Therapeutic approach for many women's skin conditions require special considerations

Women and men are not always created equal when it comes to their dermatologic concerns, frequency and presentation of several dermatologic conditions, treatment options and outcomes.

“Common dermatologic conditions may need to be addressed and thought about differently when they occur in women,” says Maria Hordinsky, M.D., professor and chairwoman, department of dermatology, the University of Minnesota, Minneapolis. “People have to take into consideration the hormonal changes that go on in a woman over the lifespan. (Treating women requires) thinking about pregnancy and the potential for pregnancy in the early years. Then, later on, thinking about the dynamics of potential drug-drug interaction in an older woman’s life."

Dr. Hordinsky says hot dermatology-related topics for women include aging’s effects on hair and skin, as well as skin changes associated with pregnancy and menopause.

Acne, rosacea and hormonal therapy

While acne affects the majority of male and female adolescents, adult women are more often affected by acne than are men, according to Bethanee J. Schlosser, M.D., Ph.D., assistant professor, departments of dermatology and obstetrics/gynecology, Northwestern University Feinberg School of Medicine, Chicago.

“Adult women with acne can present with different clinical features compared to adolescents and men with acne,” Dr. Schlosser says. “Adult women may preferentially develop acne lesions on the lower one-third of the face … and upper-neck which consist of tender nodules under the skin.”

Dr. Schlosser says acne often worsens around the time of menstruation.

“Such features suggest that adult women with acne may benefit from hormonal therapy rather than oral antibiotics and other acne treatments,” she says.

Women are more commonly affected by rosacea, but men with rosacea have been shown to have more severe rosacea and are at greater risk of developing phymatous rosacea, she says.

“Rosacea most often begins in the fourth decade of life … and many women report fluctuation of their rosacea symptoms and skin lesions with regards to the menstrual cycle and in the context of hormonal medication like oral contraceptive pills,” Dr. Schlosser says.

Similarities in psoriasis

Psoriasis presents similarly and affects both men and women nearly equally, according to Erin Boh, M.D., Ph.D., chairwoman and professor of dermatology, Tulane University Health Sciences Center, New Orleans. But women may have different concerns from the psychosocial, as well as physical perspectives, she says.

“There are a few unique issues for women - the most obvious being in those of child-bearing age,” Dr. Boh says. “For instance, I recommend phototherapy (narrowband UVB) more frequently to women who are actively trying to get pregnant, or if they are pregnant. There are few safe medications for pregnant women but, if a patient absolutely needs one, I use cyclosporine A.”

For non-pregnant, non-lactating patients, sex is not a strong factor for treatment choices, except that dermatologists should not give oral retinoids to women of childbearing age, if possible, according to Dr. Boh.

Autoimmune issues and more

Women are more likely than men to get lupus and dermatomyositis. And there is an increasing incidence and prevalence of autoimmune blistering diseases seen in women, according to Victoria Werth, M.D., professor of dermatology and medicine, University of Pennsylvania, Philadelphia.

“There are specific issues about safety of medications in women of child-bearing potential, some of which are also relevant to men. In particular, women who require steroids and might benefit from bisphosphonates to prevent bone loss usually must avoid these if they plan to have children,” Dr. Werth says. “In addition, although hydroxychloroquine and azathioprine are used routinely during pregnancy in women with a variety of autoimmune problems, drugs like chloroquine, quinacrine, methotrexate and mycophenolate should be avoided.”

Another important issue for dermatologists treating these women to consider: quality of life among women with cutaneous lupus is worse than for men, Dr. Werth says.

“The disease activity particularly affects the emotional component of quality of life,” she says.

Another concern for women: lichen sclerosis, which affects the vulvar area. Clinically, patients present with white, atrophic, shining cigarette-paper-like plaques in the vulva, perianal area and ecchymosis, says A. Mary Guo, M.D., assistant professor, department of dermatology, Saint Louis University, St. Louis.

Dermatologists should watch for a secondary change of excoriation, erosion, ulceration and hyperkeratosis when treating lichen sclerosis, Dr. Guo says.

“Patients need to have long-term follow-up to monitor the effectiveness of treatment, as well as any changes of malignancy. Rarely, patient may have lichen sclerosis and morphea overlapping, which may require systemic treatment,” she says.

Another condition affecting the vulva area, lichen simplex chronicus, results from chronic rubbing, scratching or both.

“Often, it is difficult to find out the original trigger of local pruritus. Most of these patients do have an atopic diathesis in my opinion,” Dr. Guo says.

Pregnancy concerns

Medication safety in female patients who are pregnant, nursing or trying to conceive is important. Pregnancy also can affect psoriasis, eczema and other common skin diseases, according to Dr. Schlosser.

“Pregnancy presents unique changes in the hormonal composition and immune system activity of women,” she says.

According to Dr. Schlosser, psoriasis may improve, remain stable worsen during pregnancy; however, having psoriasis can influence a woman's risk of delivering her baby prematurely.

Eczema often worsens during pregnancy.

“Many women experience eczema for the first time during pregnancy, and atopic dermatitis in pregnancy accounts for half of pregnant patients that present with an itchy skin rash,” Dr. Schlosser says.

There are several skin conditions that are unique to pregnancy. The most common, Dr. Schlosser says, is polymorphic eruption of pregnancy.

“Fortunately, polymorphic eruption of pregnancy does not carry any risks for either the pregnant woman or her fetus,” Dr. Schlosser says. “Pemphigoid gestationis, cholestasis of pregnancy and impetigo herpetiformis … all have potential negative consequences for the pregnant woman and her fetus.”

Pigmentary disorders

The pigmentary issues most likely to occur in women, according to Philadelphia dermatologist Susan Taylor, M.D., are solar lentigines, melasma and postinflammatory hyperpigmentation.

“Men do develop solar lentigines but do not seem as bothered by them and usually do not seek treatment for them. Melasma rarely occurs in men,” Dr. Taylor says. “Since fewer adult men experience acne as compared to adult women, we see less post-inflammatory hyperpigmentation in men.”

Again, the emotional component appears to be more pronounced among women. Dr. Taylor says men seem less concerned if pigmentary issues develop. Men are also less willing to use a topical medication daily or twice-daily to address the problem.

For women, pigmentary issues are more than a cosmetic problem. They affect women’s self-esteem and work and social interactions, according to Dr. Taylor, who published findings in the September 2008 issue of the Journal of Cosmetic Dermatology about how pigmentary disorders impact life quality.

Cosmetic nuances

There are nuances between especially cosmetic male and female patients, according to Heidi A Waldorf, M.D., director of laser and cosmetic dermatology at Mount Sinai Medical Center, New York.

“Female patients are generally more apologetic about 'being vain' and feel guilty about spending on themselves instead of their families. I've never heard a male patient voice those concerns,” Dr. Waldorf says. “The men in my practice more commonly ask to treat specific brown spots or red vessels while more women ask to look younger.”

In some cases, Dr. Waldorf’s approach to cosmetic treatments is different for women and men.

“I had one man who wanted his lips augmented, and that was tricky without feminizing him,” Dr. Waldorf says. “It is important to remember that the ideal male face is more angular than the ideal female face. The overall face shape should be a rectangle or rhomboid for a man, versus an upside down egg or heart for a woman.”

Dermatologists also should be careful when treating men versus women with neuromodulators.

“A man's brow should remain straight and can even be heavy. A woman's must have some arch,” Dr. Waldorf says.

Handling hair loss

Hair loss in women affects many women emotionally not only because they might have less hair but also because their hairstyling suffers, according to Dr. Hordinsky.

“The hairstyle that a man is usually simple compared to a lot of women,” she says.

Female patients might consider not taking their medications if a drug has the potential to affect hair loss or hair growth, Dr. Hordinsky says. One of the challenges in treating the aging female patient experiencing hair loss is to step back and take a look at the mechanisms of action of medications that patient is taking, she says.

“Weigh the risks and benefits. If it’s a non-scarring type of hair loss problem, talk about the tools we do have to maintain the hair follicle in a growth phase, so the patient can continue the medication … prescribed for the underlying medical problem,” Dr. Hordinsky says.

Many women have a deep emotional concern with their hair quality throughout their lives.

“It is not uncommon to see women in their 70s, 80s and even early 90s coming to the clinic with the chief complaint of hair loss, where they are seeking to improve their hair density because that is part of their image,” Dr. Hordinsky says. “And they will work very hard with the tools that we have to try and get the best clinical result possible.”

An issue for dermatologists, however, is there are few studies available to refer to on the efficacy of some devices or products on hair loss in aging women, she says.

A hair loss issue that dermatologists might see increasingly among women, according to Dr. Hordinsky, is frontal fibrosing alopecia, a condition first recognized in the mid- ’80s.

“In the past three to five years, there has been a dramatic increase in the number of patients with this entity. It seems to primarily affect postmenopausal women,” she says.

At this point, there are only hypotheses, including hormonal and inflammatory causes, and how best to manage frontal fibrosing alopecia remains a mystery. However, Duke University researchers have started a cross-country epidemiologic study to understand what might be behind this “epidemic” among postmenopausal women, Dr. Hordinsky says.

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