What happens to our skin around the time of menopause?
Around the time of menopause some of the most common skin issues I see are dryness, increased sensitivity, blemish prone skin with an increase in acne and rosacea. Skin pigmentation issues, perceived dullness and a loss of firmness are also commonly reported complaints. I will start by summarising the underlying changes that lead to these issues.
- A reduction in hyaluronic acid: At the time of menopause there is a significant loss of hyaluronic acid, an important part of skin hydration. Some studies suggest at this time there may be up to 40% loss at this point. Hyaluronic acid (HA) has many functions, from a skin care point of view it holds a 1000x its weight in water. HA maintains hydration in the skin and plays an important part in collagen synthesis. If, however, HA is used as a topical serum and it has nowhere to draw the water from it can take it from the skin itself, this is why some feel applying HA has in fact a drying effect. To counter this I always recommend applying to damp skin and applying a light moisturiser on top, this seals hydration in the skin and gives it that calm, hydrated, dewy appearance
- A loss in barrier boosting fats and oils: As we approach menopause, we also lose some of the fats in our skin that seal the skin barrier such as ceramides, these act as the cement surrounding the bricks of the skin barrier. As we lose these fats, the skin becomes drier and its ability to retain water reduces. This dry, compromised skin barrier can become irritated and sensitive. To counteract this, I recommend using moisturisers with ingredients that are very similar to those skin barrier fats such as ceramides and shea butter. I recommend ceramide rich creams such as those found in the CeraVe range, Lipkar AP Balm by La Roche Posay and Xerocalm balm by Avene amongst others. The triple lipid cream by SkinCeuticals is perfectly balanced to replace the fats and oils lost in menopausal skin with ceramides, cholesterol and fatty acids to repair the skin barrier. Do not underestimate the value of dietary fats such as omegas 3 and 6 found in oily fish, nuts and seeds amongst others.
- Increased skin sensitivity: Around the time of menopause, we see changes to the top layer of the skin the stratum corneum with loss of important fats such as ceramides, this can affect barrier function and at around age 50 we can see an increase in skin pH. A change in the naturally acidic skin barrier can start to cause issues with dryness and irritation. Products that one was previously able to tolerate may start to cause problems. I recommend using very gentle cleansers and avoiding harsh soaps. I like facial cleansers from the Toleriane range by La Roche Posay, Cetaphil’s gentle cleanser and CeraVe’s hydrating cleanser. I like Avene’s Xerocalm oil cleanser, for using in the shower. After washing the face should not feel dry and tight, if it does you need to look for a gentler cleanser.
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- A Hormonal Shift: The aetiology of menopausal acne is multifactorial, with hormonal imbalance being the major culprit. Oestrogen levels fall with menopause relative to androgens causing an imbalance. These androgens stimulate oil production that can result in acne. Genetics, stress, dietary changes, lack of sleep and exercise and other lifestyle changes are also implicated as trigger factors. As the skin barrier becomes less effective with menopause, the dryness and irritation can contribute towards the inflammatory aspect of acne. Rosacea is also more common around the time of menopause, as such it is important to get an expert diagnosis as traditional acne treatment such as topical retinoids will exacerbate rosacea, misdiagnosis between acne and rosacea is a common issue I see in my practice. I recommend gentle products that protect the skin barrier, advocate a healthy diet rich in antioxidants and skin boosting fats, and discuss strategies to introduce healthier lifestyle changes that encourages exercise and reduces stress. Topical retinoids (sometimes in combination with benzyl peroxide) can be helpful, but hydrating skin products are a must as this treatment is more difficult to tolerate in menopausal skin. Oral antibiotics may be needed, but dermatologists are more reluctant to consider them because of resistance issues and disruption to the gut microbiome. Although the contraceptive pill is not usually advisable in this age group, some prescribe the anti-androgen spironolactone under expert supervision. Ingredients to look for in skin care include azelaic acid, niacinamide and salicylic acid amongst others. Physical therapies such as LED light, chemical peels and IPL laser can both be helpful in treating both acne and boosting rejuvenation.
- Pigmentary issues: Oestrogens have important antioxidants properties, protecting against free radical damage that we might see after exposure to UV or pollution amongst others. Menopausal skin is, therefore, more prone to damage from external aggressors , making it even more important to protect the skin with a sunblock and topical anti-oxidants.
Sun damage to skin can also damage melanocytes causing uneven pigmentation, a common sign of skin ageing. Uneven pigmentation and sunspots are a common issue I am asked about around this time. At the time of perimenopause oestrogen levels fluctuate, oestrogen combined with UV exposure can result in unwanted skin pigmentation known as melasma. Oestrogen also helps regulate melanin, falling levels can result in dyspigmentation. HRT in combination with UV can trigger melasma which can also be seen on the body e.g. arms as well as the face.
To protect against pigmentary changes, I recommend a high factor sun cream that protects against UVB and UVA exposure, also longer UVA wavelengths such as UVA-1. Longer wavelengths leading to the visible light spectrum are implicated in pigmentation issues and can combine with pollution synergistically to damage collagen. I am also a fan of mineral sun creams with zinc oxide, titanium oxide and iron oxide, especially in the context of managing melasma. Vitamin C is excellent at protecting against the damage from UV exposure and supressing enzymes that facilitate the production of the skin pigment melanin. To tackle melasma, sometimes prescription skin lightening creams may be used as a short-term treatment. There is now evidence of the use of tranexamic acid both orally and topically in the treatment of melasma. Melasma treatment needs very careful assessment, as some in clinic treatments may make pigmentation worse. Pigmentation regulating Ingredients to look for in skin care include azelaic acid, arbutin, licorice, kojic acid, AHA’s and BHA’s, niacinamide and retinols.
What are the common issues associated with the menopause and skin conditions?
As above the common issues with skin and menopause are changes to the skin barrier essentially the loss of hyaluronic acid and fats and oils such as ceramides means a reduction in an ability to retain moisture, so skin becomes dry, dull and increasingly vulnerable to irritation. Hormonal shifts in conjunction with these barrier issues give rise to conditions such as acne and rosacea.
When should we begin thinking about building a routine that caters to skin changes associated with the menopause?
A would strongly advise pre-empting skin changes associated with menopause. From the forties onwards I would advise looking at skin care that is going to boost skin moisture, protect the skin barrier and highly protect against external aggressors such as pollution and UV. It is never too early to start to protect skin against UV and pollution!
How can you counteract severe dryness if you’re suffering with this?
The is to start with the right cleanser, this absolutely underpins a healthy skin care regime. If skin feels tight and dry after cleansing it suggests disruption of the skin barrier. If skin is very dry a great tip is to apply a moisturiser to the skin as a barrier to protect vulnerable areas such as around eyes when showering or washing hair. Next, layering hydration is key, first apply a hydrating serum with a humectant such as Hyaluronic acid or glycerin to draw moisture to the skin barrier. Applying to damp skin can boost that process. Then seal that moisture with a light occlusive moisturiser. When skin is very dry use skin care that has the fewest possible irritants/allergens. I love the Dermallergo range from La Roche Posay and the Xerocalm range from Avene as they have been created for the most sensitive skin and can be used with all skin types.
Are there any ingredients to avoid when going through menopause?
I think a common mistake is to look at menopausal skin and see it as dry and dull and in need of multiple actives. Whilst chemical exfoliants and retinoids can help to boost skin and correct photodamage and brighten it, it is crucially important to balance these with hydrating gentle skin care. Introduce actives slowly and balance hydration to prevent skin irritation and inflammation.
And any to incorporate specifically?
Incorporate hydration boosting actives such as hyaluronic acid and glycerin. Protect the skin from free radical damage with antioxidants such as resveratrol and vitamins C and E. Make sure you are using daily the highest quality broad spectrum SPF that will protect against UVA, UVB and longer wavelengths, this will protect collagen and elastin and reduce unwanted pigmentation. Consider a retinol and actives such as AHA’s and BHA’s but again, introduce slowly.
What should a good routine look like if you’re going through the menopause?
It should essentially be gentle and hydrating. It should contain antioxidants to protect against free radical damage from external aggressors such as pollution and UV to protect collagen and reduce pigmentary issues. Actives such as exfoliating acids and retinols must be introduced slowly and balanced with calming, hydrating skincare.
What do you wish people knew about skin/menopause that they perhaps don’t?
I wish people appreciated the change in the skin barrier a pre-empted this with products that really help to boost hydration. I also wish they realised the value of protecting against external aggressors particularly UV with a daily highly protective SPF.
And what do you think people can get wrong – if anything – with their skincare when going through menopause?
Suddenly introducing multiple potentially irritating actives without balancing with calming hydrating, barrier boosting skin care.
Any other key things to note?
If considering in-clinic treatments I advise looking for those that can help to even skin tone such as peels, followed by those that can introduce hyaluronic acid such as Profhilo, polynucleotides and Revive skin boosters, there are other good skin boosters out there too, this is not an exhaustive list. Finally look for treatments that boost collagen such as platelet rich plasma therapy (PRP), IPL, micro-needling with or without radiofrequency and fractional laser amongst others. I am also interested in the emerging exosome treatments. These will help to mitigate against common skin changes with menopause and will be the most beneficial, crucially giving natural results. If you can identify a treatment… it’s unlikely to be a successful treatment.
