Navigating Women’s Health Dermatology Through Life’s Stages
© 2024 HMP Global. All Rights Reserved.
Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of the Dermatology Learning Network or HMP Global, their employees, and affiliates.
Women’s health dermatology is an integral aspect of practice for all dermatologists, addressing the myriad changes in skin, hair, and vulvar health that occur throughout different life stages, such as puberty, pregnancy, perimenopause, and post menopause. These transitions present unique dermatologic challenges and require tailored approaches to care. By addressing specific needs at each stage, dermatologists can provide comprehensive and empathetic care, enhancing both the health and confidence of their patients.
Adolescents and Young Adults
Hair Removal
Adolescent girls often navigate changes in their bodies during puberty while learning how to care for their skin properly. Questions about hair commonly arise, including where hair naturally grows, how puberty affects hair growth, and methods for hair removal. An estimated 80% of women in Western cultures engage in pubic hair removal, with particularly high prevalence among younger age groups.1 Primary motivations include aesthetic concerns, a desire for cleanliness, cultural norms, and preferences of sexual partners.2 Options for hair removal include shaving, waxing, electrolysis, and laser treatments.
Although hair removal is not necessary, it is a common practice with potential complications. Women commonly report genital itching, rashes, ingrown hairs, folliculitis, and pseudofolliculitis.3 Shaving and waxing can create microtrauma in the epidermis, leaving the skin vulnerable to infection.4 Additionally, applying wax at high temperatures, often seen with home wax kits, can cause superficial to partial thickness burns.4 Given the prevalence of hair removal practices in younger age groups, we recommend educating patients on safe hair removal practices and appropriate skin care after treatment. Instructions include only shaving pubic hair when wet, shaving with the grain of hair, and being mindful not to take multiple passes over the same area. Applying topical hydrocortisone or topical clindamycin after shaving may prevent superficial skin infections or irritation. Additional advice, such as using razors or clippers specifically made for pubic hair and wearing breathable underwear, are useful recommendations for this age group.
Finally, we advocate for recognizing hair as a natural part of life and encourage those who do not wish to shave, pluck, or trim to embrace their natural state. While there may be some aesthetic preferences for hair removal practices, there is also a significant risk of infection, dermatitis, and postinflammatory hyperpigmentation.5
Acne
The onset of puberty often coincides with the emergence of acne, particularly hormonal acne that is centered on the jawline and cheeks. For most cases of mild to moderate acne, topical treatments, such as tretinoin or benzoyl peroxide creams, are effective for management. However, for moderate to severe acne, combined oral contraceptives (COCs) have shown efficacy in reducing acne flares and are recommended for adolescent girls.6,7 Approved COCs for acne treatment include the following combined oral contraceptives: norgestimate/ethinyl estradiol (EE), norethindrone acetate/EE/ferrous fumarate, drospirenone/EE, and drospirenone/EE/ levomefolate.8 Measuring patients’ blood pressure and ensuring they have no signs or symptoms of pregnancy, in addition to presenting within 7 days after menses or having had no sexual intercourse after the start of their last menses, are necessary before starting COCs.
Patients should be counseled that improvement with COCs generally takes place within 3 to 6 months, although other acne treatments may be considered in combination with COCs for expedited improvement.8 Although generally well tolerated, adverse effects of birth control pills can include headaches, intermenstrual bleeding, and breast tenderness.6 For patients who either do not wish to start birth control or have contraindications, such as breastfeeding or a history of venous thromboembolism, spironolactone at 100 mg daily has been shown to significantly reduce acne in adolescent female patients.7,9
The Skin Care Routine
It is essential to address the “skin care routine” often portrayed on social media platforms like TikTok and Instagram when discussing adolescent girls and their skin.10 With estimates suggesting that as many as 70% of adolescent girls are active on social media, and approximately 51% of Generation Z prefer to search on TikTok rather than Google, the influence of these platforms is undeniable.11,12 While social media can be an excellent medium for sharing health practices that may not be widely discussed offline, it also raises concerns about misinformation and commercialism.12 Among adolescent girls, we recommend a modest skin care routine that includes a gentle cleanser with ceramides alongside a daily sunscreen and moisturizer.
Vulvar Health and Education
Another prevalent topic of discussion on social media is the vulvovaginal skin care routine.13 From a young age, women are often socialized to over wash their vulvas to feel “clean,” a practice rooted in the misguided ideology that women’s genitalia are inherently dirty.14 We recommend using plain water alone or gently washing this area with non-soap based cleansers during showers or baths. The vaginal area is self-cleaning and does not require washing, which can lead to irritant contact dermatitis and other potential health risks.15,16 By promoting gentle and informed care practices, we can help dispel harmful myths and support women’s health and comfort.
When working with adolescent and young women, it is crucial to educate patients on the proper terminology. Referring to the entire female genitalia as the “vagina” is disempowering and anatomically incorrect.13 Using euphemisms like “pancake” or “flower” further reinforces the notion that female sexual health must be dressed in less accurate terms to be publicly discussed.17 We wholeheartedly discourage this practice. Young adolescents should be informed that the external part of their genitalia is called the vulva. This empowers them with correct knowledge and fosters a healthier understanding of their bodies.
Pregnancy and Postpartum
Hair
During pregnancy, there are significantly more hairs in the anagen cycle, leading many to report lush and full hair.18,19 Patients may notice more hair on the scalp in addition to an increased rate of hair growth. The anagen rate increases during pregnancy, whereas the telogen rate increases in the postpartum period, causing postpartum hair loss as described below.18,19
Hirsutism may also occur during pregnancy due to an increase in placental or ovarian androgens. This manifests as thick or excessive male-pattern hair growth on the face, chest, lower abdomen, and other areas. Hirsutism generally has an excellent prognosis and tends to resolve in the postpartum period. However, severe or persistent hirsutism warrants further evaluation to rule out secondary causes of increased androgen levels.20
Telogen effluvium, most often occurring 1 to 5 months postpartum but potentially lasting up to 1 to 2 years, can be deeply distressing for patients.21 Unfortunately, no specific treatment exists for postpartum telogen effluvium at this time. Therefore, it is crucial to reassure patients about the prognosis for hair regrowth, which is generally excellent. Additionally, other underlying causes of hair loss, such as iron deficiency anemia and thyroid disorders, may present during the postpartum phase, necessitating the exclusion of these potential exacerbating factors.
Skin
Women undergoing the significant hormonal changes of pregnancy and the postpartum period may experience acne, benefiting from specific therapeutic interventions. Many efficacious acne treatments, such as isotretinoin, are contraindicated during pregnancy. Additionally, certain topicals like retinoids and tazarotene are not recommended due to insufficient safety data.22 Oral contraceptives cannot be used by pregnant and breastfeeding women, and spironolactone is contraindicated during pregnancy, requiring a 1-month washout period before conception.
For mild to moderate acne, recommended topical treatments include azelaic acid, clindamycin, and benzoyl peroxide creams.22 For moderate to severe acne, oral antibiotics, such as amoxicillin, cephalexin, and clindamycin, may be considered.22 However, oral trimethoprim-sulfamethoxazole should be avoided during pregnancy.
An estimated 70% of pregnant women experience hyperpigmentation of the skin on the face, known as melasma or the mask of pregnancy.20 This skin darkening primarily affects the malar and mandibular regions and can improve after pregnancy, although around 30% of women experience continued hyperpigmentation. Treatment options during pregnancy and lactation include improved sun protection and azelaic acid. After pregnancy and breastfeeding, hydroquinone and tretinoin creams can be used to lighten the affected areas.
Stretch marks commonly present during pregnancy, particularly in Caucasian women. Unfortunately, treatment options are limited during pregnancy, and randomized controlled trials on this manifestation are lacking. During the postpartum period, stretch marks may be treated with topical tretinoin 0.1% cream applied nightly for 3 months.23 Other benign but cosmetically concerning conditions seen during pregnancy include spider angiomas, palmar erythema, and linea nigra. Most of these regress during the postpartum period and do not warrant further workup or treatment unless desired by the patient for cosmetic reasons.
Certain dermatologic conditions warrant special attention during pregnancy due to their potential implications for maternal and fetal health. Intrahepatic cholestasis of pregnancy (ICP) is one such condition that can present acutely during the second and third trimesters, characterized by generalized itching, often localized to the palms and soles.24 Typically, a primary rash is not observed, although excoriations and prurigo nodules may be indicative of ICP. There should be a low threshold for ordering tests, such as total bile acids, a hepatic function profile, and total and direct bilirubin, to rule out ICP. However, it is important to note that pruritus may precede an elevation in bile acids, necessitating repeat laboratory assessments. The current recommended treatment for ICP is oral ursodeoxycholic acid.21
Pregnancy can lead to either improvement or exacerbation of certain skin conditions due to hormonal changes that are thought to induce a switch to an adaptive Th2-mediated immune response.25 Atopic dermatitis may either first appear or worsen during pregnancy due to these immunologic shifts, whereas psoriasis, primarily driven by a Th17-mediated immune response, often improves during pregnancy but can flare postpartum.25 Safe treatments for atopic dermatitis during pregnancy include emollients and low- to medium-potency topical corticosteroids. In severe cases, narrowband UVB (NB-UVB) phototherapy and systemic steroids may be required. Although there is no known risk to maternal-fetal health associated with atopic dermatitis during pregnancy, the potential for superficial skin infections underscores the importance of prompt recognition and early treatment of flares.26 Psoriasis flares during pregnancy can also be managed with low- to mid-potency topical corticosteroids and NB-UVB therapy. However, a rare and severe form of generalized acute pustular psoriasis, known as impetigo herpetiformis, may be triggered during the third trimester.27 This condition necessitates close monitoring and treatment due to significant risks to both maternal and fetal health. Understanding the impact of pregnancy on these immune-mediated skin conditions and providing appropriate and safe treatment options are essential for optimizing outcomes for both the mother and the baby.
Vulvar Health
Significant edema frequently occurs in the lower extremities, ankles, and even the vulva during pregnancy due to hormonal and physiologic changes. Regularly elevating the ankles and wearing compression stockings can help mitigate some of this swelling. Vulvar varicosities are more likely to develop during pregnancy, possibly due to the anatomical obstruction of the uterus on the venous plexus of the pelvis, which connects to the external genital veins, compounded by venous insufficiency.28 Patients may present with difficulty walking or local discomfort. Vulvar varicosities can be diagnosed through a vulvar examination and typically resolve within 30 days postpartum. While these varicosities are not a direct contraindication to vaginal birth, data are limited and there is a legitimate concern about bleeding from vulvovaginal lacerations.28 Compression therapy from a vulvar varicosity support garment can alleviate pressure, pain, and edema during pregnancy.
Genitourinary syndrome of lactation (GSL) is a recently recognized condition that occurs in postpartum patients experiencing low levels of estrogen and progesterone due to prolactin inhibition.29 Similar to genitourinary syndrome of menopause (GSM), these patients may experience vulvovaginal atrophy, dryness, dysuria, and dyspareunia. Effective topical preparations include vaginal hyaluronic acid, nonhyaluronic acid moisturizers, and pelvic floor physical therapy, which can be particularly beneficial for patients also experiencing postpartum urinary incontinence.30 Vaginal estrogen is a safe and effective treatment for postpartum and breastfeeding patients and can be prescribed as 1 to 2 g nightly for 2 weeks, followed by 2 to 3 times a week.31 Some providers may prefer to start patients on the maintenance dosing. There is no evidence suggesting that vaginal estrogen is absorbed systemically at significant levels, transferred through breastmilk, or that it affects breastmilk supply.29,32,33 Recognizing and treating GSL can significantly improve the quality of life for postpartum patients, emphasizing the importance of early diagnosis and appropriate intervention.
The Menopause Transition and Post Menopause
Hair
An estimated 38% of women over age 70 experience some degree of hair loss or thinning.34 Androgenic alopecia (AGA) occurs in 2 patterns: female-pattern hair loss (FPHL) and male-pattern hair loss (MPHL). FPHL typically manifests at the vertex of the scalp, resulting in a widened hair part, and can occur due to increased androgens during the menopausal transition and genetic factors. Treatments for AGA include topical minoxidil 5% foam and solution, typically applied twice daily. Oral minoxidil, dosed around 2.5 to 5 mg daily, has recently shown similar efficacy to topical minoxidil for MPHL and may be less irritating and easier to take.35 Additionally, combining topical minoxidil with oral spironolactone 100 mg daily has demonstrated improved efficacy and patient satisfaction over topical minoxidil and finasteride for FPHL.36 Telogen effluvium, as described in the postpartum period, can also be experienced during the menopausal transition, presenting as diffuse hair loss without a specific pattern.
Women experiencing perimenopause or post menopause may also encounter other hair changes, including greying hair or achromotrichia. Although some causes may be due to vitamin B12, iron, or copper deficiencies and potentially reversible, achromotrichia is an otherwise normal part of the aging process.37 Cosmetic options for treatment include hair dyeing with permanent or semipermanent dyes, although this can be irritating to the scalp. Currently, treatment options with oral medications are limited and lack sufficient evidence for recommendation.37 Comprehensive dermatologic care should include guidance on safe cosmetic practices and recognition of reversible causes of hair changes to support women’s overall hair health during these life stages.
During menopause, women may experience increased facial hair, which can be managed through trimming, threading, and lasering.38 Lasering of facial hair works by targeting pigmented hair, which tends to decrease with age and menopause, so care should be taken to undergo laser treatment while the hair still has pigment. Spironolactone or other aldosterone-suppressing medications can be considered, given that the increase in hair growth during menopause is hypothesized to be due to increased androgens in the skin.39 Additionally, topical eflornithine 13.9% cream can be applied to affected regions on the face twice daily for excessive hair growth.40
Skin
Disconcerting skin changes can occur during menopause, primarily wrinkles that develop due to changes in collagen and fat loss in the temporal and buccal regions of the face. Skin atrophy from collagen loss occurs first in early menopause and may present as wrinkling or a crepe-like texture.34 This is secondary to the systemic drop or fluctuations in estrogen and resulting decreased estrogen in the dermis that occurs during menopause. Xerosis is also common, particularly after menopause, as declining estrogen decreases sebaceous gland production, leading to dry, itchy skin. Additionally, oral and conjunctival mucosa may become dryer during this time. Treatments of choice include emollients and artificial tear eye drops. Actinic lentigines become more common with age and are associated with lifetime UV damage.
While hormone replacement therapy should primarily be considered in patients experiencing vasomotor symptoms from menopause, there are noted positive effects on the skin, including increased dermal thickness, elasticity, and hydration, although the benefit for wrinkles remains unclear. Other treatment options include improved photoprotection, hyaluronic acid fillers, and correcting any underlying nutritional or vitamin deficiencies.34
Notably, menopause is a challenging period for many women, not only due to physical symptoms but also due to societal pressures and judgment. Providing emotional support alongside medical treatment is crucial during this transition. Encouraging open discussions about patients’ experiences and concerns, connecting them with support groups, and validating their feelings can significantly contribute to their overall well-being and mental health.
Vulvar Health
Women over age 65 may not visit their OB-GYN due to no longer needing Pap smears.41 For many women, their dermatologist may be the only doctor they see regularly, making it essential to include vulvar evaluations and address vulvar skin concerns as a standard part of every postmenopausal patient’s visit. Notably, an estimated 50% to 70% of women experience symptoms consistent with GSM, although most cases are underrecognized and undertreated.42 Signs and symptoms of GSM include dysuria, vulvovaginal atrophy, increased susceptibility to urinary tract infections, and dyspareunia. Patients benefit from treatment with vaginal estrogen, which is safe to use in most women, including those with a history of estrogen-positive breast cancer.43
Lichen sclerosus (LS) is an autoimmune dermatosis primarily affecting the vulva and genital region. LS is characterized by white, thin plaques that can distort genital architecture and cause uncomfortable sensations like dysuria, itching, and burning. Although often associated with women after menopause, LS can affect women of any age. As women age out of Pap smears, vulvar examinations become uncommon, leading to potential underdiagnosis and worse outcomes. LS is treated with topical clobetasol 0.05% ointment, typically applied once daily. Patients should be advised to avoid the inguinal folds to prevent skin atrophy. Otherwise, topical clobetasol is safe to apply to the vulvar mucosa in all age groups, including pregnant women.
Irritant contact dermatitis (ICD) is an inflammatory condition caused by persistent contact with irritating substances like urine or fecal matter, commonly affecting the vulva and inguinal region. ICD is prevalent in older adults due to increased rates of incontinence. Persistent contact with these substances can macerate the epidermis, leaving the skin vulnerable to trauma and friction.42 First-line therapy for ICD includes proper hygiene and over-the-counter 40% zinc oxide pastes for barrier protection, along with pelvic floor physical therapy for incontinence. These patients should be managed by a multidisciplinary team to ensure comfort, dignity, and continued quality of life.
Conclusion
Empowering women through personalized skin care across their lifespan is not merely about addressing health concerns but also about fostering self-confidence and well-being. By recognizing and responding to the distinct dermatologic needs that arise during adolescence, pregnancy, perimenopause, and post menopause, we can offer more than just treatment—we can provide a holistic approach to health that champions the unique journeys of women. As dermatologists, our role is to continually evolve with scientific advancements and empathetic understanding, ensuring that every woman feels seen, supported, and celebrated in her skin.
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Disclosure: The authors report no relevant financial relationships.
