Why Acne, Flushing, and Dermatitis Worsen Before Menstruation

In conversations with patients, many report that acne worsens before menstruation, their face feels hotter, or dermatitis becomes more severe.

These changes are primarily caused by fluctuations in estrogen and progesterone hormones.

This article will explain hormonal changes throughout the menstrual cycle and how these changes affect the skin.

Menstrual Cycle and Hormonal Changes

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Around the start of menstruation, both estrogen and progesterone are low. After menstruation ends, estrogen begins to rise and peaks just before ovulation. After ovulation, progesterone rises, and estrogen also rises again gradually. Both hormones then drop together just before menstruation.¹

Due to these hormonal changes, body temperature rises from after ovulation until before menstruation, which can worsen heat sensation and flushing, and acne and dermatitis may worsen before menstruation.

Why Acne Worsens Before Menstruation

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In a study of 400 women, 44% reported that acne worsened before menstruation, indicating that premenstrual acne exacerbation is quite common.^2,3

Just before menstruation, estrogen and progesterone drop, increasing the relative influence of androgens (male hormones) on sebaceous glands.⁴ When sebaceous glands respond more sensitively to androgen stimulation, sebum production increases, which can worsen acne.

The hypothesis that premenstrual acne is caused by a sudden increase in testosterone was once popular, but studies measuring testosterone daily found it was only slightly elevated around ovulation and did not rise significantly just before menstruation. In fact, day-to-day variations were greater than differences across the menstrual cycle.⁵

Why Flushing and Dermatitis Worsen

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After ovulation, basal body temperature rises by approximately 0.3–0.5°C due to the influence of progesterone. While this change is generally not noticeable, for individuals with many heat receptors in the skin who are sensitive to heat or who have rosacea, flushing, or burning sensations, it can be a stimulus that causes facial flushing.^1,6

Atopic dermatitis often worsens starting about one week before menstruation. A recently proposed hypothesis is that elevated progesterone after ovulation impairs skin barrier function and worsens immune responses related to itching.⁷ Additionally, during this period, elevated body temperature and sweat irritate the skin, and when combined with sleep deprivation or stress, itching, stinging, and dryness can become more severe.

How to Relieve Severe Symptoms

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Flushing and Heat Sensation

If heat sensation and flushing worsen from after ovulation until before menstruation, especially in the 5–7 days before menstruation, reduce stimuli that cause facial flushing such as hot showers, saunas, excessive alcohol consumption, and spicy foods. There is no need to stop exercising, but it is better to avoid intense exercise that overheats the face and to reduce intensity in cooler environments.⁶

Dermatitis

If itching or redness begins around one week before menstruation, it is advisable to use topical anti-inflammatory agents such as Protopic or Elidel early, before symptoms worsen.⁸

Premenstrual Acne

Spironolactone and Winlevi are medications that can be used to treat acne in adult women.⁹ If acne is generally fine but worsens only before menstruation, these two medications may be considered before traditional sebum regulators such as isotretinoin. This is because they reduce the influence of androgens involved in premenstrual acne exacerbation and generally cause less discomfort than isotretinoin.

Spironolactone is an oral medication that reduces sebum and acne by making sebaceous glands less responsive to androgens. In a clinical trial starting at 50 mg per day and increasing to 100 mg, 82% of participants reported improvement in acne after 24 weeks, compared to 63% who took placebo.¹⁰ However, it may cause frequent urination, headache, dizziness, breast tenderness, or menstrual irregularities. Blood tests are required for individuals with kidney disease or those taking medications that increase potassium, and it cannot be taken during pregnancy.¹⁰

Winlevi is a 1% clascoterone cream applied to the face. It blocks androgen receptors in the applied area to reduce sebum and inflammation. In a clinical trial applying it twice daily for 12 weeks, 18–20% of participants experienced a reduction of two or more grades, achieving nearly clear skin, compared to 7–9% with placebo.¹¹ The applied area may become red, dry, flaky, or itchy, but most cases are mild. Unlike spironolactone, systemic side effects such as frequent urination or dizziness are rare, but it also cannot be used during pregnancy.^11,12

If efficacy is the priority, spironolactone may be considered; if systemic side effects from oral medication are a concern, Winlevi may be considered. Although there are no clinical trials directly comparing the two medications, a comprehensive analysis of multiple clinical trials found that high-dose spironolactone at 200 mg per day was more effective.¹³

If severe premenstrual skin changes are accompanied by menstrual irregularities, hirsutism, female pattern hair loss, or infertility, testing for PMOS (formerly PCOS) or androgen excess may be considered.^14,15 If severe urticaria, edema, or blisters recur at the same time each month, rare progesterone hypersensitivity should also be evaluated.¹⁶

If Your Skin Worsens at the Same Time Each Month

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Premenstrual acne, flushing, and dermatitis exacerbation occur at similar times, but treatment methods differ. For acne, reduce the influence of androgens; for flushing, reduce heat stimuli; and for dermatitis, use anti-inflammatory agents early when symptoms begin.

If symptoms are generally fine but repeatedly worsen before menstruation, it is recommended to start treatment before exacerbation occurs, referring to the above information, rather than waiting to calm symptoms after they worsen.

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References

1. Baker FC, Siboza F, Fuller A. Temperature regulation in women: Effects of the menstrual cycle. Temperature (Austin). 2020;7(3):226-262.
2. Stoll S, Shalita AR, Webster GF. The effect of the menstrual cycle on acne. J Am Acad Dermatol. 2001;45(6):957-60.
3. Lucky AW. Quantitative documentation of a premenstrual flare of facial acne in adult women. Arch Dermatol. 2004;140(4):423-4.
4. Bagatin E, Freitas THP, Rivitti-Machado MC, et al. Adult female acne: a guide to clinical practice. An Bras Dermatol. 2019;94(1):62-75.
5. Bui HN, Sluss PM, Blincko S, et al. Dynamics of serum testosterone during the menstrual cycle evaluated by daily measurements with an ID-LC-MS/MS method and a 2nd generation automated immunoassay. Steroids. 2013;78(1):96-101.
6. American Academy of Dermatology. How to prevent rosacea flare-ups. 2026.
7. McSwiney NT, Hutchison E, Moran R, et al. Impact of the menstrual cycle on exacerbations of atopic dermatitis: a systematic review. Clin Exp Dermatol. 2025;50(9):1748-1754.
8. American Academy of Dermatology. Atopic dermatitis clinical guideline. 2026.
9. Reynolds RV, Yeung H, Cheng CE, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2024;90(5):1006.e1-1006.e30.
10. Santer M, Lawrence M, Renz S, et al. Effectiveness of spironolactone for women with acne vulgaris (SAFA) in England and Wales: pragmatic, multicentre, phase 3, double blind, randomised controlled trial. BMJ. 2023;381:e074349.
11. Hebert A, Thiboutot D, Stein Gold L, et al. Efficacy and Safety of Topical Clascoterone Cream, 1%, for Treatment in Patients With Facial Acne: Two Phase 3 Randomized Clinical Trials. JAMA Dermatol. 2020;156(6):621-630.
12. Korea Pharmaceutical Information Institute. Winlevi Cream Medication Guide. 2026.
13. Basendwh MA, Alharbi AA, Bukhamsin SA, et al. The efficacy of Topical Clascoterone versus systematic spironolactone for treatment of acne vulgaris: A systematic review and network meta-analysis. PLoS One. 2024;19(5):e0298155.
14. Teede HJ, Tay CT, Laven JJE, et al. Recommendations From the 2023 International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome. J Clin Endocrinol Metab. 2023;108(10):2447-2469.
15. Endocrine Society. Polyendocrine Metabolic Ovarian Syndrome: New name to improve diagnosis and care of condition affecting 170 million women worldwide. 2026.
16. Lipman ZM, Labib A, Vander Does A, et al. Autoimmune Progesterone Dermatitis: A Systematic Review. Dermatitis. 2022;33(4):249-256.