Skin Disorders During Menopause
Menopause is the cessation of menstrual periods due to the loss of ovarian function. Among the various phases of a woman’s life, menopause has the greatest impact on health and has been one of the most neglected areas of research. Hormonal changes caused by menopause can lead to problems in the skin and its annexes, and despite the high frequency of dermatologic signs and symptoms, studies on this topic are limited. In this article, we review the skin disorders that result from the hormonal changes of menopause and other common dermatoses observed during this period and assess possible therapeutic approaches.
Practice Points
- Frontal fibrosing alopecia may respond to finasteride or dutasteride.
- Acute and chronic telogen effluvium may be associated with iron deficiency, mostly related to malabsorption or chronic gastrointestinal bleeding, during perimenopause.
- Oral and topical isoflavones may reduce skin aging in menopausal women.
- The use of estrogens as hormone replacement therapy in menopausal women promotes an increase in skin thickness and/or collagen content.
Senile Alopecia
Starting at 50 years of age, scalp hairs show varying degrees of change in pigmentation, growth, and diameter. Despite the normal ratio of telogen to anagen hair, there may be a considerable reduction in follicular density. The clinical distinction between senile alopecia and androgenetic alopecia can be challenging, and the conditions may coexist.24
Androgenetic Alopecia
,Up to 50% of women experience androgenetic alopecia, or female pattern hair loss (FPHL), during their lives.24 It is the main cause of hair loss in women, and women in perimenopause are the most affected. Hair regrowth is difficult when treatment is not instituted early in perimenopausal FPHL.24 The pathogenesis involves a progressive reduction in the hair cycle, resulting in shrinkage of the hair follicles.37 Unlike the pathogenesis of androgenetic alopecia in men, little is known about the role of androgens in FPHL.37 The measurement of androgen levels is not recommended in the absence of symptoms of virilization or in the absence of abnormal clinical patterns or progression.24
Three clinical forms of FPHL have been described: (1) Ludwig classification (diffuse central thinning concentrated in the parieto-occipital region with the frontal hairline intact), (2) Olsen classification (thinning of the central line and a consequent Christmas tree pattern), and (3) Hamilton classification (frontotemporal or vertex recession, which is seen less often than the other 2 forms). Female pattern hair loss primarily is treated with a 2% to 5% minoxidil solution,38 which is able to interrupt hair loss or induce mild to moderate regrowth in 60% of patients with FPHL.37 The effectiveness of the treatment should only be assessed after 1 year of use.37 Contact dermatitis is the main adverse effect, but its incidence may be reduced by up to 82% by using vehicles that do not contain propylene glycol.39 If the use of minoxidil solution is not possible, good results also have been reported with antiandrogen medications, such as spironolactone.40 These drugs are especially useful in cases of hyperandrogenism.37
Conventional doses of finasteride 1 mg daily, as used in men, have shown discrepant results in menopausal women.41-45 Improvement of FPHL has been shown in studies using doses of 2.5 mg or higher for a minimum of 12 months.42-45 The use of dutasteride, an inhibitor of 5α-reductases I and II, promotes greater inhibition (100%) of dihydrotestosterone activity than finasteride (70%) in men; however, it has not yet been approved by the US Food and Drug Administration for treatment in women.46
Impaired Wound Healing
Wound healing also is affected by aging. Delays in healing may be more closely related to the decrease in estrogen levels than to intrinsic aging. A comparison between the expression of genes associated with healing in young and elderly men showed that most of the genes are regulated exclusively by estrogen, which could explain the higher incidence of chronic ulcers in elderly men compared to women.47 However, menopausal women also are at risk for development of chronic ulcers.48 Ashcroft et al49 showed that the use of topical estrogen accelerates the healing of acute incisional wounds by increasing transforming growth factor β.
Healing of the oral mucosa is associated with a higher rate of complications and longer recovery time in women than in men. Estrogens produce anti-inflammatory effects, whereas progesterone demonstrates a proinflammatory effect. Testosterone has anti-inflammatory effects and is able to modify the proinflammatory state in the oral mucosae of menopausal women. Wound healing in menopausal women who are not receiving HRT tends to be slower than in those who are receiving HRT. Age is not necessarily an important factor in wound healing. Premenopausal and younger women have shown no notable differences in healing. Nevertheless, after menopause, differences in wound healing have been found, indicating that hormonal status may be more crucial to wound healing than age.50
Common Dermatoses With No Hormonal Associations
Brittle Nail Syndrome
Brittle nail syndrome (BNS) affects 20% of the population with a female-to-male ratio of 2:1.The pathogenesis of BNS involves factors that affect the adhesion of corneocytes to the nail plate and alter nail formation from its matrix; the former process produces onychoschizia, whereas the latter leads to onychorrhexis.51
The normal nail contains approximately 18% water, and nails with less than 16% water content are more likely to develop weakness.52 Nail water content appears to be negatively influenced by repetitive occupational exposure to water, and its increase is proportional to the frequency of moisturizer use. The use of certain nail polishes and cuticle removers is considered one of the main reasons for nail weakness in those who have frequent manicures.53
