Compared to users of other hormonal IUDs, those who chose Skyla® showed the lowest risk of developing rosacea one-year, three years and five years after placement, according to new data from researchers at Drexel University College of Medicine, recently published in the Journal of the American Academy of Dermatology. In a research letter, the authors offer new data from over 170,000 hormonal IUD and 40,000 non-hormonal copper IUD users on one of the skincare effects that may result as hormonal contraceptives alter androgen and estrogen receptors.
Placed in the uterus through the cervix, IUDs aim to prevent pregnancy for up to 10 years. The two main IUD options are hormonal — five FDA-approved hormonal options are currently available to United States consumers—and copper, under the brand name Paraguard®. When placed correctly by a medical professional, IUDs are 99% effective at preventing pregnancy. All options come with some possible side effects, including nausea, hypertension and cramping, among others.
The Drexel News Blog checked in with lead author Alexis Arza, a fourth-year medical student, and Erum Ilyas, MD, interim academic chair of Dermatology, both in Drexel’s College of Medicine, about what their findings mean for patients looking to prevent pregnancy through a long-acting reversible contraceptive.
Can hormonal IUDs cause rosacea?
Ilyas: I have noted for years that there is a specific look or appearance of the facial skin for women with hormonal IUDs that are dealing with breakouts. I frequently observe a background of persistent facial redness as well as subtle swelling of the facial skin that affects the overall texture including excess dryness and visibly widened or enlarged pores. These changes often go unnoticed in the early stages, with patients typically seeking evaluation later when breakouts or flares become more prominent. By the time I see these women, it is common for these individuals to have had their hormonal IUD in place for 1 to 3 years. In many cases, even before reviewing the patient’s medical history, a pattern has been emerging with this classic clinical presentation that we have seen more consistently with hormonal IUDs. Addressing early signs can help mitigate the progression to more noticeable skin concerns.
What were the main findings of your multi-center study of adult women who use IUDs?
Arza: For every 100,000 women using an IUD for one year: Liletta ® users had about 634 cases of rosacea. Mirena ® users had about 529 cases of rosacea. Skyla® users had about 409 cases of rosacea. Copper IUD users had about 381 cases of rosacea. This means that users of hormonal IUDs (especially Liletta and Mirena) were more likely to develop rosacea compared to users of the Copper IUD.
Compared to the Copper IUD: Liletta ® users had a 66.5% higher risk of developing rosacea after one year. Mirena ® users had a 38.9% higher risk. Skyla ® users showed a 7.4% higher risk, but this was not statistically significant, meaning it might be due to chance. Over time (up to 5 years), the trend remained. Liletta ® consistently had the highest rosacea rates. Mirena ® showed a moderate increase in risk compared to Copper IUDs. Skyla did not show a clear, significant increase.
The findings for Liletta ® and Mirena ® were statistically significant (p < 0.001), meaning there’s a very low probability these results occurred by chance. For Skyla ®, the results were not statistically significant (p > 0.05), indicating no strong evidence of an increased risk.
What are the signs of rosacea and are they difficult to treat?
Ilyas: Background redness, facial flushing, broken blood vessels called telangiectasias, and even breakouts can be seen with rosacea. The breakouts have a different quality to them then with acne. Acne at its core is clogged pores that become inflamed, “come to a head”, and pop like a pimple – there can be a satisfaction that patients have from a pimple popping and resolving. With rosacea, there is redness, swelling, and at times there is an attempt to “pop” these, but nothing comes out—maybe just clear fluid and they often get worse. Sometimes patients will note that they have “pimples” under the skin that can last weeks or months and not budge.
These findings are not difficult to treat or manage but the key is making the right diagnosis. If traditional acne medications are used, some will experience worsening symptoms with more dryness and irritation. We can often manage rosacea through the use of oral and/or topical medications to control the underlying symptoms and findings along with a simple skincare routine.
Do some hormonal IUDs come with a lower rosacea risk?
Ilyas: The data evaluated found an association but does not give us enough information to determine why without further research. Our suspicion is that there may be a dose related effect given that Mirena releases 20 mcg of levonorgestrel, Liletta 19 mcg of levonorgestrel, and Skyla 14 mcg of levonorgestrel.
If someone is considering a hormonal IUD and concerned about rosacea, what steps should they take?
Arza: Although rosacea is a benign condition, it may cause cosmetic and symptomatic discomfort. Some patients report burning sensations and overall discomfort associated with their rosacea. We recommend that patients experiencing bothersome symptoms consult their dermatologist for management, which can include topical or oral medications depending on the severity. Most patients respond well to these treatments and can continue using their hormonal IUD. If flares are persistent, we recommend consulting with their gynecologist about nonhormonal IUDs or alternative contraceptives such as oral contraceptives (OCPs).
Ilyas and colleagues also recently published an analysis comparing rates of rosacea among users of IUDs (hormonal and/or copper) vs those on oral contraceptive pills, finding significantly higher rates of rosacea among those using an IUD at one, three and five years after insertion.
Ilyas, who has observed this association in patients for years, says contraception decisions should be based on patient preferences and needs in consultation with their gynecologist. That said, Ilyas says it’s still important to acknowledge the potential for skin changes in this population.
“When managed early, these changes can often be addressed effectively without needing to switch the form of contraception, said Ilyas. “Awareness of early signs and symptoms, along with timely consultation with a dermatologist, can help reduce the likelihood of worsening conditions or flares. Since many patients seek help after experiencing significant breakouts and associated discomfort, identifying and managing earlier signs—such as facial flushing and changes in skin texture—can help prevent progression and improve outcomes.”
