpigmentation (PIH) scars align more closely with the typical presentation of acne and its healing process.

CW was also diagnosed with phase 2 or moderate adrenal fatigue, androgen excess, and estrogen dominance based on salivary hormone results. 

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Treatment Overview

• Discontinue testosterone injections by gradually reducing the frequency to every other week initially, and then stopping altogether. High testosterone levels in saliva testing, along with persistent acne breakouts, served as the primary rationale. 

• The patient was started on a skin-specific probiotic that contains 50 billion CFU‡ from a diverse blend of bacterial strains, including S. boulardii, B. coagulans, various Lactobacillus (e.g., L. plantarum, L. rhamnosus, L. acidophilus) and Bifidobacterium species (e.g., B. lactis, B. breve, B. bifidum, B. longum), along with B. subtilis and B. clausii. These strains were selected to support the skin microbiome and gut-skin axis. The formula also includes phytoceramides and a proprietary blend of Ayurvedic herbs to support sebum balance and inflammation modulation, including fermented Indian frankincense, triphala, holy basil, fenugreek, elecampane, camu camu, mangosteen, açaí, ginger, white peony, rose hip, asparagus, and Huang Qi. Vitamin C from acerola cherry extract was included for antioxidant support. In addition to targeting acne-related factors internally, the formula helps modulate immune response through the enteric immune system.

• An adrenal support formula containing 60 mg of Rhodiola per capsule, 16 mg of Holy Basil, and a proprietary blend of Ashwagandha, Oats, and Schisandra was prescribed as one capsule to be taken in the morning and one capsule before lunchtime on an empty stomach. The focus on chronic stress during CW’s health history and intake process, coupled with Phase 2 moderate adrenal fatigue and low cortisol levels, highlighted the need for adrenal support. Her facial skin was severely red and inflamed, and the slow healing of scars also indicated that low cortisol levels were not effectively supporting her immune system for overall skin health. 

• CW also received customized mind-body techniques to help her manage stress daily, including breathing exercises during the day and a positive skin affirmation to reduce excessive anxiety about her skin. As she implemented the recommended changes, the patient was encouraged to address stressful and discouraging thoughts related to her skincare routine.  

• CW was started on a new, gentle cleanser and moisturizer featuring hyaluronic acid and herbal antioxidants for moisture and repair, along with a separate occlusive oil containing rosehip, sea buckthorn, and serrated wrack. She was to use the oil sparingly, applying 1-2 drops in the last step of her skincare routine to seal in hydration from the cleansing and moisturizing steps. 

• The patient experienced a gradual allergic reaction over the first 1-2 months of treatment due to the line of skincare products recommended to her, most likely because of the high antioxidant content in the topicals. She was subsequently switched to a cleansing oil balm, facial serum, and stable vitamin C oil containing olive squalane, olive oil, olive leaf water, Anchusa Azurea, beet, and chicory for gentler soothing and repair. 

• CW was put on vitamin D3 to support immunity, hormone balance, mood and stress management, and gut health, all connected to skin health. 

• The patient was put on progesterone cream instead of capsules, for better absorption and to help reverse pronounced estrogen dominance that had been coinciding with acne symptoms. She was to apply 10 mg cream 30 minutes before bedtime to thin-skinned areas in rotation.

• Future Plan: Retest hormones out of range in three months, followed by a follow-up appointment. 

OUTCOME AND FOLLOW-UP

CW moved out of state and could not schedule a second appointment. However, she recently emailed an update (nine months after her last appointment) reporting that her skin had healed significantly due to a gentle skincare routine featuring olive oil and olive leaf water. The frequency and duration of her acne symptoms, hot flashes, sleep disruptions, unmanaged stress, and skin-related anxiety had also decreased. She continued using the adrenal support therapy, mind-body techniques, probiotics, progesterone cream, and vitamin D3. Improved sleep quality aided skin barrier renewal overnight. Discontinuing testosterone injections also contributed positively. Future considerations involve retesting hormones and adjusting CW’s bio-identical hormone therapies. 

CONCLUSION

Skincare routines that moisturize, soothe, and repair the skin’s lipid barrier externally – combined with internal natural therapies such as adrenal support, gut and immune protocols, androgen balancing, and treatment for estrogen dominance – may provide a comprehensive approach to treating menopausal acne without further damaging the skin.

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References

(1) Adult Acne. American Academy of Dermatology Association. Accessed March 13, 2025. https://www.aad.org/public/diseases/acne/really-acne/adult-acne

(2) Khunger N, Mehrotra K. Menopausal Acne – Challenges And Solutions. Int J Womens Health. 2019 Oct 29;11:555-567. doi: 10.2147/IJWH.S174292. PMID: 31754313; PMCID: PMC6825478.