Epidemiology and Management of Acne in Adult Women

Abstract

Adult acne is becoming recognized as a unique form of acne including either early (adolescent) acne that remains persistent or late onset acne. Women are predominantly affected in adult acne and will be focus of this review. The epidemiology and the characteristics of adult acne are discussed including clinical differences between adolescent and adult acne. We review topical therapies such as antibiotics, retinoids, dapsone, azelaic acid and combination-based therapies. We also review systemic therapeutic considerations, including antibiotics, isotretinoin, oral contraceptives, and hormonal modulators. We discuss the use of light-based therapies such as visible light and photodynamic therapy. Alternative therapies such as the use of botanical and phytochemical therapies are reviewed as well. Finally, we discuss the clinical and laboratory screening for considering polycystic ovarian syndrome when evaluating adult women with acne.

This is a preview of subscription content, log in to check access.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.

    Goulden V, Stables GI, Cunliffe WJ. Prevalence of facial acne in adults. J Am Acad Dermatol. 1999;41:577–80.

    CAS  PubMed  Google Scholar 

  2. 2.

    Goulden V, Clark SM, Cunliffe WJ. Post-adolescent acne: a review of clinical features. Br J Dermatol. 1997;136:66–70.

    CAS  PubMed  Google Scholar 

  3. 3.

    Klassen AF, Newton JN, Mallon E. Measuring quality of life in people referred for specialist care of acne: comparing generic and disease-specific measures. J Am Acad Dermatol. 2000;43:229–33.

    CAS  PubMed  Google Scholar 

  4. 4.

    Pruthi GK, Babu N. Physical and psychosocial impact of acne in adult females. Indian J Dermatol. 2012;57:26–9.

    PubMed Central  PubMed  Google Scholar 

  5. 5.

    Poli F, Dreno B, Verschoore M. An epidemiological study of acne in female adults: results of a survey conducted in France. J Eur Acad Dermatol Venereol. 2001;15:541–5.

    CAS  PubMed  Google Scholar 

  6. 6.

    Perkins AC, Maglione J, Hillebrand GG, Miyamoto K, Kimball AB. Acne vulgaris in women: prevalence across the life span. J Womens Health (Larchmt). 2012;21:223–30.

    Google Scholar 

  7. 7.

    Khunger N, Kumar C. A clinico-epidemiological study of adult acne: is it different from adolescent acne? Indian J Dermatol Venereol Leprol. 2012;78:335–41.

    PubMed  Google Scholar 

  8. 8.

    Shaw JC, White LE. Persistent acne in adult women. Arch Dermatol. 2001;137:1252–3.

    CAS  PubMed  Google Scholar 

  9. 9.

    Perkins AC, Cheng CE, Hillebrand GG, Miyamoto K, Kimball AB. Comparison of the epidemiology of acne vulgaris among Caucasian, Asian, Continental Indian and African American women. J Eur Acad Dermatol Venereol. 2011;25:1054–60.

    CAS  PubMed  Google Scholar 

  10. 10.

    Stoll S, Shalita AR, Webster GF, Kaplan R, Danesh S, et al. The effect of the menstrual cycle on acne. J Am Acad Dermatol. 2001;45:957–60.

    CAS  PubMed  Google Scholar 

  11. 11.

    Lucky AW. Quantitative documentation of a premenstrual flare of facial acne in adult women. Arch Dermatol. 2004;140:423–4.

    PubMed  Google Scholar 

  12. 12.

    da Cunha MG, Fonseca FL, Machado CD. Androgenic hormone profile of adult women with acne. Dermatology. 2013;226:167–71.

    PubMed  Google Scholar 

  13. 13.

    Rahman MM, Khondker L, Hazra SC, Khan MSI. Association of serum testosterone with acne vulgaris in women-a case control study. Journal of Pakistan Association of Dermatologists. 2012;22:105–11.

    Google Scholar 

  14. 14.••

    Choi CW, Lee DH, Kim HS, Kim BY, Park KC, et al. The clinical features of late onset acne compared with early onset acne in women. J Eur Acad Dermatol Venereol. 2011;25:454–61. This study confirmed that adult acne has unique clinical characteristics, presenting with proportionally greater inflammatory lesions and primarily occupying the lower third of the face. Additionally, they objectively measured p. acnes colonization and sebum production and found that these factors could not explain the differences in presentation between adults and adolescents.

    CAS  PubMed  Google Scholar 

  15. 15.

    Jeremy AH, Holland DB, Roberts SG, Thomson KF, Cunliffe WJ. Inflammatory events are involved in acne lesion initiation. J Invest Dermatol. 2003;121:20–7.

    CAS  PubMed  Google Scholar 

  16. 16.

    Lavker RM, Leyden JJ, McGinley KJ. The relationship between bacteria and the abnormal follicular keratinization in acne vulgaris. J Invest Dermatol. 1981;77:325–30.

    CAS  PubMed  Google Scholar 

  17. 17.

    Leeming JP, Holland KT, Cuncliffe WJ. The microbial colonization of inflamed acne vulgaris lesions. Br J Dermatol. 1988;118:203–8.

    CAS  PubMed  Google Scholar 

  18. 18.

    Leyden JJ, McGinley KJ, Mills OH, Kligman AM. Propionibacterium levels in patients with and without acne vulgaris. J Invest Dermatol. 1975;65:382–4.

    CAS  PubMed  Google Scholar 

  19. 19.

    Thielitz A, Reinhold D, Vetter R, Bank U, Helmuth M, et al. Inhibitors of dipeptidyl peptidase IV and aminopeptidase N target major pathogenetic steps in acne initiation. J Invest Dermatol. 2007;127:1042–51.

    CAS  PubMed  Google Scholar 

  20. 20.

    Ganceviciene R, Bohm M, Fimmel S, Zouboulis CC. The role of neuropeptides in the multifactorial pathogenesis of acne vulgaris. Dermatoendocrinol. 2009;1:170–6.

    CAS  PubMed Central  PubMed  Google Scholar 

  21. 21.

    Ottaviani M, Alestas T, Flori E, Mastrofrancesco A, Zouboulis CC, et al. Peroxidated squalene induces the production of inflammatory mediators in HaCaT keratinocytes: a possible role in acne vulgaris. J Invest Dermatol. 2006;126:2430–7.

    CAS  PubMed  Google Scholar 

  22. 22.

    Knaggs HE, Wood EJ, Rizer RL, Mills OH. Post-adolescent acne. Int J Cosmet Sci. 2004;26:129–38.

    CAS  PubMed  Google Scholar 

  23. 23.

    Kohl E, Steinbauer J, Landthaler M, Szeimies RM. Skin ageing. J Eur Acad Dermatol Venereol. 2011;25:873–84.

    CAS  PubMed  Google Scholar 

  24. 24.

    Farage MA, Miller KW, Berardesca E, Maibach HI. Clinical implications of aging skin: cutaneous disorders in the elderly. Am J Clin Dermatol. 2009;10:73–86.

    PubMed  Google Scholar 

  25. 25.

    Addor FA, Schalka S. Acne in adult women: epidemiological, diagnostic and therapeutic aspects. An Bras Dermatol. 2010;85:789–95.

    PubMed  Google Scholar 

  26. 26.

    Cunliffe WJ, Gould DJ. Prevalence of facial acne vulgaris in late adolescence and in adults. Br Med J. 1979;1:1109–10.

    CAS  PubMed Central  PubMed  Google Scholar 

  27. 27.

    Kane A, Niang SO, Diagne AC, Ly F, Ndiaye B. Epidemiologic, clinical, and therapeutic features of acne in Dakar, Senegal. Int J Dermatol. 2007;46 Suppl 1:36–8.

    PubMed  Google Scholar 

  28. 28.

    Williams C, Layton AM. Persistent acne in women : implications for the patient and for therapy. Am J Clin Dermatol. 2006;7:281–90.

    PubMed  Google Scholar 

  29. 29.

    Khanna N, Gupta SD. Acneiform eruptions after facial beauty treatment. Int J Dermatol. 1999;38:196–9.

    CAS  PubMed  Google Scholar 

  30. 30.

    Singh S, Mann BK, Tiwary NK (2013) Acne Cosmetica Revisited: A Case-Control Study Shows a Dose-Dependent Inverse Association between Overall Cosmetic Use and Post-Adolescent Acne. Dermatology.

  31. 31.

    Draelos ZD, DiNardo JC. A re-evaluation of the comedogenicity concept. J Am Acad Dermatol. 2006;54:507–12.

    PubMed  Google Scholar 

  32. 32.

    Capitanio B, Sinagra JL, Bordignon V, Cordiali Fei P, Picardo M, et al. Underestimated clinical features of postadolescent acne. J Am Acad Dermatol. 2010;63:782–8.

    PubMed  Google Scholar 

  33. 33.

    Capitanio B, Sinagra JL, Ottaviani M, Bordignon V, Amantea A, et al. Acne and smoking. Dermatoendocrinol. 2009;1:129–35.

    CAS  PubMed Central  PubMed  Google Scholar 

  34. 34.

    Lolis MS, Bowe WP, Shalita AR. Acne and systemic disease. Med Clin North Am. 2009;93:1161–81.

    CAS  PubMed  Google Scholar 

  35. 35.

    Cakir GA, Erdogan FG, Gurler A. Isotretinoin treatment in nodulocystic acne with and without polycystic ovary syndrome: efficacy and determinants of relapse. Int J Dermatol. 2013;52:371–6.

    CAS  PubMed  Google Scholar 

  36. 36.

    Liang SJ, Hsu CS, Tzeng CR, Chen CH, Hsu MI. Clinical and biochemical presentation of polycystic ovary syndrome in women between the ages of 20 and 40. Hum Reprod. 2011;26:3443–9.

    CAS  PubMed  Google Scholar 

  37. 37.

    Sirmans SM, Pate KA. Epidemiology, diagnosis, and management of polycystic ovary syndrome. Clin Epidemiol. 2013;6:1–13.

    PubMed Central  PubMed  Google Scholar 

  38. 38.

    Dumesic DA, Lobo RA. Cancer risk and PCOS. Steroids. 2013;78:782–5.

    CAS  PubMed  Google Scholar 

  39. 39.

    Cheng V, Doshi KB, Falcone T, Faiman C. Hyperandrogenism in a postmenopausal woman: diagnostic and therapeutic challenges. Endocr Pract. 2011;17:e21–25.

    PubMed  Google Scholar 

  40. 40.

    Trakakis E, Papadavid E, Dalamaga M, Koumaki D, Stavrianeas N, et al. (2012) Prevalence of non classical congenital adrenal hyperplasia due to 21-hydroxylase deficiency in Greek women with acne: a hospital-based cross-sectional study. J Eur Acad Dermatol Venereol.

  41. 41.

    Chen W, Obermayer-Pietsch B, Hong JB, Melnik BC, Yamasaki O, et al. Acne-associated syndromes: models for better understanding of acne pathogenesis. J Eur Acad Dermatol Venereol. 2011;25:637–46.

    CAS  PubMed  Google Scholar 

  42. 42.

    Jarratt MT, Brundage T. Efficacy and safety of clindamycin-tretinoin gel versus clindamycin or tretinoin alone in acne vulgaris: a randomized, double-blind, vehicle-controlled study. J Drugs Dermatol. 2012;11:318–26.

    CAS  PubMed  Google Scholar 

  43. 43.

    Campbell Jr JL. A comparative review of the efficacy and tolerability of retinoid-containing combination regimens for the treatment of acne vulgaris. J Drugs Dermatol. 2007;6:625–9.

    PubMed  Google Scholar 

  44. 44.

    Puizina-Ivic N, Miric L, Carija A, Karlica D, Marasovic D. Modern approach to topical treatment of aging skin. Coll Antropol. 2010;34:1145–53.

    PubMed  Google Scholar 

  45. 45.•

    Patel M, Bowe WP, Heughebaert C, Shalita AR. The development of antimicrobial resistance due to the antibiotic treatment of acne vulgaris: a review. J Drugs Dermatol. 2010;9:655–64. The development of resistant organisms is a concern with chronic antibiotic therapy. This review points out several serious implications, including the possibility of inducing resistance in bacterial species that cause serious illness.

    PubMed  Google Scholar 

  46. 46.

    Sagransky M, Yentzer BA, Feldman SR. Benzoyl peroxide: a review of its current use in the treatment of acne vulgaris. Expert Opin Pharmacother. 2009;10:2555–62.

    CAS  PubMed  Google Scholar 

  47. 47.

    Dutil M. Benzoyl peroxide: enhancing antibiotic efficacy in acne management. Skin Therapy Lett. 2010;15:5–7.

    PubMed  Google Scholar 

  48. 48.

    Pickert A, Raimer S. An evaluation of dapsone gel 5 % in the treatment of acne vulgaris. Expert Opin Pharmacother. 2009;10:1515–21.

    CAS  PubMed  Google Scholar 

  49. 49.

    Scheinfeld N. Aczone, a topical gel formulation of the antibacterial, anti-inflammatory dapsone for the treatment of acne. Curr Opin Investig Drugs. 2009;10:474–81.

    CAS  PubMed  Google Scholar 

  50. 50.

    Tanghetti E, Dhawan S, Green L, Ling M, Downie J, et al. Clinical evidence for the role of a topical anti-inflammatory agent in comedonal acne: findings from a randomized study of dapsone gel 5 % in combination with tazarotene cream 0.1 % in patients with acne vulgaris. J Drugs Dermatol. 2011;10:783–92.

    CAS  PubMed  Google Scholar 

  51. 51.

    Tanghetti E, Harper JC, Oefelein MG. The efficacy and tolerability of dapsone 5 % gel in female vs male patients with facial acne vulgaris: gender as a clinically relevant outcome variable. J Drugs Dermatol. 2012;11:1417–21.

    CAS  PubMed  Google Scholar 

  52. 52.

    Thiboutot D. Versatility of azelaic acid 15 % gel in treatment of inflammatory acne vulgaris. J Drugs Dermatol. 2008;7:13–6.

    PubMed  Google Scholar 

  53. 53.•

    Woolery-Lloyd HC, Keri J, Doig S. Retinoids and azelaic acid to treat acne and hyperpigmentation in skin of color. J Drugs Dermatol. 2013;12:434–7. This review shows that both azelaic acid and retinoids may improve post-inflammatory hyperpigmentation in skin of color. The authors note that physicians are sometimes hesitent to use retinoids in this population, due to percieved hypersensitivity, and suggest that this may be unwarranted.

    CAS  PubMed  Google Scholar 

  54. 54.

    Kircik LH. Efficacy and safety of azelaic acid (AzA) gel 15 % in the treatment of post-inflammatory hyperpigmentation and acne: a 16-week, baseline-controlled study. J Drugs Dermatol. 2011;10:586–90.

    CAS  PubMed  Google Scholar 

  55. 55.

    Pazoki-Toroudi H, Nilforoushzadeh MA, Ajami M, Jaffary F, Aboutaleb N, et al. Combination of azelaic acid 5 % and clindamycin 2 % for the treatment of acne vulgaris. Cutan Ocul Toxicol. 2011;30:286–91.

    CAS  PubMed  Google Scholar 

  56. 56.

    Pazoki-Toroudi H, Nassiri-Kashani M, Tabatabaie H, Ajami M, Habibey R, et al. Combination of azelaic acid 5 % and erythromycin 2 % in the treatment of acne vulgaris. J Dermatolog Treat. 2010;21:212–6.

    CAS  PubMed  Google Scholar 

  57. 57.

    Zouboulis CC, Fischer TC, Wohlrab J, Barnard J, Alio AB. Study of the efficacy, tolerability, and safety of 2 fixed-dose combination gels in the management of acne vulgaris. Cutis. 2009;84:223–9.

    PubMed  Google Scholar 

  58. 58.

    Gollnick HP, Draelos Z, Glenn MJ, Rosoph LA, Kaszuba A, et al. Adapalene-benzoyl peroxide, a unique fixed-dose combination topical gel for the treatment of acne vulgaris: a transatlantic, randomized, double-blind, controlled study in 1670 patients. Br J Dermatol. 2009;161:1180–9.

    CAS  PubMed  Google Scholar 

  59. 59.

    Kircik LH, Peredo MI, Bucko AD, Loss Jr RW, Fowler Jr JF, et al. Safety of a novel gel formulation of clindamycin phosphate 1.2 %-tretinoin 0.025 %: results from a 52-week open-label study. Cutis. 2008;82:358–66.

    PubMed  Google Scholar 

  60. 60.

    Ghali F, Kang S, Leyden J, Shalita AR, Thiboutot DM. Changing the face of acne therapy. Cutis. 2009;83:4–15.

    PubMed  Google Scholar 

  61. 61.

    Alexis AF. Clinical considerations on the use of concomitant therapy in the treatment of acne. J Dermatolog Treat. 2008;19:199–209.

    CAS  PubMed  Google Scholar 

  62. 62.

    Gollnick H, Cunliffe W, Berson D, Dreno B, Finlay A, et al. Management of acne: a report from a Global Alliance to Improve Outcomes in Acne. J Am Acad Dermatol. 2003;49:S1–37.

    PubMed  Google Scholar 

  63. 63.

    Martin B, Meunier C, Montels D, Watts O. Chemical stability of adapalene and tretinoin when combined with benzoyl peroxide in presence and in absence of visible light and ultraviolet radiation. Br J Dermatol. 1998;139 Suppl 52:8–11.

    CAS  PubMed  Google Scholar 

  64. 64.

    Nyirady J, Lucas C, Yusuf M, Mignone P, Wisniewski S. The stability of tretinoin in tretinoin gel microsphere 0.1 %. Cutis. 2002;70:295–8.

    PubMed  Google Scholar 

  65. 65.

    Haedersdal M, Togsverd-Bo K, Wulf HC. Evidence-based review of lasers, light sources and photodynamic therapy in the treatment of acne vulgaris. J Eur Acad Dermatol Venereol. 2008;22:267–78.

    CAS  PubMed  Google Scholar 

  66. 66.

    Ross EV. Optical treatments for acne. Dermatol Ther. 2005;18:253–66.

    PubMed  Google Scholar 

  67. 67.

    Papageorgiou P, Katsambas A, Chu A. Phototherapy with blue (415 nm) and red (660 nm) light in the treatment of acne vulgaris. Br J Dermatol. 2000;142:973–8.

    CAS  PubMed  Google Scholar 

  68. 68.

    de Arruda LH, Kodani V, Bastos Filho A, Mazzaro CB. A prospective, randomized, open and comparative study to evaluate the safety and efficacy of blue light treatment versus a topical benzoyl peroxide 5 % formulation in patients with acne grade II and III. An Bras Dermatol. 2009;84:463–8.

    PubMed  Google Scholar 

  69. 69.

    Faghihi G, Isfahani AK, Hosseini SM, Radan MR. Efficacy of intense pulsed light combined with topical erythromycin solution 2 % versus topical erythromycin solution 2 % alone in the treatment of persistent facial erythematous acne macules. Adv Biomed Res. 2012;1:70.

    PubMed Central  PubMed  Google Scholar 

  70. 70.

    Jang MS, Doh KS, Kang JS, Jeon YS, Suh KS, et al. A comparative split-face study of photodynamic therapy with indocyanine green and indole-3-acetic acid for the treatment of acne vulgaris. Br J Dermatol. 2011;165:1095–100.

    CAS  PubMed  Google Scholar 

  71. 71.

    Huh SY, Na JI, Huh CH, Park KC. The effect of photodynamic therapy using indole-3-acetic Acid and green light on acne vulgaris. Ann Dermatol. 2012;24:56–60.

    CAS  PubMed Central  PubMed  Google Scholar 

  72. 72.

    Simpson RC, Grindlay DJ, Williams HC. What's new in acne? An analysis of systematic reviews and clinically significant trials published in 2010-11. Clin Exp Dermatol. 2011;36:840–3. quiz 843-844.

    CAS  PubMed  Google Scholar 

  73. 73.

    Costa CS, Bagatin E. Evidence on acne therapy. Sao Paulo Med J. 2013;131:193–7.

    PubMed  Google Scholar 

  74. 74.

    Garner SE, Eady A, Bennett C, Newton JN, Thomas K, et al. Minocycline for acne vulgaris: efficacy and safety. Cochrane Database Syst Rev. 2012;8, CD002086.

    PubMed  Google Scholar 

  75. 75.•

    Jung GW, Tse JE, Guiha I, Rao J. Prospective, randomized, open-label trial comparing the safety, efficacy, and tolerability of an acne treatment regimen with and without a probiotic supplement and minocycline in subjects with mild to moderate acne. J Cutan Med Surg. 2013;17:114–22. This randomized controlled trial showed that use of a probiotic supplement improves the anti-acne effects of concurrently used antibiotics while also significantly reducing adverse events including vaginal candida infections.

    PubMed  Google Scholar 

  76. 76.

    Haider A, Shaw JC. Treatment of acne vulgaris. JAMA. 2004;292:726–35.

    CAS  PubMed  Google Scholar 

  77. 77.

    Harper JC. Should dermatologists prescribe hormonal contraceptives for acne? Dermatol Ther. 2009;22:452–7.

    PubMed  Google Scholar 

  78. 78.

    Arowojolu AO, Gallo MF, Lopez LM, Grimes DA. Combined oral contraceptive pills for treatment of acne. Cochrane Database Syst Rev. 2012;7, CD004425.

    PubMed  Google Scholar 

  79. 79.•

    Gallo MF, Lopez LM, Grimes DA, Schulz KF, Helmerhorst FM (2011) Combination contraceptives: effects on weight. Cochrane Database Syst Rev: CD003987. Many women are concerned about weight gain when starting oral contraceptive pills and this may reduce patient compliance with OCPs. This Cochrane review found no evidence of significant weight gain with combined OCPs but note that more studies including placebo or control groups are needed to validate these findings.

  80. 80.

    Palli MB, Reyes-Habito CM, Lima XT, Kimball AB. A single-center, randomized double-blind, parallel-group study to examine the safety and efficacy of 3 mg drospirenone/0.02 mg ethinyl estradiol compared with placebo in the treatment of moderate truncal acne vulgaris. J Drugs Dermatol. 2013;12:633–7.

    CAS  PubMed  Google Scholar 

  81. 81.

    Shaw JC. Low-dose adjunctive spironolactone in the treatment of acne in women: a retrospective analysis of 85 consecutively treated patients. J Am Acad Dermatol. 2000;43:498–502.

    CAS  PubMed  Google Scholar 

  82. 82.

    Krunic A, Ciurea A, Scheman A. Efficacy and tolerance of acne treatment using both spironolactone and a combined contraceptive containing drospirenone. J Am Acad Dermatol. 2008;58:60–2.

    PubMed  Google Scholar 

  83. 83.

    Shaw JC, White LE. Long-term safety of spironolactone in acne: results of an 8-year followup study. J Cutan Med Surg. 2002;6:541–5.

    PubMed  Google Scholar 

  84. 84.

    Kamangar F, Shinkai K. Acne in the adult female patient: a practical approach. Int J Dermatol. 2012;51:1162–74.

    PubMed  Google Scholar 

  85. 85.

    Brahm J, Brahm M, Segovia R, Latorre R, Zapata R, et al. Acute and fulminant hepatitis induced by flutamide: case series report and review of the literature. Ann Hepatol. 2011;10:93–8.

    PubMed  Google Scholar 

  86. 86.

    van Vloten WA, van Haselen CW, van Zuuren EJ, Gerlinger C, Heithecker R. The effect of 2 combined oral Contraceptives containing either drospirenone or cyproterone acetate on acne and seborrhea. Cutis. 2002;69:2–15.

    PubMed  Google Scholar 

  87. 87.

    Rademaker M. Isotretinoin: dose, duration and relapse. What does 30 years of usage tell us? Australas J Dermatol. 2013;54:157–62.

    PubMed  Google Scholar 

  88. 88.

    Mandekou-Lefaki I, Delli F, Teknetzis A, Euthimiadou R, Karakatsanis G. Low-dose schema of isotretinoin in acne vulgaris. Int J Clin Pharmacol Res. 2003;23:41–6.

    CAS  PubMed  Google Scholar 

  89. 89.

    Amichai B, Shemer A, Grunwald MH. Low-dose isotretinoin in the treatment of acne vulgaris. J Am Acad Dermatol. 2006;54:644–6.

    PubMed  Google Scholar 

  90. 90.

    Akman A, Durusoy C, Senturk M, Koc CK, Soyturk D, et al. Treatment of acne with intermittent and conventional isotretinoin: a randomized, controlled multicenter study. Arch Dermatol Res. 2007;299:467–73.

    CAS  PubMed Central  PubMed  Google Scholar 

  91. 91.••

    Rademaker M, Wishart JM, Birchall NM (2013) Isotretinoin 5 mg daily for low-grade adult acne vulgaris - a placebo-controlled, randomized double-blind study. J Eur Acad Dermatol Venereol. Low dose isotretinoin is shown to effectively treat low-grade adult acne with continued improvement over 32 weeks and minimal side effects. This study shows that isotretinoin may be appropriate for mild acne in adults and that long courses with low dose are effective with fewer adverse effects than higher dose regimens.

  92. 92.

    Lee JW, Yoo KH, Park KY, Han TY, Li K, et al. Effectiveness of conventional, low-dose and intermittent oral isotretinoin in the treatment of acne: a randomized, controlled comparative study. Br J Dermatol. 2011;164:1369–75.

    CAS  PubMed  Google Scholar 

  93. 93.

    Dantuluri S, North-Lewis P, Karthik SV. Gotu Kola induced hepatotoxicity in a child - need for caution with alternative remedies. Dig Liver Dis. 2011;43:500.

    PubMed  Google Scholar 

  94. 94.

    Keane FM, Munn SE, du Vivier AW, Taylor NF, Higgins EM. Analysis of Chinese herbal creams prescribed for dermatological conditions. BMJ. 1999;318:563–4.

    CAS  PubMed  Google Scholar 

  95. 95.

    Fung HT, Fung CW, Kam CW. Lead poisoning after ingestion of home-made Chinese medicines. Emerg Med (Fremantle). 2003;15:518–20.

    Google Scholar 

  96. 96.

    Azimi H, Fallah-Tafti M, Khakshur AA, Abdollahi M. A review of phytotherapy of acne vulgaris: perspective of new pharmacological treatments. Fitoterapia. 2012;83:1306–17.

    CAS  PubMed  Google Scholar 

  97. 97.•

    Fisk WA, Lev-Tov HA, Sivamani RK (2014) Botanical and Phytochemical Therapy of Acne: A Systematic Review. Phytotherapy Research In Press. This manuscript systematically reviews clinical studies of botanical and phytochemical agents for the treatment of acne.

  98. 98.•

    Abreu AC, McBain AJ, Simoes M. Plants as sources of new antimicrobials and resistance-modifying agents. Nat Prod Rep. 2012;29:1007–21. This study discuss the potential of phytochemicals and plant extracts with antimicrobial properties to slow the development of antibiotic-resistant bacteria. They suggest that some phytochemicals may restore sensitivity of bacteria to some antibiotics.

  99. 99.

    Sharquie KE, Al-Turfi IA, Al-Shimary WM. Treatment of acne vulgaris with 2 % topical tea lotion. Saudi Medical Journal. 2006;27:83–5.

    PubMed  Google Scholar 

  100. 100.

    Sharquie KE, Noaimi AA, Al-Salih MM. Topical therapy of acne vulgaris using 2 % tea lotion in comparison with 5 % zinc sulphate solution. Saudi Medical Journal. 2008;29:1757–61.

    PubMed  Google Scholar 

  101. 101.

    Enshaieh S, Jooya A, Siadat AH, Iraji F. The efficacy of 5 % topical tea tree oil gel in mild to moderate acne vulgaris: A randomized, double-blind placebo-controlled study. Indian Journal of Dermatology, Venereology and Leprology. 2007;73:22–5.

    PubMed  Google Scholar 

  102. 102.

    Orafidiya LO, Agbani EO, Oyedele AO, Babalola OO, Onayemi O. Preliminary clinical tests on topical preparations of Ocimum gratissimum linn leaf essential oil for the treatment of acne vulgaris. Clinical Drug Investigation. 2002;22:313–9.

    CAS  Google Scholar 

  103. 103.

    Orafidiya LO, Agbani EO, Oyedele AO, Babalola OO, Onayemi O, et al. The effect of aloe vera gel on the anti-acne properties of the essential oil of Ocimum gratissimum Linn leaf - A preliminary clinical investigation. International Journal of Aromatherapy. 2004;14:15–21.

    CAS  Google Scholar 

  104. 104.•

    Yoon JY, Kwon HH, Min SU, Thiboutot DM, Suh DH. Epigallocatechin-3-gallate improves acne in humans by modulating intracellular molecular targets and inhibiting P. acnes. J Invest Dermatol. 2013;133:429–40. This study reports in vitro and clinical data supporting the anti-acne properties of EGCG, a polyphenol phytochemical isolated from green tea. In vitro studies demonstrate sebosuppressive, anti-inflammatory and antimicrobial effects and a randomized controlled split face trial demonstrated clinical efficacy and tolerability in 35 patients with average age of 22. EGCG may be an alternative to antibiotics or irritating medications, although studies comparing these therapies are lacking. Of note, the study was methodologically rigorous and there is a need for adequate and well controlled studies for anti-acne botanicals.

    CAS  PubMed  Google Scholar 

  105. 105.

    Jung MK, Ha S, Son JA, Song JH, Houh Y, et al. Polyphenon-60 displays a therapeutic effect on acne by suppression of TLR2 and IL-8 expression via down-regulating the ERK1/2 pathway. Archives of Dermatological Research. 2012;304:655–63.

    CAS  PubMed  Google Scholar 

  106. 106.•

    Fabbrocini G, Staibano S, De Rosa G, Battimiello V, Fardella N, et al. Resveratrol-containing gel for the treatment of acne vulgaris: A single-blind, vehicle-controlled, pilot study. American Journal of Clinical Dermatology. 2011;12:133–41. This vehicle controlled study demonstrated clinical efficacy of topical resveratrol, a phytochemical isolated from plants including grapes and peanuts.

    PubMed  Google Scholar 

  107. 107.

    Paranjpe P, Kulkarni PH. Comparative efficacy of four Ayurvedic formulations in the treatment of acne vulgaris: a double-blind randomised placebo-controlled clinical evaluation. J Ethnopharmacol. 1995;49:127–32.

    CAS  PubMed  Google Scholar 

  108. 108.•

    Banaszewska B, Pawelczyk L, Spaczynski RZ, Duleba AJ. Effects of simvastatin and metformin on polycystic ovary syndrome after six months of treatment. J Clin Endocrinol Metab. 2011;96:3493–501. This study supports the use of metformin and simvastatin to improve signs of hirsuitism, including acne, in patients with PCOS. Improvement continued over the six-month trial suggesting that improvements may be slow and patients should be prepared to stay on therapy for an extended period of time.

    CAS  PubMed  Google Scholar 

  109. 109.

    Duleba AJ, Banaszewska B, Spaczynski RZ, Pawelczyk L. Simvastatin improves biochemical parameters in women with polycystic ovary syndrome: results of a prospective, randomized trial. Fertil Steril. 2006;85:996–1001.

    CAS  PubMed  Google Scholar 

  110. 110.

    Israni DA, Mehta TY, Shah SR, Goyal RK. Effect of metformin therapy in female visiting dermatologist for acne vulgaris having endocrine and sonographic characteristics of polycystic ovary syndrome (PCOS). Asian Journal of Pharmaceutical and Clinical Research. 2013;6:76–82.

    CAS  Google Scholar 

  111. 111.

    Harborne L, Fleming R, Lyall H, Sattar N, Norman J. Metformin or antiandrogen in the treatment of hirsutism in polycystic ovary syndrome. J Clin Endocrinol Metab. 2003;88:4116–23.

    CAS  PubMed  Google Scholar 

  112. 112.

    Kodaman PH, Duleba AJ. Statins in the treatment of polycystic ovary syndrome. Semin Reprod Med. 2008;26:127–38.

    CAS  PubMed Central  PubMed  Google Scholar 

  113. 113.

    Armitage J. The safety of statins in clinical practice. Lancet. 2007;370:1781–90.

    CAS  PubMed  Google Scholar 

  114. 114.

    Antons KA, Williams CD, Baker SK, Phillips PS. Clinical perspectives of statin-induced rhabdomyolysis. Am J Med. 2006;119:400–9.

    CAS  PubMed  Google Scholar 

  115. 115.

    Fallah A, Deep M, Smallwood D, Hughes P. Life-threatening rhabdomyolysis following the interaction of two commonly prescribed medications. Australas Med J. 2013;6:112–4.

    PubMed Central  PubMed  Google Scholar 

  116. 116.

    Kolodziejczyk B, Duleba AJ, Spaczynski RZ, Pawelczyk L. Metformin therapy decreases hyperandrogenism and hyperinsulinemia in women with polycystic ovary syndrome. Fertil Steril. 2000;73:1149–54.

    CAS  PubMed  Google Scholar 

  117. 117.

    Bozzo P, Chua-Gocheco A, Einarson A. Safety of skin care products during pregnancy. Can Fam Physician. 2011;57:665–7.

    PubMed Central  PubMed  Google Scholar 

  118. 118.

    Acosta KA, Haver MC, Kelly B. Etiology and therapeutic management of erythema nodosum during pregnancy: an update. Am J Clin Dermatol. 2013;14:215–22.

    PubMed  Google Scholar 

  119. 119.

    Tuffanelli DL. Successful pregnancy in a patient with dermatitis herpetiformis treated with low-dose dapsone. Arch Dermatol. 1982;118:876.

    CAS  PubMed  Google Scholar 

  120. 120.•

    Panchaud A, Csajka C, Merlob P, Schaefer C, Berlin M, et al. Pregnancy outcome following exposure to topical retinoids: a multicenter prospective study. J Clin Pharmacol. 2012;52:1844–51. This study evaluated the risk of birth defects associated with topical retinoid use a during pregnancy. They found no evidence of retinoic acid embryopathy.

    CAS  PubMed  Google Scholar 

  121. 121.

    Kallen BA, Otterblad Olausson P, Danielsson BR. Is erythromycin therapy teratogenic in humans? Reprod Toxicol. 2005;20:209–14.

    PubMed  Google Scholar 

  122. 122.

    McCormack WM, George H, Donner A, Kodgis LF, Alpert S, et al. Hepatotoxicity of erythromycin estolate during pregnancy. Antimicrob Agents Chemother. 1977;12:630–5.

    CAS  PubMed Central  PubMed  Google Scholar 

  123. 123.••

    Guastella E, Longo RA, Carmina E. Clinical and endocrine characteristics of the main polycystic ovary syndrome phenotypes. Fertil Steril. 2010;94:2197–201. This study describes four phenotypic subtypes of PCOS and demonstrates that women with normal ovulation or normal ovarian morphology may still have PCOS. Recognizing all subtypes of PCOS is important in order to appropriately screen for and treat common comorbidities including metabolic syndrome and cardiovascular disease.

    CAS  PubMed  Google Scholar 

Download references

Compliance with Ethics Guidelines

Conflict of Interest

WA Fisk declares no conflicts of interest.

HA Lev-Tov declares no conflicts of interest.

RK Sivamani declares no conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Raja K. Sivamani.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Fisk, W.A., Lev-Tov, H.A. & Sivamani, R.K. Epidemiology and Management of Acne in Adult Women. Curr Derm Rep 3, 29–39 (2014). https://doi.org/10.1007/s13671-014-0071-4

Download citation

Keywords

  • Adult
  • Woman
  • Acne
  • Epidemiology
  • Management
  • Hormone
  • Polycystic
  • Ovarian
  • Syndrome
  • Therapy
  • Isotretinoin
  • Botanical
  • Phytochemical