American Journal of Clinical Dermatology

, Volume 7, Issue 5, pp 281–290

Persistent Acne in Women

Implications for the Patient and for Therapy
Therapy in Practice

Abstract

Acne is traditionally regarded as a skin disorder of the teenage years. However, recent epidemiologic studies have shown that a significant number of female patients aged >25 years experience acne. One recent community-based UK study estimated the prevalence of facial acne in adult women aged between 26 and 44 years to be 14%. It is not clear whether there is a true increase in acne in this age group or whether these patients are less tolerant of their acne and/or better informed of available therapies and so seek advice. The reasons for persistent acne are not fully understood. External factors such as use of certain cosmetics, ingestion of drugs, and endocrine abnormalities should all be considered when managing these patients. Post-adolescent acne in females can be divided into ‘persistent acne’, which represents a continuation of acne from adolescence into adult life, and ‘late-onset’ acne, which describes significant acne occurring sometimes for the first time after the age of 25 years. The clinical picture of each of these forms of acne in adult females can differ slightly from conventional adolescent disease. The course of each form is more indolent. Because of these variations, the approach to investigation and management of these cases may have subtle differences when compared with that for teenage disease. Acne treatment should aim to reduce sebum, comedogenesis, propionibacteria population, and inflammation. Treatment selection will depend on the acne grade and site as well as the patient‘s preference and ability to comply with therapy. Maintenance therapy plays an important role in managing this group of patients. As the response to treatment is inevitably slow, patients must be encouraged to adhere to the chosen treatment regimen.

This article reviews the literature on persistent acne in women in terms of clinical presentation and possible etiologic factors, and outlines principles of therapy related to managing these cases.

References

  1. 1.
    Burton JL, Cunliffe WJ, Stafford L, et al. The prevalence of acne vulgaris in adolescence. Br J Dermatol. 1971; 85: 119–26PubMedCrossRefGoogle Scholar
  2. 2.
    Goulden V, Stables GI, Cunliffe WJ. The prevalence of facial acne in adults. J Am Acad Dermatol. 1999; 41: 577–80PubMedGoogle Scholar
  3. 3.
    Shafer T, Nienhaus A, Vieluf D, et al. Epidemiology of acne in the general population: the risk of smoking. Br J Dermatol. 2001; 145: 100–4CrossRefGoogle Scholar
  4. 4.
    Goulden V, Clark SM, Cunliffe WJ. Post adolescent acne: a review of clinical features. Br J Dermatol. 1997; 136: 66–70PubMedCrossRefGoogle Scholar
  5. 5.
    Marks R. Acne and its management beyond the age of 35 years. Am J Clin Dermatol. 2004; 5 (6): 459–62PubMedCrossRefGoogle Scholar
  6. 6.
    Gollnick MD, Cunliffe W, Berson D, et al. Management of acne: a report from a global alliance to improve outcomes in acne. J Am Acad Dermatol. 2003; 49: S I–38CrossRefGoogle Scholar
  7. 7.
    McGeown CH, Goulden V, Holland D, et al. Sebum excretion in post adolescent acne compared to controls and adolescent acne [abstract]. J Invest Dermatol. 1997; 108: 386Google Scholar
  8. 8.
    Sheehan-Dare RA, Hughes BR, Cunliffe WJ. Clinical markers of androgenicity in acne vulgaris. Br J Dermatol. 1988 Dec; 119 (6): 723–30PubMedCrossRefGoogle Scholar
  9. 9.
    Thiboutot D. Acne: hormonal concepts and therapy. Clin Dermatol 2004 Sep-Oct; 22 (5): 419–28PubMedCrossRefGoogle Scholar
  10. 10.
    Vershoore M. Aspect hormonaux de l’acne. Ann Dermatol Venereol. 1987; 114: 439–54Google Scholar
  11. 11.
    Lawrence D, Shaw M, Katz M. Elevated free testosterone concentration in men and women with acne vulgaris. Clin Exp Dermatol. 1986; 11: 263–73PubMedCrossRefGoogle Scholar
  12. 12.
    Lucky AW, McGuire J, Rosenfield RL, et al. Plasma androgens in women with acne vulgaris. J Invest Dermatol. 1983; 81: 70–4PubMedCrossRefGoogle Scholar
  13. 13.
    Pochi PE, Comite H, Longcope C. Hormone blood levels in women with acne [abstract]. J Invest Dermatol. 1986; 86: 501Google Scholar
  14. 14.
    Sultan C, Oliel V, Audran F, et al. Free and total plasma testosterone in men and women with acne. Acta Derm Venereol (Stockh). 1986; 66: 301–4Google Scholar
  15. 15.
    Lookingbill DP, Horton R, Demers LM, et al. Tissue production of androgens in women with acne. J Am Acad Dermatol. 1985; 12: 481–7PubMedCrossRefGoogle Scholar
  16. 16.
    Carmina E, Lobo RA. Evidence for increased androsterone metabolism in some normoandrogenic women with acne. J Clin Endocrinol Metab. 1993; 76: 1111–4PubMedCrossRefGoogle Scholar
  17. 17.
    Thiboutot D, Gilliland K, Light J, et al. Androgen metabolism in sebaceous glands from subjects with and without acne. Arch Dermatol. 1999; 135: 1041–5PubMedCrossRefGoogle Scholar
  18. 18.
    Allam SG. Acne vulgaris in the sixth decade and beyond [Master of Science thesis]. Cardiff: University of Wales, 1991Google Scholar
  19. 19.
    Eady EA, Gloor M, Lleyden JJ. Propionibacterium acnes resistance: a worldwide problem. Dermatology. 2003; 206: 54–6PubMedCrossRefGoogle Scholar
  20. 20.
    Eady EA, Cove JH, Holland KT, et al. Erythromycin resistant propionibacteria in antibiotic treated acne patients: association with therapeutic failure. Br J Dermatol. 1989; 121: 51–7PubMedCrossRefGoogle Scholar
  21. 21.
    Ozolins M, Eady EA, Avery A, et al. Comparison of five antimicrobial regimens for treatment of mild to moderate inflammatory facial acne vulgaris in the community: randomised controlled trial. Lancet. 2004; 364: 2188–95PubMedCrossRefGoogle Scholar
  22. 22.
    Till AE, Goulden V, Cunliffe WJ, et al. The cutaneous microflora of adolescent, persistent and late-onset acne patients does not differ. Br J Dermatol. 2000; 142: 885–92PubMedCrossRefGoogle Scholar
  23. 23.
    Mills OH, Kligman AM. Acne detergicans. Arch Dermatol. 1975 Jan; 111 (1): 65–8PubMedCrossRefGoogle Scholar
  24. 24.
    Kligman AM, Mills Jr OH. ‘Acne cosmetica’. Arch Dermatol. 1972; 106 (6): 843–50PubMedCrossRefGoogle Scholar
  25. 25.
    Khanna N, Gupta SD. Acneiform eruptions after facial beauty treatment. Int J Dermatol. 1999; 38 (3): 196–9PubMedCrossRefGoogle Scholar
  26. 26.
    Cunliffe WJ. Clinical features of acne. In: Marks R, editor. Acne. London: Martin Dunitz, 1989: 11–75Google Scholar
  27. 27.
    Kligman AM. Post adolescent acne in women. Cutis. 1991; 48: 75–7PubMedGoogle Scholar
  28. 28.
    Knaggs HE, Wood EJ, Rizer RL, et al. Post adolescent acne. Int J Cosmet Sci. 2004; 26: 129–38PubMedCrossRefGoogle Scholar
  29. 29.
    Cunliffe WJ. Acne and unemployment [letter]. Br J Dermatol. 1986; 115: 386PubMedCrossRefGoogle Scholar
  30. 30.
    Layton AM, Seukaran D, Cunliffe WJ. Scarred for life?. Dermatology. 1997; 195: 15–21PubMedCrossRefGoogle Scholar
  31. 31.
    Myhill JE, Leichtmen SR, Bumett JW. Self-esteem and social assertiveness in patients receiving isotretinoin treatment for cystic acne. Cutis. 1988; 41: 171–3Google Scholar
  32. 32.
    Lasek RJ, Chren MM. Acne vulgaris and the quality of life of adult dermatology patients. Arch Dermatol. 1998; 134: 454–8PubMedCrossRefGoogle Scholar
  33. 33.
    Derman RJ. Androgen excess in women. Int J Fertil Menopausal Stud. 1996 Mar–Apr; 41 (2): 172–6PubMedGoogle Scholar
  34. 34.
    McLaughlin B, Barrett P, Finch T, et al. Late-onset adrenal hyperplasia in a group of Irish females who presented with hirsutism, irregular menses and/or cystic acne. Clin Endocrinol. 1990; 32: 57–64CrossRefGoogle Scholar
  35. 35.
    Leyden JJ. Antibiotic resistance in the topical treatment of acne vulgaris. Cutis. 2004 Jun; 73 (6 Suppl.): 6–10PubMedGoogle Scholar
  36. 36.
    Griffiths CEM. Nicotinamide 4% gel for the treatment of inflammatory acne. J Dermatolog Treat. 1995; 6 Suppl. 1: S8–10Google Scholar
  37. 37.
    Dreno B, Bettoli V, Ochsendorf F. European recommendations on the use of oral antibiotics for acne. Ear J Dermatol. 2004; 14 (6): 391–9Google Scholar
  38. 38.
    Tan AW, Tan HH. Acne vulgaris: a review of antibiotic therapy. Expert Opin Pharmacother. 2005 Mar; 6 (3): 409–18PubMedCrossRefGoogle Scholar
  39. 39.
    Shaw JC, White LE. Persistent acne in adult women. Arch Dermatol. 2001; 137: 1252–3PubMedGoogle Scholar
  40. 40.
    DeRossi SS, Hersh EV. Antibiotics and oral contraceptives. Dent Clin North Am. 2002; 46 (4): 653–4PubMedCrossRefGoogle Scholar
  41. 41.
    Thiboutot D. Hormones and acne: pathophysiology, clinical evaluation, and therapies. Semin Cutan Med Surg. 2001; 20: 144–53PubMedCrossRefGoogle Scholar
  42. 42.
    Huber J, Foidart JM, Wuttke W, et al. Efficacy and tolerability of a monophasic oral contraceptive containing ethinylestradiol and drospirenone. Eur J Contracept Reprod Health Care. 2000; 5: 25–34PubMedCrossRefGoogle Scholar
  43. 43.
    Shaw JC. Hormonal therapy in dermatology. Dermatol Clin. 2001; 19: 169–78PubMedCrossRefGoogle Scholar
  44. 44.
    Goodfellow A, Alaghband-Zadeh J, Carter G, et al. Oral spironolactone improves acne vulgaris and reduces sebum excretion. Br J Dermatol. 1984; 111: 209–14PubMedCrossRefGoogle Scholar
  45. 45.
    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: 498–502PubMedCrossRefGoogle Scholar
  46. 46.
    Yemisci A, Gorgulu A, Piskin S. Effects and side-effects of spironolactone therapy in women with acne. J Eur Acad Dermatol Venereol. 2005 Mar; 19 (2): 163–6PubMedCrossRefGoogle Scholar
  47. 47.
    Cusan L, Dupont A, Belanger A, et al. Treatment of hirsutism with the pure antiandrogen flutamide. J Am Acad Dermatol. 1990; 23: 462–9PubMedCrossRefGoogle Scholar
  48. 48.
    Manso G, Thole Z, Salquiero E, et al. Spontaneous reporting of hepatotoxicity associated with antiandrogens: data from the Spanish Pharmacovigilance System. Pharmacoepidemiol Drug Saf. 2006 Apr; 15 (4): 253–9PubMedCrossRefGoogle Scholar
  49. 49.
    Shaw JC. Acne: effect of hormones on pathogenesis and management. Am J Clin Dermatol. 2002; 3 (8): 571–8PubMedCrossRefGoogle Scholar
  50. 50.
    Ostlere LS, Rumsby G, Holownia P, et al. Carrier status for steroid 21-hydroxylase deficiency is only one factor in the variable phenotype of acne. Clin Endocrinol. 1998; 48: 209–15CrossRefGoogle Scholar
  51. 51.
    Saihan E, Burton J. Sebaceous gland suppression in female acne patients by combined glucocorticoid-oestrogen treatment. Br J Dermatol. 1981; 103: 139–42CrossRefGoogle Scholar
  52. 52.
    Pochi P, Strauss J. Sebaceous gland inhibition from combined glucocorticoid-estrogen treatment. Arch Dermatol. 1976; 112: 1108–9PubMedCrossRefGoogle Scholar
  53. 53.
    Cunliffe WJ, van de Kerkhof PC, Caputo R, et al. Roaccutane treatment guidelines: results of an international survey. Dermatology. 1997; 194 (4): 351–7PubMedCrossRefGoogle Scholar
  54. 54.
    Committee for Proprietary Medicinal Products (CPMP). Summary information on a referral opinion following an arbitration pursuant to article 30 of directive 2001/83/ED, for Roaccutane and associated names [online]. London: European Agency for the Evaluation of Medicinal Products, 2003. Available from URL: http://www.emea.eu.int/pdfs/human/referral/isotretinoin/281103en.pdf [Accessed 2006 Sep 13]Google Scholar
  55. 55.
    Committee for Proprietary Medicinal Products (CPMP). Annex III: amended summary of product characteristics of the reference member state [online]. London: European Agency for the Evaluation of Medicinal Products, 2003. Available from URL: http://www.emea.europa.eu/pdfs/human/referral/roaccutane/284603enl.pdf [Accessed 2006 Sep 13]Google Scholar
  56. 56.
    Committee for Proprietary Medicinal Products (CPMP). Annex II: scientific conclusions and grounds for amendment of the summary(ies) of product characteristics presented by the EMEA [online]. London: European Agency for the Evaluation of Medicinal Products, 2003. Available from URL: http://www.emea.europa.eu/pdfs/human/referral/roaccutane/284603enl.pdf [Accessed 2006 Sep 13]Google Scholar
  57. 57.
    US FDA Center for Drug Evaluation and Research. Alert for healthcare professionals: isotretinoin (marketed as Accutane) [online]. Rockville (MD): FDA, 2005. Available from URL: http://www.fda.gov/cder/drug/InfoSheets/HCP/IsotretinoinHCP.htm [Accessed 2006 Sep 13]Google Scholar
  58. 58.
    Marqueling AL, Zane LT. Depression and suicidal behavior in acne patients treated with isotretinoin: a systematic review. Semin Cutan Med Surg. 2005 Jun; 24 (2): 92–102PubMedCrossRefGoogle Scholar
  59. 59.
    Goulden V, Clark SM, McGeown C, et al. Treatment of acne with intermittent isotretinoin. Br J Dermatol. 1997 Jul; 137 (1): 106–8PubMedCrossRefGoogle Scholar
  60. 60.
    Zane LT. Acne maintenance therapy: expanding the role of topical retinoids?. Arch Dermatol. 2006 May; 142 (5): 638–40PubMedCrossRefGoogle Scholar
  61. 61.
    Goulden V, Clark SM, Cunliffe WJ. Treatment of adult acne with low-dose intermittent isotretinoin [abstract]. Br J Dermatol. 1996; 135: 20CrossRefGoogle Scholar
  62. 62.
    Cunliffe WJ. Treatment of acne. In: Cunliffe WJ, editor. Acne. London: Martin Dunitz Ltd, 1991: 252–87Google Scholar
  63. 63.
    Breathnach AS. Melanin hyperpigmentation of skin. Cutis. 1996; 57: 36–45PubMedGoogle Scholar
  64. 64.
    Pepall LM, Cosgrove MP, Cunliffe WJ. Ablation of whiteheads by cautery under topical anaesthetic. Br J Dermatol. 1991; 125: 256–9PubMedCrossRefGoogle Scholar
  65. 65.
    Atzori L, Brundu MA, Orru A. Glycolic acid peeling in the treatment of acne. J Eur Acad Dermatol Venereol. 1999; 12: 119–22PubMedCrossRefGoogle Scholar

Copyright information

© Adis Data Information BV 2006

Authors and Affiliations

  1. 1.Department of DermatologyHarrogate and District Foundation TrustHarrogateUK

Personalised recommendations