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.
Similar content being viewed by others
Notes
The use of trade names is for product identification purposes only and does not imply endorsement.
References
Burton JL, Cunliffe WJ, Stafford L, et al. The prevalence of acne vulgaris in adolescence. Br J Dermatol. 1971; 85: 119–26
Goulden V, Stables GI, Cunliffe WJ. The prevalence of facial acne in adults. J Am Acad Dermatol. 1999; 41: 577–80
Shafer T, Nienhaus A, Vieluf D, et al. Epidemiology of acne in the general population: the risk of smoking. Br J Dermatol. 2001; 145: 100–4
Goulden V, Clark SM, Cunliffe WJ. Post adolescent acne: a review of clinical features. Br J Dermatol. 1997; 136: 66–70
Marks R. Acne and its management beyond the age of 35 years. Am J Clin Dermatol. 2004; 5 (6): 459–62
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–38
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: 386
Sheehan-Dare RA, Hughes BR, Cunliffe WJ. Clinical markers of androgenicity in acne vulgaris. Br J Dermatol. 1988 Dec; 119 (6): 723–30
Thiboutot D. Acne: hormonal concepts and therapy. Clin Dermatol 2004 Sep-Oct; 22 (5): 419–28
Vershoore M. Aspect hormonaux de l’acne. Ann Dermatol Venereol. 1987; 114: 439–54
Lawrence D, Shaw M, Katz M. Elevated free testosterone concentration in men and women with acne vulgaris. Clin Exp Dermatol. 1986; 11: 263–73
Lucky AW, McGuire J, Rosenfield RL, et al. Plasma androgens in women with acne vulgaris. J Invest Dermatol. 1983; 81: 70–4
Pochi PE, Comite H, Longcope C. Hormone blood levels in women with acne [abstract]. J Invest Dermatol. 1986; 86: 501
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: 301–4
Lookingbill DP, Horton R, Demers LM, et al. Tissue production of androgens in women with acne. J Am Acad Dermatol. 1985; 12: 481–7
Carmina E, Lobo RA. Evidence for increased androsterone metabolism in some normoandrogenic women with acne. J Clin Endocrinol Metab. 1993; 76: 1111–4
Thiboutot D, Gilliland K, Light J, et al. Androgen metabolism in sebaceous glands from subjects with and without acne. Arch Dermatol. 1999; 135: 1041–5
Allam SG. Acne vulgaris in the sixth decade and beyond [Master of Science thesis]. Cardiff: University of Wales, 1991
Eady EA, Gloor M, Lleyden JJ. Propionibacterium acnes resistance: a worldwide problem. Dermatology. 2003; 206: 54–6
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: 51–7
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: 2188–95
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: 885–92
Mills OH, Kligman AM. Acne detergicans. Arch Dermatol. 1975 Jan; 111 (1): 65–8
Kligman AM, Mills Jr OH. ‘Acne cosmetica’. Arch Dermatol. 1972; 106 (6): 843–50
Khanna N, Gupta SD. Acneiform eruptions after facial beauty treatment. Int J Dermatol. 1999; 38 (3): 196–9
Cunliffe WJ. Clinical features of acne. In: Marks R, editor. Acne. London: Martin Dunitz, 1989: 11–75
Kligman AM. Post adolescent acne in women. Cutis. 1991; 48: 75–7
Knaggs HE, Wood EJ, Rizer RL, et al. Post adolescent acne. Int J Cosmet Sci. 2004; 26: 129–38
Cunliffe WJ. Acne and unemployment [letter]. Br J Dermatol. 1986; 115: 386
Layton AM, Seukaran D, Cunliffe WJ. Scarred for life?. Dermatology. 1997; 195: 15–21
Myhill JE, Leichtmen SR, Bumett JW. Self-esteem and social assertiveness in patients receiving isotretinoin treatment for cystic acne. Cutis. 1988; 41: 171–3
Lasek RJ, Chren MM. Acne vulgaris and the quality of life of adult dermatology patients. Arch Dermatol. 1998; 134: 454–8
Derman RJ. Androgen excess in women. Int J Fertil Menopausal Stud. 1996 Mar–Apr; 41 (2): 172–6
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: 57–64
Leyden JJ. Antibiotic resistance in the topical treatment of acne vulgaris. Cutis. 2004 Jun; 73 (6 Suppl.): 6–10
Griffiths CEM. Nicotinamide 4% gel for the treatment of inflammatory acne. J Dermatolog Treat. 1995; 6 Suppl. 1: S8–10
Dreno B, Bettoli V, Ochsendorf F. European recommendations on the use of oral antibiotics for acne. Ear J Dermatol. 2004; 14 (6): 391–9
Tan AW, Tan HH. Acne vulgaris: a review of antibiotic therapy. Expert Opin Pharmacother. 2005 Mar; 6 (3): 409–18
Shaw JC, White LE. Persistent acne in adult women. Arch Dermatol. 2001; 137: 1252–3
DeRossi SS, Hersh EV. Antibiotics and oral contraceptives. Dent Clin North Am. 2002; 46 (4): 653–4
Thiboutot D. Hormones and acne: pathophysiology, clinical evaluation, and therapies. Semin Cutan Med Surg. 2001; 20: 144–53
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: 25–34
Shaw JC. Hormonal therapy in dermatology. Dermatol Clin. 2001; 19: 169–78
Goodfellow A, Alaghband-Zadeh J, Carter G, et al. Oral spironolactone improves acne vulgaris and reduces sebum excretion. Br J Dermatol. 1984; 111: 209–14
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
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): 163–6
Cusan L, Dupont A, Belanger A, et al. Treatment of hirsutism with the pure antiandrogen flutamide. J Am Acad Dermatol. 1990; 23: 462–9
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): 253–9
Shaw JC. Acne: effect of hormones on pathogenesis and management. Am J Clin Dermatol. 2002; 3 (8): 571–8
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: 209–15
Saihan E, Burton J. Sebaceous gland suppression in female acne patients by combined glucocorticoid-oestrogen treatment. Br J Dermatol. 1981; 103: 139–42
Pochi P, Strauss J. Sebaceous gland inhibition from combined glucocorticoid-estrogen treatment. Arch Dermatol. 1976; 112: 1108–9
Cunliffe WJ, van de Kerkhof PC, Caputo R, et al. Roaccutane treatment guidelines: results of an international survey. Dermatology. 1997; 194 (4): 351–7
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]
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]
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]
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]
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): 92–102
Goulden V, Clark SM, McGeown C, et al. Treatment of acne with intermittent isotretinoin. Br J Dermatol. 1997 Jul; 137 (1): 106–8
Zane LT. Acne maintenance therapy: expanding the role of topical retinoids?. Arch Dermatol. 2006 May; 142 (5): 638–40
Goulden V, Clark SM, Cunliffe WJ. Treatment of adult acne with low-dose intermittent isotretinoin [abstract]. Br J Dermatol. 1996; 135: 20
Cunliffe WJ. Treatment of acne. In: Cunliffe WJ, editor. Acne. London: Martin Dunitz Ltd, 1991: 252–87
Breathnach AS. Melanin hyperpigmentation of skin. Cutis. 1996; 57: 36–45
Pepall LM, Cosgrove MP, Cunliffe WJ. Ablation of whiteheads by cautery under topical anaesthetic. Br J Dermatol. 1991; 125: 256–9
Atzori L, Brundu MA, Orru A. Glycolic acid peeling in the treatment of acne. J Eur Acad Dermatol Venereol. 1999; 12: 119–22
Acknowledgments
This review paper was not supported by external commercial funding and there are no conflicts of interest to declare.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Williams, C., Layton, A.M. Persistent Acne in Women. Am J Clin Dermatol 7, 281–290 (2006). https://doi.org/10.2165/00128071-200607050-00002
Published:
Issue Date:
DOI: https://doi.org/10.2165/00128071-200607050-00002