Hormonal Contraceptives and Dermatology

Natalie M. Williams; Michael Randolph; Ali Rajabi-Estarabadi; Jonette Keri; Antonella Tosti


Am J Clin Dermatol. 2021;22(1):69-80. 

In This Article


Rosacea is a common dermatologic condition characterized by facial erythema, inflammatory papulopustules, and/or telangiectasias. It most commonly affects lightly-complected middle-aged individuals, with women diagnosed at younger ages than men. Rosacea has traditionally been divided into four subtypes: (1) erythematotelangiectactic rosacea (ETTR); (2) papulopustular rosacea (PPR); (3) phymatous rosacea; and (4) ocular rosacea. However, several rosacea experts have recently recommended a more patient-centric phenotype approach over subtyping.[96] Both genetic and environmental factors are believed to play roles in the pathogenesis, with the primary issue centered around an increase in blood flow to the skin.

While cardiovascular and gastrointestinal diseases are the more classic comorbidities that have been reported with rosacea, recent studies have demonstrated significant associations between rosacea and female hormone imbalances.[97] Data from the Nurses' Health Study II, which included over 75,000 females with rosacea, found that women with rosacea were more likely to be postmenopausal and less likely to be current COC users.[98] While the role of hormones in the etiology of rosacea has not been elucidated, studies investigating hormonal contraceptives have suggested a hormonal influence in specific subtypes.[99]

A number of factors are known to aggravate rosacea, including alcohol, spicy foods, and sun exposure. There are reports that reproductive hormones, whether endogenous or exogenous, can also be added to this list (Table 4). In a study of 53 female rosacea patients, 13 reported COC use, pregnancy, or menstruation as exacerbating factors for their rosacea.[100] The mechanism by which COCs may trigger rosacea is speculated to be due to the ability of estrogen to potentiate the effects of corticosteroids on the skin, such as telangiectasias.[101] Earlier generations of COCs that were high in estrogen were found to increase rosacea by more than threefold.[99] Rosacea fulminans, or pyoderma faciale, is often considered a specific type of rosacea and may be particularly related to hormonal factors. Exacerbating factors for rosacea fulminans include pregnancy and emotional distress.[102,103] It is proposed that emotional disturbances can cause hormonal fluctuations, leading to increased sebum production.[104] With this reasoning, hormonal factors may also be a trigger for rosacea fulminans in females taking COCs. While some reports have exhibited patients taking COCs before the eruption of rosacea fulminans, no significant associations have been established.[102]

Alternatively, some studies suggest that COCs may improve skin lesions in patients with rosacea. One of the earliest reports to demonstrate this effect followed 30 women with rosacea treated with 3 mg of CMA and 0.1 mg of mestranol for up to 18 months.[105] In general, papulopustular lesions were more quickly and easily treated than the erythema. Complete recovery or significant improvement was obtained in 18 of 30 (60%) patients. Of note, females with endocrine disorders were more responsive to treatment, with 70% recovering compared with 30% of women without such abnormalities. Similarly, Mauss treated three women with PPR with a CPA-containing oral contraceptive in combination with 10 mg of CPA daily between days 5 and 19 of the menstrual cycle.[106] At 3 months' follow-up, this regimen completely cleared all papules and pustules, but had no effect on telangiectasias.

As with COCs, there is limited evidence to suggest that the non-oral forms of hormonal contraception are associated with rosacea. A case report by Choudry et al. described a 36-year-old woman who developed rosacea after the insertion of a progesterone-releasing IUD.[107] The patient experienced papules, pustules, and flushing over the face for a 2-year period after implantation. Her symptoms resolved 6 months after removal of the IUD. Rosacea has also been reported as an adverse effect in trials of other methods of hormonal contraception, including combined contraceptive vaginal rings, such as the NuvaRing® (Merck & Co., Inc.).[108]

Ultimately, hormonal contraceptives are not clear triggers of rosacea and have not been decisively proven to be effective in treating this condition. While larger, randomized studies are needed to further assess the efficacy of hormonal contraceptives in treating rosacea, the current literature suggests that this option may be more beneficial for the papulopustular variant or women with pre-existing endocrine imbalances.