The menopause and perimenopause have been receiving increased coverage of late in the consumer and medical press. Western women on average spend over a third of their lives post-menopausal which has led to concerns regarding postmenopausal health care [1].
Research into the topic has been slowly increasing – for example, the number of published papers in the National Library of Health (PubMed) shows an increase of around 20% over the last decade. Consequently, women are increasingly able to access the information they need to manage the effects of this period of life as well as deal with the associated comorbidities. But what about the affects on the skin and the feet? This blog looks at the available evidence to date.
Menopause, Marketing and Meno-washing
The increased interest in menopause has not gone unnoticed by commercial companies as a marketing opportunity. There has been a surge of "meno-washing," - where many products (face creams, skin care products, shampoos and many others) have been suddenly labelled and marketed as menopause “must-haves”.
Overblown marketing claims can leave people feeling confused as to what is best for their health. The British Skin Foundation has highlighted concerns about scaremongering and brands cashing in on women's anxieties. They've also given some great advice on what ingredients to look for to support skin health during menopause, rather than just buying anything with "menopause" on the label. Their blog is certainly worth a read – click here.
So how does the menopause affect health?
The menopause typically hits around the age of 51, with perimenopause occurring in the early to mid-40s (though this can vary). The drop in oestrogen, progesterone, and testosterone can trigger a whole host of symptoms and increase the risk of heart disease, dementia, type 2 diabetes, osteoporosis, and even premature mortality.
Surprisingly, there's not a huge amount of research specifically on how menopause affects skin, and even less on the skin of the foot or lower limb. The few studies available have small numbers of participants. A survey showed that around 64% of women report skin problems during perimenopause/menopause, with dryness being the main complaint [2].
Menopause or natural ageing?
The challenge for researchers is to untangle the effects of menopause and hormonal changes with general chronological ageing, photoageing, environmental factors and poor skin care practices. Well designed studies are required to assess the effects of these multiple variables.
What we do know is that physiological skin ageing speeds up during menopause [3]. Slower cell turnover, cellular atrophy, degenerative changes in connective tissue, decreased capacity for tissue repair, increased skin laxity, and a drop in collagen causing slackness [1, 4, 5]. Women lose one third of skin collagen in the first five years of menopause [2]. Declining oestrogen detrimentally impacts the skin’s extracellular matrix (ECM) which provides strength, elasticity and resilience [6]. But what skin effects can be directly attributed to the menopause alone?
Most research focuses on the drop in oestrogen. Skin (especially on the face, genitals, and lower limbs) is packed with oestrogen receptors. While it is not fully understood what role oestrogen plays within the epidermis, it has been shown it stimulates the production of ceramides, sebum, and hyaluronic acid [4, 5] – the skins natural moisturising factors.
Less oestrogen means less of these natural moisturisers leading to dry skin, which doesn't shed properly. This can cause a build-up of dead skin cells - scale, a weakened skin barrier, and an increased risk of itch. Existing eczema and psoriasis can also flare up during the menopause [2, 3].
Studies have shown how epidermal thickness is reduced and the stratum corneum thickness increases post menopause [6]. Oestrogen is also thought the influence the vascularity of skin [6] along with wound healing [1]. Oestrogen prevents the age-related delayed wound healing by dampening the inflammatory response, and by downregulating the production of pro-inflammatory cytokines [7].
Interestingly, applying oestrogen directly to the skin has been shown to reduce trans epidermal water loss and improve the skin's barrier function [2], highlighting how important oestrogen is for skin health. Hormone replacement therapy (HRT) can also reverse some of these changes [3], boosting water retention, dermal thickness, hyaluronic acid production, DNA repair capacity and collagen production, while reducing dryness and wrinkles, and maintain better skin integrity. However, HRT is not suitable for all women. Consequently, what about topical treatments like emollients?
This is an interesting question, but should we be recommending special “menopause” foot creams? And if so, what ingredients should we be looking for? And, do we really need separate "menopausal skin products" as suggested by some authors [8]?
Emollients and menopausal skin
A recent pilot study by Kendall et al [9] showed a direct link between low oestrogen and reduced ceramide production in the skin. Ceramides are a diverse class of lipids, with over 1000 identified and 21 sub-classes identified in the human stratum corneum (SC). Along with cholesterol and fatty acids, these lipids form the SC lipid matrix and influence the structure and function of the epidermal barrier. By comparing the skin of pre- and post-menopausal women, the study identified that menopause reduced the amount of ceramides in the SC and showed that the ceramides produced in a hypo-oestrogenic state were shorter in structure.
By assessing trans epidermal water loss, the study went on to indicate that shorter ceramides form a less effective epidermal barrier, allowing increased TEWL in post-menopausal skin. Interestingly post-menopausal women on HRT had SC ceramide abundance and lengths similar to premenopausal women as well as higher levels of serum female hormone. This supports the theory that oestrogen directly affects ceramide metabolic pathway and has a direct role in regulating the epidermal barrier. Although the authors identified that age related effects on skin pH and decreased sebum production could have influenced the ceramide profile in the cohort used.
Based on the evidence available emollients containing ceramides may be beneficial for oestrogen-deficient skin, especially for those women unable to use HRT. However, ceramide containing creams are generally more expensive, and in the UK, there are very few foot creams marketed with a significant ceramide content.
What research do we need?
Oestrogen deficiency seriously impacts skin health, affecting its function, barrier, hydration, and healing. A compromised skin barrier makes people more prone to eczema, a common issue in older adults. We really need more research on how menopause affects the skin of the lower limb and foot, including the impact of reduced progesterone and testosterone, not just oestrogen.
Difficulties arise in recognising when perimenopause begins in order to study the effects of fluctuating hormone levels on the skin. The menopause journey occurs at different ages and over varying time spans. For example, those who undergo a surgical menopause will be suddenly plunged into a hypo-oestrogen state, whilst those entering the natural phase of the peri/menopause will experience fluctuating hormone levels over many years. Both these situations are likely to reflect differently on skin integrity.
More research is needed to see if the various forms of HRT have a long-term beneficial effect on skin integrity, and if topical oestrogen cream has potential uses in skin care products, and at what percentage? Topical oestrogen is already used for vaginal atrophy and might have potential for other skin conditions. Indeed a recent paper detailed its use as a treatment for keratoderma climactericum – a hyperkeratotic skin condition thought to be related to the menopause [10] - see my previous blog. We also need more investigation into the best ingredients for menopause skincare, like ceramides, other natural moisturizing factors (NMFs), retinoids, nicotinamides, and glycolic acid, and whether these would be beneficial specifically in foot emollients.
Conclusion
Based on the current evidence, the best advice is to recommend emollients that mimic the skin's natural moisturizing factors as closely as possible, which are often depleted in perimenopausal and menopausal patients. This means foot creams which contain ceramides, hyaluronic acid, urea (but not necessarily at high concentrations) and glycerine. In addition, we should also advise against practices that degrease or dry out the skin, such as the use of soaps, overly hot showers, and products containing sodium lauryl sulphate.
Michelle Reynolds MSc is a podiatrist based near Stockport, Manchester
References
1. Brincat, M.P., Oestrogens and the skin. J Cosmet Dermatol, 2004. 3(1): p. 41-9.
2. Kamp, E., et al., Menopause, skin and common dermatoses. Part 2: skin disorders. Clinical and Experimental Dermatology, 2022. 47(12): p. 2117-2122.
3. Wines, N. and E. Willsteed, Menopause and the skin. Australasian Journal of Dermatology, 2001. 42(3): p. 149-160.
4. Merzel Šabović, E.K., T. Kocjan, and I. Zalaudek, Treatment of menopausal skin – A narrative review of existing treatments, controversies, and future perspectives. Post Reproductive Health, 2024. 30(2): p. 85-94.
5. Zouboulis, C.C., et al., Skin, hair and beyond: the impact of menopause. Climacteric, 2022. 25(5): p. 434-442.
6. Mellody, K.T., et al., Influence of menopause and hormone replacement therapy on epidermal ageing and skin biomechanical function. Journal of the European Academy of Dermatology and Venereology, 2022. 36(7): p. e576-e580.
7. Brincat, M. and J.V.Pollacco, Menopause and the effects of Hormone Replacement Therapy on skin aging: A Short Review,. Gynecological and Reproductive Endocrinology & Metabolism, 2024. 5(1).
8. Foulc, P., et al., Impact of menopause on the skin…information still insufficient. J Eur Acad Dermatol Venereol, 2024. 38(1): p. e29-e31.
9. Kendall, A.C., et al., Menopause induces changes to the stratum corneum ceramide profile, which are prevented by hormone replacement therapy. Sci Rep, 2022. 12(1): p. 21715.
10. Norman, T.E., et al., Palmoplantar keratoderma climactericum successfully treated with topical oestrogen. JEADV Clinical Practice, 2024. 3(1): p. 309-312.