Menopause and skin

Dermatologists discuss dermatologic changes before and during menopause and the dermatoses that may occur.

Feature

By Allison Evans, Assistant Managing Editor, December 1, 2025

Menopausal transitions can be stressful. While rapidly declining estrogen levels can wreak havoc internally, many of these changes involve the skin, hair, and vulvar region — all of which can severely impact self-esteem, relationships, and everyday functioning.

Menopause, a time marked by not having menstrual periods for 12 months in a row, typically happens between the ages of 45 to 55. Perimenopause starts about two to eight years before menopause. During this time, women may notice changes, including drier skin, decreased skin laxity, hair loss, acne, and vulvovaginal dryness, said Melissa Mauskar, MD, FAAD, current member of the board of directors for the Women's Dermatologic Society, associate professor in the departments of dermatology and obstetrics and gynecology in Dallas, and director of the Vulvar Health Program at UT Southwestern.

"This transition from perimenopause to menopause can affect every single organ in your body, and since skin is the largest organ, we see those effects in so many places that dermatologists interface with on a daily basis," she added. 

Skin and nail changes 

During menopause, skin quickly loses collagen, which can lead to skin thinning, wrinkling, and sagging. Studies show that women's skin loses about 30% of its collagen during the first five years after menopause. After that, the decline is more gradual with women losing about 2% of their collagen every year for the next 20 years. 

As hormone levels plummet, these skin changes can also cause some women to develop teenage-like acne. "Acne treatment was designed for the teenage or early adult patient," noted Miriam Pomeranz, MD, FAAD, associate professor at NYU Grossman School of Medicine and chief of dermatology service at Bellevue Hospital. 

"When you're treating acne for perimenopausal or post-menopausal patients, you need to balance the irritation of topical treatments with the underlying dryness of the skin. You can advise patients to use a moisturizer first and then apply the topical acne treatment as well as using water-based cosmetics," she recommended.

"After menopause, estrogen levels rapidly decrease, while testosterone diminishes gradually, causing a relative androgen excess. You may see female pattern hair loss, acne, and hirsutism in these patients," Dr. Mauskar said. "That's when spironolactone becomes a go-to treatment to help with that excess androgen."

Dr. Mauskar noted that topical retinoids are tried and true for hormonal acne during perimenopause. "I try to get patients to use topical retinoids not only for their acne but also to help with fine lines, wrinkles, and dyspigmentation."

"After menopause, estrogen levels rapidly decrease, while testosterone diminishes gradually, causing a relative androgen excess. You may see female pattern hair loss, acne, and hirsutism in these patients."

On the other hand, some women may notice that their persistent acne disappears, said Nanette Silverberg, MD, FAAD, editor-in-chief of the International Journal of Women's Dermatology and chief of pediatric dermatology for Mount Sinai Health Systems. "Unfortunately, some women may then get rosacea, which is significantly triggered by hot flashes," she added.

Dermatologists agree that sun protection is one of the best, and simplest, ways to reduce skin changes from menopause. Sunscreen can reduce the compounding effect of light on collagen loss, reduce and prevent wrinkles, and prevent further thinning of the skin. Sunscreen can also help treat dark spots that can develop or darken during menopause. Dr. Mauskar emphasized that a lot of patients in that perimenopausal transition can still prevent some of the later stages of skin changes by using sunscreen.

"While skin and hair changes may be the most prominent symptoms during perimenopause and post-menopause, some patients may also notice nail changes," said Audrey Fotouhi, MD, FAAD, assistant professor of medicine at the University of Chicago. "Patients may experience longitudinal ridging or onychorrhexis, which are often related to xerosis. I tell my patients that their nails are going to get wrinkled like their skin." Patients may also experience nail changes from lichen planus, which is more common during the menopause process, she added.

Caring for your skin during menopause

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Share these tips with your patients about how to address skin changes during menopause, including age spots, facial hair, and hair loss. 

Flaring of inflammatory skin conditions

During perimenopause, some patients experience flares of atopic activity from vascular flaring. "Patients with atopic dermatitis or asteatotic dermatitis may experience extreme itching during hot flashes," Dr. Silverberg pointed out. 

"Sometimes people have had discontinuous atopic dermatitis throughout adulthood and may experience flaring during that perimenopausal period," she added. Other inflammatory conditions, like psoriasis, can flare during perimenopause. With hormonal fluctuations linked to inflammatory disease activity, systemic estrogen and/or progesterone may potentially be a useful treatment.

"As women age, there is a shift in becoming more Th2 dominant in terms of an immune response, which drives a lot of the different forms of skin involvement that we see in perimenopausal and post-menopausal women," said Jenny Murase, MD, FAAD, former secretary of the Women's Dermatologic Society, past co-editor in chief of the International Journal of Women's Dermatology, and associate clinical professor at the University of California, San Francisco.

"Something is shifting in the immune system to become more allergic dominant, and that can present as itching or red bumps. Eczema can become more prominent because we don't make as much oil on the surface of the skin as we age," Dr. Murase said. Because of this immune shift, she is more hesitant to use immunosuppressive agents in older patients.

"It's important to continue gathering data as the relationship between perimenopausal and menopausal changes and flaring of skin conditions is not well understood."

The impact of menopause on hidradenitis suppurativa (HS) is unclear, with contradictory and inconsistent evidence. While menopause had previously been thought to be accompanied by a decline in HS disease severity, a 2020 study found that after menopause, participants reported either worsening (40%) or no change (44%) in HS symptoms. The authors speculated that this could be because patients were older at the time of menopause and had a longer time to develop increased numbers of lesions in more anatomic regions, so that the overall disease burden was thought to be higher with menopause (doi: 10.1016/j.ijwd.2020.07.002). Additionally, there is some evidence to suggest that hormone replacement therapy has a risk of worsening disease activity.

"It's important to continue gathering data as the relationship between perimenopausal and menopausal changes and flaring of skin conditions is not well understood," said Dr. Silverberg. "It's hard to say why these conditions flare. Is it because people are gaining weight, which contributes to inflammation? Is it the tendency toward metabolic syndrome that comes with age?"

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Hair

Women in perimenopause and/or menopause may have an increased risk of a genetic predisposition for hair thinning — the most common one being androgenetic alopecia, said Kristen Lo Sicco, MD, FAAD, associate professor at the Ronald O. Perelman Department of Dermatology at NYU Grossman School of Medicine. The progressive hair thinning can occur at the temples and at the top of the scalp manifesting as a widened part, she said.

"During menopause, the anagen phase of the hair cycle shortens so many women will note that their hair doesn't grow as long as it used to. This is all part of androgenetic alopecia process," Dr. Lo Sicco added. "There can be textural changes as well. Some women may experience drier, more brittle hair."

Dr. Lo Sicco emphasized the importance of making sure patients are up to date on their annual physical to ensure there are no other contributing factors, such as thyroid issues or nutritional deficiencies.

For some of Dr. Mauskar's older postmenopausal patients with hair loss, she rarely prescribes topical minoxidil. "Many of these patients do not wash their hair as often and may go to the salon once a week to get their hair styled. They tend to be very resistant to topical minoxidil, and so I will often reach for an oral pill, like minoxidil, and then educate them about the fact that it may cause increased hair everywhere."

Treatments like low-dose oral minoxidil have become incredibly popular to treat both male and female pattern thinning because it's nonhormonal, and some patients are concerned about the potential for depressed mood or sexual side effects with anti-androgens, Dr. Lo Sicco said.

Finasteride is often used off-label to treat hair loss in post-menopausal women, and it's used at higher doses in women than men, she noted. "The FDA-approved dose for men is 1 mg, whereas we start most women at 2.5 mg."

Shedding light on female pattern hair loss

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Hair experts discuss the efficacy and safety of off-label treatments for female pattern hair loss. 

Vulvar dermatoses

Menopause brings with it an increased risk of certain vulvar conditions, including genitourinary syndrome of menopause and lichen sclerosus. "These conditions often go undiagnosed for years because women don't feel comfortable discussing these symptoms, and they may not be seeing their gynecologist as regularly post-menopause," Dr. Silverberg noted.

GSM

Genitourinary syndrome of menopause (GSM, previously known as vulvovaginal atrophy) affects up to 84% of post-menopausal women. Diminished estrogen levels after menopause lead to vulvovaginal thinning, decreased secretions, pale mucosa, loss of rugae, and occasional erythema. Common symptoms include dryness, burning, itching, pain, dyspareunia, and recurrent urinary tract infections. If untreated, GSM typically worsens over time and can significantly impact quality of life (doi: 10.1016/j.jaad.2025.04.052).

Low-dose topical vaginal estrogen is the cornerstone of GSM treatment, Dr. Pomeranz said. It normalizes vaginal pH, restores microflora, thickens the epithelium, enhances secretions, and provides urinary benefits. There is strong safety data showing limited systemic absorption and no increased risk of breast or endometrial cancer, heart disease, stroke, or venous thromboembolism with this therapy (doi: 10.1016/j.jaad.2025.04.052). 

Lichen sclerosus

Lichen sclerosus is a chronic inflammatory condition that can present in children and during reproductive years. However, it commonly occurs during menopause, said Dr. Pomeranz. Lichen sclerosus is very important to treat, she stressed. 

"It can cause symptoms like irritation or itching, particularly during menopause, and dyspareunia. Even without causing symptoms, it can cause scarring, which then can interfere most commonly with sex, but possibly even with urination. Other signs to be aware of include white, raised bumps, textural changes, and thinning of the skin," she added.

Without treatment, lichen sclerosus can progress to malignancy, Dr. Pomeranz explained. "There's some evidence suggesting that women who treat it don't have a higher rate of malignancy than the general population, whereas women who don't have their lichen sclerosus treated experience higher rates of malignancy — squamous cell carcinoma of the vulva in particular."

"As dermatologists, we're very adept at recognizing and treating lichen sclerosus, and the first-line treatment is still potent topical steroids. It's a fairly simple treatment that dermatologists should be comfortable prescribing," she added. 

"Our older post-menopausal patients are not getting regular pap smears anymore, so they're not getting regular gynecologic exams. We need to be the ones to look."

Dr. Pomeranz stressed that dermatologists need to recognize that topical steroids are safe to use on the modified mucous membrane of the vulva. "A topical steroid, which might normally thin skin and cause issues, tends to not cause problems if kept in those areas. If it gets onto hair-bearing skin or skin folds, then you can run into issues like striae and thinning of the skin."

Making vulvar dermatoses even more complicated to diagnose, menopause can cause changes to the structure of the vulva as well. "Lichen sclerosus often scars the labia minora by fusing them with the labia majora, but sometimes by allowing them to resorb. Menopause also sometimes allows for the resorption of the labia minora. Just because the labia minora are getting smaller, or even absent, does not by definition mean someone has lichen sclerosus," she said.

Genitourinary syndrome of menopause can cause patients to experience symptoms similar to those of lichen sclerosus or even lichen planus, including persistent dryness, pruritus, or dyspareunia, Dr. Pomeranz stated. 

"It is nearly impossible to tell whether someone has treated or partially treated lichen sclerosus or has genitourinary syndrome of menopause and is experiencing architectural changes associated with menopause," Dr. Pomeranz said. 

Examining the vulvar region is critical to ensuring there are no skin cancers, which are more common in post-menopausal women, Dr. Pomeranz noted. Vulvar squamous cell carcinoma is the most common vulvar cancer, but vulvar melanoma is deadly. "The prognosis is often poor due to late diagnosis and its high potential to metastasize."

Topical estrogen, hormone replacement therapy

While Dr. Pomeranz does not prescribe systemic estrogens, she will prescribe topical estrogen. Her menopausal patients on topical estrogen are followed by a gynecologist because, "it's possible that topical estrogen will induce spotting — and that has to be fully evaluated 100% of the time."

Many dermatologists have received little to no training in using vaginal estrogen, making it underutilized in practice. "It can make such a big difference in relieving patients' symptoms," Dr. Mauskar added. 

"If your patient is experiencing vulvar itch and they have a normal vulva, topical estrogen is a great place to start," said Dr. Fotouhi. "It is so safe, even in patients with a history of cancer. There's a lot of recent data published on its safety, including its low systemic absorption."

A 2002 Women's Health Initiative study linked systemic hormone replacement therapy (HRT) to increased cardiovascular and cancer risk, fueling longstanding misconceptions about the treatment, and an FDA boxed warning for topical vaginal estrogen. However, in November 2025, the FDA said it will remove the boxed warning from more than 20 hormone-based drugs, like estrogen and progestin, approved to ease hot flashes, night sweats, and other menopause symptoms. The FDA, led by Commissioner Marty Makary, MD, MPH, published a commentary in JAMA (doi: 10.1001/jama.2025.22259).

While most dermatologists would not find themselves prescribing HRT, it is important to be aware of patients who are using it. "In theory, at least for a subset of the population, HRT does slightly increase the rate of venous thrombosis. If a patient comes in with a swollen leg, you may want to be aware of the potential, but HRT is very low risk," Dr. Pomeranz said.

A burgeoning area of research is whether topical estrogen can prevent skin aging. "There is some data to show that topical estrogen can help prevent skin aging, especially in post-menopausal women," Dr. Lo Sicco said. According to a Brief Report in JAAD, estradiol showed improvements in skin thickness and collagen, and estriol showed improvements in wrinkles, firmness, and hydration comparable to estradiol (doi: 10.1016/j.jaad.2025.08.050). 

Despite emerging evidence demonstrating some efficacy of topical estrogen on skin aging, the heterogeneity across these studies prevents broad conclusions from being drawn.

Researchers are also questioning whether hormone replacement therapy may have benefits for women with androgenetic alopecia, Dr. Lo Sicco said. "There aren't great studies yet, although clinical studies are currently underway."

Addressing sensitive topics

While dermatologists need to be gentle in their approach and attitude when addressing concerns in sensitive areas, they also should be matter of fact. "If we transmit a sense of embarrassment, then the patient will for sure be embarrassed," Dr. Pomeranz said. "It's also important to include patients in the exam process and explain each step as you go."

If a perimenopausal or post-menopausal patient is seen with extremely dry skin, Dr. Mauskar will use that as a lead-in to talk about the fact that dry skin is something that occurs everywhere on the body, including the vulvar region. "A lot of my patients will then let me know that they actually have really dry skin on the vulva or pain with sex or UTIs. If you open the door, they are so thankful to talk about it because they're nervous to bring it up."

Dr. Fotouhi stressed the importance of making genital exams a routine part of total body skin exams. "Our older post-menopausal patients are not getting regular pap smears anymore, so they're not getting regular gynecologic exams. We need to be the ones to look."

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Benjamin Hidalgo-Matlock
Skin Care Physicians of Costa Rica

Clinica Victoria en San Pedro: 4000-1054
Momentum Escazu: 2101-9574

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