INTRODUCTION
Acne vulgaris is a common disease of the pilosebacous
unit that affects an estimated 40-50 million Americans.1,2 Greater than 95% of teenage boys and between 83% and
85% of teenage girls suffer from acne.3 The condition frequently
continues into adulthood. While boys more commonly suffer from
acne in the teenage years, greater numbers of women suffer into
adulthood.4,5,6,7 It is unclear if the number of post-adolescent women
with acne is rising as compared to the past, or whether women
are now seeking out treatment more than in the past.4
Post-adolescent acne is a significant problem for women. One
survey-based United States study found that approximately
50% of women continue to suffer from acne in their twenties,
35% in their thirties, 26% in their forties, and 15% in their fifties.
The prevalence of acne was shown to be higher in women than
in men in each of these age groups.7 A similar study from Europe
showed that beyond the age of 23, acne is more prevalent
in women than men. In their forties and fifties, 5% and 8% of
women suffered from acne, respectively.8 Several other studies
have provided similar data, showing that larger numbers of adult
women suffer from acne as compared to age matched men.9,10,11
Acne is the number one reason that patients visit a dermatologist. 12 While the mean age at which patients are seen for acne is
24 years old, 10% of visits occur in patients in their mid-thirties and forties.13 Approximately two-thirds of dermatology visits for
acne are made by women, and one-third of total acne office visits
are made by women over 25 years old.14 Acne patients suffer
from a significant psychologic burden, which has been compared
to that of patients with systemic diseases like diabetes,
asthma, arthritis, or epilepsy.15 Up to 50% of adolescents with
acne experience disturbances to their psyche, including issues
with body image, anxiety, depression, poor self-esteem, social
impairment, and thoughts of suicide.16,17 Moreover, acne treatment
is expensive. The average total cost of care related to an
acne patient’s visit to the dermatologist is estimated to be $689.14
Review of Pathogenesis
Our current understanding of the pathogenesis of acne does
not provide a clear distinction in what causes adolescent versus
adult acne. Moreover, it is unclear why acne is more prevalent in
adult women compared to age matched males. What we know
is that acne vulgaris is caused by several major pathogenic factors,
Table 1. These include abnormal follicular keratinization,18 sebum production,19 Propionibacterium acnes (P. acnes) bacteria, 20 and inflammation.20,21
Both hyperproliferation and cell retention lead to the hyperkeratinization
observed in epithelium of the pilosebaceous follicle
of acne patients. This bottle-neck effect, along with perifollicu-
