Hormonal Activity
Hormones are produced and stored by the glands in the endocrine system. This collection of glands produces a variety of hormones responsible for a multitude of actions within the body. Glands are made up of a group of hormone-producing cells. Plants also produce hormones (phytohormones) to regulate growth, metabolism and perform other basic functions. Hormone activity in humans is complex and is responsible for growth, digestion, sleep, sexual development, mood control, hunger, metabolism, skin function, texture, and almost every other activity in the body.

"Hormone function can be affected and disrupted by internal and external factors."

Male Hormonal Life Cycle
Boys typically reach puberty between the ages of 10 and 17 and begin to experience changes for up to approximately seven years. During that time, the male body primarily produces testosterone, which can be responsible for increased sebum production. This increase in sebum along with inconsistent personal hygiene habits can make acne a common challenge for teenage boys.
During the late teenage years and early 20s, acne may begin to subside, while boys with a family history of acne will likely experience a persistence of this condition. Skin care habits, sports and compliance with using acne products contribute to the control of acne breakouts through the late 20s and early 30s when testosterone production begins to slow down.
While testosterone levels in males are quite high during their teenage years and early 20s, production decreases after the age of 30 at a rate of 10 percent each decade. The level of decline varies in each individual and may even go completely unnoticed. Other men may experience symptoms that do not greatly affect sexual function or appearance while others may experience a marked reduction in testosterone levels, lack of sexual function and desire, changes in body composition, and mood fluctuations. In these instances, hormone replacement therapy is usually prescribed in order to stabilize testosterone levels and reduce symptoms.

When males go through puberty in their early teenage years, there is a dramatic increase in the hormones produced by the testes. This surge of hormones triggers changes such as the growth of body hair, deepening of the voice, and maturation of the reproductive organs. In addition to these changes, the hormonal surge during puberty increases sebum production which can lead to clogged pores and frequent acne.
On the other hand, when a man experiences a steep drop in testosterone during the onset of andropause, his skin may become dry, rough and cracked because of reduced sebum production – a necessary component to the maintenance of skin moisture balance and tone. This drop in testosterone is clinically referred to as partial androgen decline in the aging male (PADAM), aging-associated androgen deficiency (AAAD), or male hypogonadism.
In addition to impacting the quality of the epidermis,
reduction in androgen hormones also affects collagen pro-duction. As a man ages and his testosterone levels decrease, the reduced amount of collagen can produce wrinkles, sagging skin, and an overall aged appearance. For men experiencing considerable drops in testosterone, the accompanying change in the health and appearance of their skin may have a profound effect on their self-esteem, especially at a young age. Men often do not feel comfortable seeking help regarding the maintenance of their appearance; however, skin care professionals are in the position to act as resources for men and boys suffering with hormone-related skin challenges.

Female Hormonal Life Cycle
For girls, puberty begins between the ages of 9 and 14, lasting an average of four years. This extremely important hormone influx involves estrogen, progesterone and androgen hormones, such as testosterone. Girls primarily produce estrogen during puberty, although dominant androgen hormones can also be responsible for an increase in sebum production in their skin as well.
The beginning of a girl’s menstrual cycle brings about a multitude of hormonal fluctuations. During the first seven days of menstruation, estrogen levels peak and the skin is typically clear of acne breakouts. As estrogen levels begin to fall, testosterone levels are more dominant and oil production increases, playing a significant role in the occurrence of breakouts later in the month. After menstruation, estrogen decreases and progesterone levels increase, allowing fertilization to occur. This fluctuation causes the follicle walls in the skin to swell, trapping excess sebum inside. This combination creates the perfect environment for acne breakouts.
While acne is common in younger patients, hormone-induced pigment challenges become more of a concern when a woman begins taking birth control pills, becomes pregnant, or experiences other types of hormonal fluctuations. The exact reason as to why hormones trigger the melanogenesis process is not fully understood. Hormonally induced pigment deposit, also known as melasma, is one of the most difficult skin conditions to treat, not only because it is triggered by something internal, but because it is very sensitive to both ultraviolet (UV) exposure and internal, or thermal, heat. In some cases, melasma can affect both the epidermis and the dermis (known as mixed melasma), making it even more frustrating for both the client and the skin care professional.
Perimenopause marks the start of infertility in women and can begin as early as age 35. During this time, hormonal changes often affect the rise and fall of estrogen and progesterone. This constant fluctuation creates a myriad of unwanted changes – menstrual periods become irregular, melasma can return, and acne breakouts may increase. Perimenopausal skin is difficult to treat because of the frequent and unpredictable hormonal shifts. Each woman will start and stop perimenopause and go into menopause based on genetics, lifestyle, diet and general health. The increased breakouts that many women experience during this time are due to low levels of estrogen and progesterone, allowing androgen hormones to become more dominant. This drop in estrogen leads to surface dryness, trapping sebum beneath the skin, and causing an increase in acne breakouts. This erratic shift in hormones can also cause pigment changes such as melasma.

Medication-Induced Hormonal Fluctuations
Medications can often lead to hormonal fluctuations that can also cause various skin challenges. Both contraceptives and hormone replacement therapy can actually reduce breakouts by normalizing hormones, while they can increase the chances of developing pigment issues. There are several estrogen antagonist drugs, such as Tamoxifen and Femara, that are typically prescribed for breast cancer patients. They are also used for the treatment of other conditions in both men and women, specifically in growth hormone therapy in males, as it suppresses estrogen production, which may stimulate bone growth.
Many medications affect hormone activity and some are taken for solely that purpose. However, many people do not consider the skin implications of taking hormone-altering medications. A medical necessity for prescribing a medication takes precedence, but it is helpful for clients to have a versed skin care professional to help them address any skin challenges that could arise.

Hormonally Induced Skin Challenges Melasma
Over six million women in the United States suffer with melisma each year. Although men can develop hormonally induced hyperpigmentation, 90 percent of all melasma cases occur in women.1 Melasma is characterized by large, dense patches of pigmentation with distinct lines of demarcation. It can be triggered by starting or stopping contraceptive use, lactation, hormone replacement therapy, perimenopause, and/or thyroid and hormone disruptions. Melasma is not common during puberty or normal menstrual fluctuations in women. Studies indicate that the melanocytes in the skin of melasma clients have more dendrites and produce and distribute more melanosomes to the keratinocytes. Other potential causes include large, darkly pigmented melanocytes, an increased number of estrogen receptors within the melanocytes, and a possible vascular component. Additionally, increased epidermal and dermal melanin is present in melasma patients, as well as increased neurotrophin activity. Neurotrophins are proteins that encourage the growth and function of neurons (nerve cells); they are also growth factors for nerve cells. Studies have found that these neurotrophins not only encourage the growth of neurons, but they may also trigger melanogenesis. Research has demonstrated that retinoids inhibit the over-production of neurotrophins, making regular retinoid use imperative in the treatment of melasma. Melasma may or may not go away after the hormonal fluctuation has passed and it can recur with additional hormonal imbalances and UV exposure.
This is a frustrating condition to treat as there is no single definitive cause for the pigmentation. There are steps to effectively treat melasma and it is important to be consistent without being overly aggressive. The gold standard for treating hormonally induced hyperpigmentation is low percentage hydroquinone (no more than four percent in lower Fitzpatrick skin types, or two percent for higher Fitzpatrick skin types and sensitive skin), but this ingredient is typically contraindicated during pregnancy and lactation – a time that many women develop melasma. Fortunately, there are many effective alternatives to hydroquinone that are considered safe during these times, including arbutin; kojic, lactic and azelaic acids; rumex, licorice and mulberry extracts; undecylenoyl phenylalanine; and phenylethyl resorcinol.
Since melanogenesis is a complex, multi-step process and each of the aforementioned melanogenesis-inhibiting ingredients function differently, it is best to use products with a blend of several of these ingredients formulated together. This increases the chance of success by addressing multiple points of the pigment pathway at the same time.
Another important treatment option is gentle, blended chemical peels. These cannot be performed during pregnancy and lactation but are an important step in clearing the pigment deposit once lactation has ended. Combinations of low percentage trichloroacetic acid, lactic acid and retinol in conjunction with additional melanogenesis-inhibiting ingredients are recommended. These may be performed every three weeks until the skin is clear and even. Once positive outcomes are achieved, it is wise to perform chemical peels once a month to maintain results.
One of the most critical steps in any regimen is the daily use of a broad spectrum sunscreen. This is especially important for those fighting hyperpigmentation of all kinds as it worsens with UV exposure and will slow or halt any improvement already achieved.

Acne
Acne can occur any time, but it is most common during puberty, teenage years, and women experiencing perimenopause. Regardless of gender or the time period that acne occurs, the four main causes are the same. Increased keratinization within the follicle; increased sebum production due to increased androgen production or dominance; and increased P. acnes bacteria and inflammation are the main culprits of acne. The main difference between pubescent and menopausal acne are the surrounding skin challenges. Adolescent acne clients typically have resilient and oilier skin, while menopausal acne clients also fight fine lines and wrinkles, dehydration, and other age-related concerns.
Hormonal acne is typically triggered by a chain reaction starting with 5-alpha reductase, the enzyme responsible for the conversion of testosterone into dihydrotestosterone (DHT). The androgen receptors at the base of the follicle are stimulated by DHT, leading to an enlargement of the sebaceous gland and increased sebum production. The amount of DHT varies among individuals; men have more than women and younger people have more than older people. DHT also correlates with sex drive (a lack of DHT leads to sexual dysfunction). There is a direct correlation between acne and higher levels of DHT – the more you have, the more likely that acne will occur.
The stress hormone cortisol can also increase acne breakouts. Cortisol levels are often higher in acne clients. In addition, stress causes the release of neurotransmitters that increase sebum production and inflammation, causing breakouts to occur more frequently.
Since hormones are often unpredictable, controlling acne may be unpredictable. Consistency is vital when treating hormonal acne. The more controlled the acne breakouts are, the less likely future breakouts will develop.

Encourage acne clients to use the following for daily acne control:

1. An antibacterial cleanser containing liquid benzoyl peroxide (BPO), gluconolactone, salicylic acid or alpha hydroxy acids (AHA).
2. An alcohol-free, AHA toner with anti-inflammatory agents and antioxidants.
3. Corrective products containing BPO such as salicylic, azelaic, kojic and lactic acids; licorice extract or retinoids.
4. An antibacterial and anti-inflammatory moisturizer.
5. Daily use of a lightweight antioxidant and broad spectrum UV protecting products designed for breakout-prone skin.

Although daily care products are critical for treating acne, professional treatments can encourage even faster results. In-office treatments are designed to increase cell turnover and decrease bacteria and oil production. Treatments may include modified and enhanced Jessner’s formulas, salicylic acid treatments blended with anti-inflammatory ingredients, deep pore cleansing treatments, and treatments designed to enhance circulation. Puberty-induced and teenage acne clients should be treated every two weeks since this particular condition tends to be sluggish and in need of regular exfoliation. Menstrual-induced acne can be treated every four weeks, depending upon the client’s cycle.
When treating acne induced by the androgen dominance that occurs after the ovaries cease to produce estrogen in menopause, the daily regimen must also include products and ingredients that address dehydration, fine lines and wrinkles, and textural issues. Products chosen for the mature acne client should be less aggressive and increase hydration. The active ingredients used to treat this condition are the same, but should be in products designed for the mature client to avoid over-drying or irritating aging skin, and potentially aggravating the acne condition.

Treating Aging Skin Due to Hormonal Changes The Male Client
As men age and their testosterone levels begin to drop, collagen and elastin production slows dramatically and skin becomes dry. A regimen to address these challenges should include ingredients to encourage collagen and elastin production – including vitamins A and C, palmitoyl tripeptide-38, and retinoids. An aging man’s regimen should also include daily use of broad spectrum sun protection to shield existing matrix proteins from further damage. Additionally, aging men typically need more hydrating products to combat hormone-related skin dehydration. Skin care professionals should include products containing lactic and hyaluronic acid, niacinamide, glycerin and urea. These products deliver results without feeling heavy or greasy, which typically interfere with compliance in men.

The Female Client
As women age, they may have to address breakouts that they never had to experience as a teenager, but they must also combat collagen and elastin breakdown, textural changes, wrinkling and dehydration. The same ingredients recommended for men are appropriate to achieve positive outcomes in women, especially those experiencing break-outs. For aging women who have drier skin, highly moisturizing ingredients like shea butter, olive oil, niacinamide and silicones should be used.

While men and women produce differing types and levels of hormones at different stages of life, the skin care professional who has a solid relationship with clients of both sexes, as well as a vast understanding of ingredient mechanisms of action, will be able to customize both in-office and daily home care regimens that address the many skin challenges that arise throughout the lives of each client.

References
1 American Academy of Dermatology

Jennifer Wild, D.O., currently serves as a national educator for PCA SKIN and regularly speaks for the International Association for Physicians in Aesthetic Medicine. An osteopathic physician and surgeon, Dr. Wild is also board-certified in family practice and has served as a medical director for successful medical spas throughout Arizona. Since 2004, she has pursued an active interest in aesthetics, including dermal injections, laser, and professional skin care treatments and her expertise in biology and medicine have allowed her to excel within the industry.