Premenstrual acne, often called cyclical acne, is a predictable flare-up of blemishes that occurs in the days leading up to menstruation. This phenomenon is a common experience, affecting a large percentage of individuals who menstruate. These breakouts consistently emerge approximately 7 to 10 days before the start of a period, only to improve once menstruation begins. Recognizing this pattern validates the experience of many who feel their skin is fighting a monthly battle.
The Hormonal Trigger
The predictable timing of premenstrual acne is directly linked to hormonal shifts during the second half of the menstrual cycle, known as the luteal phase. After ovulation, estrogen and progesterone rise significantly, with progesterone levels peaking mid-luteal phase. Progesterone stimulates oil glands and causes the skin to swell slightly.
This swelling can compress the openings of the pores, creating a bottleneck for the oil being produced underneath. As the end of the cycle approaches, both estrogen and progesterone levels drop sharply, while the levels of androgens, specifically testosterone, remain stable.
The resulting imbalance creates a state of relative androgen dominance just before the period. Androgens stimulate the sebaceous glands, and this relative increase acts as the primary trigger for the breakout, setting the stage for increased oil production and pore congestion.
How Hormones Affect Skin
Androgen dominance in the late luteal phase stimulates sebaceous glands to produce excess sebum, the skin’s natural oil. This excess oil provides a rich environment for the growth of Cutibacterium acnes. The combination of increased sebum and compressed pores quickly leads to blockage.
Dead skin cells become trapped within these congested pores alongside the excess oil, a process termed follicular hyperkeratinization. This mixture forms a microcomedone, the earliest stage of an acne lesion. When C. acnes bacteria multiply rapidly, the body initiates an immune response.
This inflammatory reaction causes the characteristic deep, red, and painful lesions seen in premenstrual acne. Breakouts frequently manifest as inflammatory papules, pustules, or cystic nodules, particularly along the jawline, chin, and neck.
Immediate Management Strategies
Managing cyclical acne proactively involves adjusting skincare routines during the luteal phase to preempt the hormonal trigger. Targeted intervention during the week or two before menstruation can be beneficial. Over-the-counter (OTC) topical treatments containing salicylic acid or benzoyl peroxide are the first line of defense.
Salicylic acid is oil-soluble and penetrates the pore lining to chemically exfoliate and clear out trapped sebum and dead cells, helping to prevent clogging. Benzoyl peroxide works by introducing oxygen into the pore, which kills the C. acnes bacteria, and offers anti-inflammatory benefits.
Benzoyl peroxide is useful for active, red breakouts, while salicylic acid addresses clogged pores and blackheads. Lifestyle adjustments can also help moderate the monthly flare. Managing stress and prioritizing adequate sleep helps manage inflammation and oil production.
Medical Treatment Options
For individuals whose premenstrual acne is severe, painful, or unresponsive to OTC management, prescription medical options are available. Combined oral contraceptives (COCs) are a frequent choice because they address hormonal fluctuation. The estrogen component in COCs increases sex hormone-binding globulin (SHBG), which binds to free testosterone, reducing androgens available to stimulate oil glands.
This action decreases sebaceous gland size and overall sebum production. Some newer progestins, such as drospirenone, possess anti-androgenic properties that further suppress androgen effects. Prescription topical retinoids, synthetic Vitamin A derivatives, are also prescribed to normalize skin cell turnover and prevent pore blockage.
For highly inflamed or cystic acne, a dermatologist may prescribe oral antibiotics to reduce bacteria and inflammation. The anti-androgen medication spironolactone blocks androgen receptors, significantly lowering oil production. Consulting a healthcare provider is warranted when breakouts are deep, painful, cause scarring, or when topical treatments fail after several months.