[Acne] Help with hormonal/perimenopausal acne & products/routine

I have been struggling with hormonal acne due to perimenopause. I entered peri early (age 30) due to chemo and I'm now 40 and the acne has really started getting worse in the last few years. I would say the pimples are not numerous, but they are bad when they happen. My low estrogen skin is oily and not forgiving and my self confidence has definitely taken a hit. Breakouts are mainly on the forehead and chin, sometimes along the hairline.

A big problem I'm having is when the pustules do come to a head, I end up in a never ending cycle of them breaking open on their own, then getting a sort hard exterior after closing up again, then just filling back up with pus. I repeated this process about 8 times in a row on a couple of spots on my forehead and now I'm left with wide purple scars from the wound getting wider and wider. I am NOT popping anything intentionally. A lot of these spots are on taught areas of my forehead and then end up getting a tiny opening either while I'm sleeping or when I'm in the shower. I don't know how to prevent it or what I should do when it happens. I usually apply BP/clinda and slap a pimple patch on it.

My situation re: medication is complicated -- I know that I probably need to try spironolactone, but the derm I've been seeing is hesitant to do oral meds because I have a lot of chronic medical issues, so I take a lot of medications already. I have BP/clinda, tret, and now Dapsone gel for breakouts. I feel like topicals just aren't working for me at all so far.

I know my estrogen levels are extremely low (post-menopausal) and I can't take HRT or birth control due to a contraindication. I have evidence of other hormonal issues (like melasma) that the derm says are all related. I have barely had acne at all in my life. Prior to this, I only got acne from taking corticosteroids and it responded beautifully to BP/clinda and tret. This acne that I'm getting now is VERY different from the acne I got with steroids. This acne is much angrier, deeper, and much more persistent. It can take 2-4 weeks to clear up a spot sometimes and my skin is honestly not taking it well. I'm afraid my face is going to fill up with scars I can't get rid of.

Is there anything I can do? Do I need to get a second opinion from a different clinic? I will put my routine below in case anyone has suggestions. I was considering trying azelaic acid or BHA, but I'm honestly not sure what would be best to add in considering what I'm using already. Anyway, I am open to hearing suggestions on helping the acne, dealing with acne "wounds," and also any oily skin suggestions since I'm new to that. Thanks!

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AM Routine: CeraVe cleanser, benzoyl peroxide/clindamycin gel, Hero ForceShield sunscreen, Cetaphil daily moisturizer

PM Routine: CeraVe cleanser, tretinoin, Cetaphil moisturizer

As needed: Dapsone gel (just added), pimple patches like regular or microdart ones