Toward Optimal Health: The Experts Discuss Facial Skin and Related Concerns in Women

Jodi Godfrey Meisler, M.S., R.D.

Introduction

Sometimes, quality of life issues can be over-looked or marginalized when concern about chronic diseases captures medical attention or redirects patient focus. However, the daily embarrassment of ordinary but undesirable facial hair or acne can overshadow otherwise good health or become a daily struggle. Facial hair growth should be viewed as much a health issue as a social issue and should not be discounted as a purely cosmetic concern. The same is true for acne. It is difficult enough to get through the teen years with this expected but nonetheless traumatic problem, but it becomes an even greater burden in adulthood. An estimated 15% of adult women have adult acne. Such facial conditions can cause low self-esteem and may even lead to depression.

With patient time brief and reasons for the physician visit often more acute -- the flu, chronic pain, hypertension, thyroid disease, diabetes, gastrointestinal ailments -- nagging concerns, such as persistent acne or unwanted facial hair, too often are forgotten or skipped. However, for women who are struggling with either of these dermatological problems, they can be a source of trauma or suppressed concern. They could also be a sign of an antigen excess syndrome that is hard to detect, given the monthly swings in hormone levels and the murky hormone shifts that occur during perimenopause.

Treatment options for acne have improved, and advances in hair removal are available, promoting a more active role for clinicians in managing these patient concerns. It would benefit many women if primary care practitioners had greater sensitivity to these concerns when a patient mentions them or if physicians noted these conditions and inquired about whether they are a concern for the patient. The author spoke with two dermatologists about acne and hair growth to provide an update focused on the diagnosis and treatment of these subtle medical concerns in women.

Hilary Baldwin, M.D.: There is a direct clinical association. Adult acne can be an extension of teenage acne, most often in women. However, some women who develop acne in adulthood never experienced teenage acne, whereas others may have had acne that went away, only to return in midlife.

Wilma F. Bergfeld, M.D.: Adult acne appears to be a growing problem. Past understanding focused on genetics and hormones, but we have gone beyond that to recognize that acne, in both the young and old, is affected by multiple factors, including genetics, microorganisms, hormones, and inflammation as well as external, topical products, all of which can aggravate the condition. It is not just the presence of these factors, as, for example, the immune response to microorganisms is different among individuals.

Dr. Baldwin: The precise cause of acne is unknown, but it is often associated with at least one hormonal abnormality in healthy women. At some point, many women will have slightly abnormal androgen levels.

The first consideration should be to distinguish between acne that is related to an underlying medical condition and acne vulgaris. Acne that occurs in adult women as part of a medical problem may result from polycystic ovarian syndrome (PCOS), a tumor, hyperplasia (ovary or adrenal gland overproduction), or a testosteronesecreting tumor, which is likely in the ovaries.

Dr. Bergfeld: An adult woman with acne without a teenage history of acne should be looked at closely for hormonal irregularities. That said, I often look at hormones, particularly for cases of inflammatory acne, because there are likely to be increased circulating androgens. We have learned that older women can have elevated androgens episodically released by the ovaries, a fact that was not appreciated in the past. As a screening tool, there are three hormones to measure, dehydroepiandrosterone (DHEA), free testosterone, and total testosterone. These values might fall within a normal range, but levels may have to be checked a few times during the month to find the androgen excess, as older women often experience episodic androgen levels. The other problem is that currently acceptable laboratory ranges are too high. Therefore, it is best to have the screening done by an endocrinology laboratory that has a normal range for these values. In addition, the ranges are not adjusted for the older population, and, thus, care must be taken in the interpretation to gain proper perspective.

It takes more than just a blood test, however, to properly diagnose the cause(s) of the acne. Clinical suspicion is required. Frequently, acne is not the only symptom. The patient may have facial hair, an oily scalp or face, or increased body hair, all of which are signs of androgen excess. This can be treated.

Dr. Baldwin: Although rosacea has been termed adult acne, it is a skin disorder with a completely different pathology from acne. Rosacea has three characteristics: generalized redness in the center of the face (across the nose and top of the cheeks and sometimes the center of the forehead and chin), an increased tendency to flush, acneiform eruptions (cysts and red papules), and rhinophyma (a bumpy, doughy, misshapen nose, which is more common in men). Women who are fair skinned may be diagnosed more often if only because the condition is more obvious. The red nose traditionally considered a drinker's nose most likely has always been caused by rosacea and not excessive alcohol intake. Alcohol does, however, make the redness present in a person with rosacea temporarily more pronounced.

Dr. Bergfeld: In an older woman, rosacea and acne almost always go together. Rosacea is a heterogeneous disorder characterized by acne, dilated blood vessels, and a flushed face. Microorganisms are involved in both rosacea and acne.

Dr. Baldwin: When a woman has a hormonal imbalance causing acne, the condition will most likely occur as a triad: facial acne, male pattern hair loss on the scalp, and male pattern hair growth on the body. When otherwise healthy women experience hair loss, it occurs as a uniform thinning across the entire scalp. If a part is made in the front of the head and compared with a part in the back of the head, the part width will be the same. One sex-specific difference is that women always maintain their front hair line -- it may be thin or even reduced to but a few hairs, but it is still there.

For those women who experience such thinning, it is a normal course of aging, and it is hereditary, often with a more senior female family member or sister having experienced it as well.

[Author's note: The genetic predisposition of male pattern baldness being passed down on the paternal side is a myth. Baldness is a genetic trait, period.]

When hair loss in a woman occurs as temporal recession or a bald spot at the vertex or both, similar to that in men, it is symptomatic of a hormone imbalance. Excessive hair growth on the body also has a male pattern to it. Increased hair is noted on the face, upper back, central chest (except nipples), and between the umbilicus and pubic hair.

In women with hormonal abnormalities, the resulting acne frequently is difficult to treat. A failure to respond to isotretinoin (Accutane, Hoff-mann-LaRoche, Nutley, NJ) is sometimes a signal of hormonal imbalance. Women who have not yet tried to get pregnant would not have been worked up for PCOS, which is a likely diagnosis in women who are in their 20s and early 30s.

Dr. Baldwin: Five hormones can be checked: DHEAS, free testosterone, prolactin, and in women who are still menstruating, follicle-stimulating hormone (FSH) and luteinizing hormone (LH). When the levels of FSH and LH are high, the cause of irregular menstrual cycles is most likely that of perimenopause; FSH and LH imbalances also help with the diagnosis of PCOS.

Dr. Bergfeld: Women with PCOS tend to be obese, and obese patients are at risk for elevated lipids, hypertension, and diabetes. Persistent androgen excess can lead to endometrial cancer and possibly increased breast cancer risk, as well as infertility. These women have a higher incidence of early death from heart disease unless the condition is diagnosed early and well managed. The woman with PCOS often shows clinical signs known as the seborrhea, acne, hirsutism, alopecia (SAHA) syndrome. Secondarily, PCOS patients tend to have abdominal or central obesity and menstrual irregularities. It is important for primary care physicians to pick up on these subtle signs of possible PCOS. Treatment can prevent the shortened life expectancy. The challenge for the primary care physician is to make the diagnosis based on clinical judgment, not from laboratory findings.

[Author's note: A more complete discussion of PCOS can be found in the Conversation with the Experts column, Journal of Women's Health 2002; 11(7):579.]

Dr. Baldwin: The physician should manage these patients proactively to prevent acne from recurring rather than treating the acne after the fact, which is why the approach is long term. Treating adult acne is more difficult than treating teenage acne because the aging skin of a woman often cannot handle the same topical products, which are very drying and irritating. Therefore, a 45-year-old woman is unlikely to be able to use the products that would work for a younger woman. Also, many women who have perimenopausal acne are likely to have it clear up at menopause, so treatment can be approached in terms of patients' biological timetables.

The most effective approach is always polytherapy because there are at least two underlying factors producing acne, clogged pores and the presence of many bacteria. When both factors are addressed simultaneously, the patient will improve more rapidly. It is important to start with a milder, lower-dose retinoid and a low-irritancy, topical antibiotic than are normally recommended for younger skin. As the patient becomes accustomed to the products, the concentrations can be increased. The patient should be warned up-front not to expect any dramatic improvement before 6 weeks, and most acne medications can take up to 8-12 weeks to be fully effective. After the first month, there will be little or no noticeable change; after 8 weeks, the treatment will begin to show considerable improvement; and at 3 months, there will be obvious results of the therapy's effectiveness.

It is good practice to have the patient return for a follow-up visit at 6 weeks, or sooner if there is irritation, to check on improvement. If there is no irritation and no clear sign of improvement, the physician may consider increasing the dose of one of the products. If both topical products have been increased without significant change, oral medication can be added. An oral antibiotic may be advisable, and in certain women, a low-dose oral contraceptive (OC) may be useful, especially if a patient has flareups every time she menstruates or if she has PCOS. Isotretinoin (Accutane; Hoffman-LaRoche, Inc., Nutley, NJ) is another option for severe cystic acne or acne unresponsive to conventional therapy. Two forms of contraception are required to prevent pregnancy since birth defects are common with this drug. The low dose OC is not reliable to prevent pregnancy and should not be depended on as the only means of contraceptive.

Dr. Bergfeld: Treatment of acne in older women is difficult but not impossible. One of the challenges in addressing adult acne is that retinoid treatment is not covered by health insurance because it is assumed that the prescription is intended to treat wrinkles.

The most effective treatment for acne is antiandrogens, which include OCs in younger women, selected so that the progesterone is nonandrogenic, and hormone replacement therapy (HRT) for perimenopausal and menopausal women. Given the media frenzy around the Women's Health Initiative (WHI) study, the basic message for many women has been lost. There is a need for estrogen to keep a woman's body functioning at a healthy state. Without it, everything falls (i.e., muscles, skin, hair loss, bone density) and dries out (i.e., gums, vagina). The major risk to women in menopause is cardiovascular, which can be assessed with a thorough medical history. Similarly, women with a high risk for breast or colon cancer should be referred to a specialist to address this particular concern. Until a better option for HRT is found, some women may want to opt for short-term therapy, and others may want a reasonable alternative. Phytoestrogens appear to help only with hot flashes. The trend is to prescribe raloxifene (Evista, Eli Lilly and Company, Indianapolis, IN) to improve bone density. However, this antiestrogen increases testosterone activity and can produce an androgen excess in some women, so it should not be viewed as an estrogen alternative.

Dr. Baldwin: Effective management of the redness associated with rosacea is difficult. Often, laser treatments are necessary to ablate the blood vessels. The acneiform lesions are best controlled with long-term topical or oral antibiotics, which are highly effective. The antibiotics act as anti-inflammatory agents, so there is no issue of resistance, and they are safer than traditional anti-inflammatory drugs. Tetracycline and erythromycin are the preferred antibiotics for acne or rosacea.

Topical retinoids are contraindicated in patients with rosacea in whom facial redness is prominent, as these drugs increase blood flow to the face. Topical steroids are also contraindicated for rosacea because long-term use causes an increase in vascular size, which will lead to a worsening of the redness. Topical steroids can also cause steroid acne that may take longer than 6 months to overcome. This said, a low oral dose (10-20 mg) of steroids for 2 days prior to an important event, such as a wedding, can work wonders, and there are no side effects.

Dr. Bergfeld: It is recommended that high-potency steroids should be avoided and those in the hydrocortisone family should be prescribed so that drug penetration is less, thus minimizing atrophy.

Benzoperoxide agents are useful to attack microorganisms, as is precipitated sulfur in the form of sodium sulfacetamide (Sulfacet, Aventis Pharma, Collegeville, PA) because it comes with makeup color added for cosmetic camouflage. Minocycline (Minocin, Wyeth-Ayerst, College-ville, PA) is an antibiotic that is both antimicrobial and anti-inflammatory. Accutane will kill the yeast and the bacteria, making it a good therapeutic option. Metronidazole (MetroGel, Galderma Laboratories LP, Fort Worth, TX) is used to reduce Demodex (hair follicle mites). Antihistamines, although not widely used, can be successful in reducing flushing. Vitamin C lotions are interesting because they can reduce redness, which may be advantageous for an older patient who is difficult to treat. Finally, facial peels and laser treatment offer a sound onetime option to reduce redness -- essentially by exfoliating the skin and thereby getting rid of the microorganisms and damaged follicles -- and resurface the skin. Microdermabrasion has been used but must be repeated every week or two, with limited success.

Dr. Bergfeld: When a woman with these conditions enters menopause, you have to remove the stimulants, which are the microorganisms and the immune response to them, and then address any underlying hormonal problems. Combined therapies which include estrogens and antiandrogen have been used with limited success because they are costly injectables and still temporary. Ovary reduction seems to be coming back as a means to reduce the production of hormone excess.

Dr. Baldwin: Hygiene (regular washing) has been ruled out as a viable cause of acne. Similarly, Helicobacter pylori has been clinically disproved as a trigger for rosacea. There are no good, controlled studies showing an association between diet and acne, with the exception that seaweed or kelp tablets can produce an acneiform reaction to iodine. Allergies do not produce acne, nor do new cosmetics, which can produce a skin reaction or rash in some women. In this era of natural products, some cosmetics have never been tested for acnegenicity. Thus, I recommend that women who are prone to acne be advised to avoid products that are labeled as not having been tested on animals (even though most of the individual ingredients have been tested.) Acne patients need products that have been tested and are known not to cause blackheads or pimples.

Cosmetics, including hair pomades made specifically for African Americans, typically are not tested, and many are comedogenic. If a patient has pimples and blackheads exclusively on her forehead, she should be asked if she uses pomade because at least 70% of African American women still use these products. The clinician can tactfully direct these patients to choose a brand that does not contain mineral oil, which is usually the culprit.

There is reason to believe that stress may trig-ger an acne or rosacea flare because it causes changes in hormones associated with acne. However, stress alone is not the cause of these conditions. Additionally, identifying stress as a trigger is remarkably unhelpful unless something constructive can be suggested to the patient to alleviate it.

Dr. Bergfeld: The challenge is that there are overlapping factors affecting acne. There has been a lot of controversy on the topic of diet. Some patients will insist that a certain food, such as chocolate, causes them to have a nearly immediate flareup, but it is more likely that patients who seem to have acne reactions actually have nutritional deficiencies. It is very likely that some of the women who are struggling with acne are poor eaters. The two worst offenders are fast food junkies and vegetarians. It is common for many women to have low iron stores.

There is no doubt that acute stress can play a role in acne as well as in hair loss, indicating possible multiple expressions translated to an over-action of the ovaries and adrenal glands, which is temporary but may produce clinical signs of acne or hair loss or both. Stress can be additive, in that there are already several factors present and stress is the final trigger to push the body into a reaction that produces acne. If a clinical pattern is evident in which certain situations are stressful to the patient, treatment can be coordinated to anticipate the circumstances in which a flareup is likely. This pattern can be determined by having patients keep a health calendar.

The hardest patients to manage are women in perimenopause because the estrogen/testosterone ratio gets smaller but is hard to discern.

Dr. Baldwin: No herbal remedies have been shown to be effective. However, nicotinic acid is an effective anti-inflammatory agent that may work in some women who have inflammatory acne. Nicomide (Sirius Laboratories, Vernon Hills, IL), a combination of nicotinic acid, folic acid, and zinc that requires a prescription, can be used alone or with antibiotics or introduced as a way to withdraw the patient from antibiotics.

Dr. Bergfeld: Some women are taking saw palmetto in topical form, such as in shampoos and scalp treatments, which may be of some help if the woman has androgen excess. It has been used in Europe to treat enlarged prostate, but the dose in these products is much lower.

Dr. Bergfeld: Excess facial hair growth is most common in women of Mediterranean and Jewish Eastern European ancestry, but it is not to be accepted as idiopathic, as the textbooks say. This is a sign of a hormonal abnormality that is hereditary and measurable, if only subtle.

Dr. Baldwin: Many women will experience unwanted hair growth as they age. This is particularly true when there is a family history of facial hair growth. Before concluding that this hair growth is pathological, it is important to inquire about a family history and onset. If a mother, grandmother, sister, or aunt has experienced unwanted hair growth and the growth did not have a sudden onset, it is most likely a normal process. A precipitous appearance of hair in male pattern locations would indicate the need to rule out a tumor. There are three distinctly abnormal places for women to have hair: the center of the chest, on the shoulder blades, and between the top of the pubic hair and the navel. Women typically have a flat line at the top of the pubic region forming a triangle of pubic hair, whereas men's pubic hair merges with hair on the belly up to the navel, forming a diamond. Women may have a thin vertical line of hair between the pubic area and the navel, but if hair appears in a diamond shape (known as a male escutcheon), it is most likely a symptom of virilization. If two of the three symptoms, male pattern baldness, virilization, and acne, occur in a woman, she should be evaluated for hormonal imbalance. Similarly, a woman who has PCOS can be expected to have symptoms of virilization as well as irregular periods and an inability to conceive. However, many of the women who have unwanted hair growth or acne or both are nearing menopause, and abnormal menses also could be sign of perimenopause.

Dr. Baldwin: Electrolysis under the chin is very useful, but it is not as effective on the upper lip, where it tends to form scars where the needle is inserted. In particular, African American women have a tendency for hyperpigmentation and even scarring. Finally, in the best of hands, an individual electrolysis session is only about 30% effective, although all hairs may be eradicated eventually.

Waxing is a very viable option, for women who do not have a reaction to the paraffin. Some women will get pimples. Otherwise, repeated waxing will eventually cause the hairs to stop growing, as with electrolysis or plucking.

The best option for Caucasian women may be the laser because it results in longer hair-free intervals. Some hairs are permanently destroyed or thinned. Women of color may have too little contrast between the skin pigment and the hair pigment for the laser to be effective. Because African American women suffer from ingrown hair on the chin, the best option for the chin area may be eflornithine cream (Vaniqa, Women First Health-care, San Diego, CA; www.vaniqa.com), which inhibits the enzyme necessary for hair growth.

Epilators work like shaving and offer a temporary solution that can cause irritation. However, it is an old wives' tale that shaving or similar methods of hair removal cause hair to grow back faster and more full. A hair that is cut at the skin level will grow back at the thickness of the hair shaft, but a plucked hair will regrow with a tapered end, appearing softer and less noticeable. Eventually, however, it will turn into a dark, thick hair.

Dr. Bergfeld: Vaniqa was developed to address this problem, which affects nearly 12% of adult women, yet it never took off because the delivery vehicle is too greasy, and it promoted acne. It should have been formulated as a water-soluble product to be more appealing.

Arab and Mediterranean women rely on a process called sugaring, which is similar to waxing and can be effective.

A final thought: physicians who do not know electrolysis or laser specialists can check out the electronic yellow pages and chat sites on the Internet to find out who is locally recommended or suggest that patients who are looking for a referral try this method.

Dr. Bergfeld: Postmenopausal women who were experiencing reduced libido were given Estratest (esterified estrogens and methyltestosterone; Solvay Pharmaceuticals, Marietta, GA), which is a combination of estrogen and testosterone. Although it improves libido, it also may lead to hirsutism, acne, and alopecia. There are drugs given to the perimenopausal-postmenopausal woman that can exaggerate or even induce androgen excess. These women should have their testosterone level checked.

DHEA is promoted to restore youth and vitality, but some patients will have 4-10 times the normal level in their body, which produces androgen problems. Therefore, women should be warned to look out for adverse events and to report any suspicious changes or reactions.

Dr. Bergfeld: The best initial step is to ask the patient to keep a health calendar that includes a dietary record. If stressful events, menstrual cycle, and diet are recorded, a pattern may become evident.

From the health calendar, a pattern may be found in which the flareups in acne (and hair shedding) occur about 6 weeks after the stressful event. This pattern can be used to anticipate future therapy initiation. Another aspect of treatment is timing of discontinuation, especially of oral medications, such as Minocin and Accutane. The patient will remain clear for 4-8 weeks, and then the acne will flare again because drugs stay in the body and continue to provide a therapeutic effect for up to 6 weeks after the drug is withdrawn, giving both the patient and the clinician a false sense of well-being. The cell turnover in the skin is about 30 days, so the withdrawal of topical medications will have a shortened but still latent efficacy after medication is discontinued. A flareup is likely to occur as soon as the tissue drug reserve is depleted. These factors should be considered in the timing of drug introduction and withdrawal.

In patients who appear to be poor eaters, it may be useful to measure serum vitamin A, zinc, and iron. Anemic women do not heal well, and their hair sheds. Zinc is necessary for tissue healing, and it is an antiantigen. A daily supplement of 100 mg of zinc has been shown to suppress acne. By identifying nutrient deficiencies and giving these women nutrient supplements, both acne and hair loss can be reduced.

Dr. Bergfeld: Except in the last stages, hair loss will not be evident to the physician just by looking at the patient. It is safe to say that if a woman voices concern about hair loss, she is likely to be shedding at an abnormal rate. Two helpful questions can be asked: How many hairs are lost in a typical day? (Women normally lose 50-100 hairs per day.) "How much hair has been lost? (Women usually respond accurately with a percentage for loss of volume.) Other questions include: Are you using the same size barrette or the same number of ties to clip back your hair? These women frequently will say that they have had to go a smaller size barrette or wrap the tie an extra time. Reviewing an old photo can be very helpful in comparing hair volume over time. The patient can be instructed to capture the hair on the brush from the first combing in the morning, place it in an envelope, and date the envelope. This should be repeated in 2 weeks. You can expect 20-50 hairs, so if the woman has shed 200-300, there is a significant problem.

Once shedding has been established, the cause must be determined. The practitioner should go back in the patient's history to ascertain any major clinical events (i.e., illnesses, stress, change in medication, weight loss, and dietary changes) 6 weeks to 6 months earlier that might provide a rationale for the hair loss. If there is no family history of male pattern baldness, the patient can be assured that most of the hair will regrow within 4-6 months. If there is the genetic propensity, this could be the triggering event for female pattern hair loss. It is important to see the patient again in a few months to check for regrowth.

Another method of checking for hair loss is to examine the midpart line. The clinician can use the Savin Hair Density Scale (1994), which provides a photographic example of seven levels of hair loss. This scale can be used to evaluate current status as well as future changes in regrowth or further hair loss.

Hilary Baldwin, M.D., is associate professor of dermatology at SUNY Downstate Medical Center, Brooklyn, New York.


Wilma F. Bergfeld, M.D., is professor of dermatology at the Cleveland Clinic Foundation as well as head of clinical research and dermatopathology. She is a past-president of the American Academy of Dermatology (1992) and the Women's Dermatology Society.

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