INTRODUCTION
Acne is a common facial disorder that affects predominately
adolescents, however, many patients are now presenting
before and after the teenage years with acne. Although
acne vulgaris (AV) is the classic descriptive term, with “vulgaris”
implying the common type, AV is probably not the best description
as many adult women present with clinical presentations that are
not common in adolescents with AV or in adult males. Hence, the
word acne itself is probably better to use when discussing the postadolescent
female subset, as it encompasses both AV and other
specific patterns such as the hormonal pattern (described later).
Recently, there is growing evidence that AV among adults is increasing
with an estimate of 12 to 14% between the ages of 25 to
50 years old.1-4 Although the majority of epidemiological studies of
AV focus on adolescents, the mean age of presentation for treatment
of AV is 24 years old and approximately 10% of visits are
by patients who are from 35 to 44 years old.5 In addition, many
patients with postadolescent AV have more persistence of acne
lesions, with scarring observed in some cases.6 The duration of AV
lesions in adults has been correlated with marked adverse psychosocial
effects.7 It has been shown that patients with adverse
emotional effects associated with their AV experience negative
psychosocial impact that is similar in magnitude to patients with
psoriasis, a skin disorder that causes significant psychological
disability in many people.8 To add, women tend to comprise a major
portion of post-teen adult patients with AV. A subset of these
women can also have other systemic signs of hyperandrogenism
and associated conditions such as polycystic ovarian syndrome
(PCOS). Studies have estimated the prevalence of acne to be 9.8%
to 34% in women with PCOS.9 Those patients with PCOS tend
to have moderate to severe acne in greater than 50% of cases.9
However, the majority of women with adult acne do not have abnormal levels of circulating androgens but can still be treated with
oral spironolactone and/or oral contraceptives (OCs).10,11
Background of Acne Vulgaris in Adult Women
Acne in post-adolescent women is defined as persistent or new
onset of acne lesions after 25 years of age.10-12 The prevalence of
acne in adult female from the ages of 25 to 40 years was noted
to be as high as 41%.10 Also, 51% of those women were from
the ages of 20 to 29 years.13 In many clinical trials completed in
patients with AV, the mean age of enrolled subject is often 18 to
19 years, suggesting that a number of subjects were past their
teenage years. There may also be a genetic component to the
presence of acne in adult women past teenage years. Researchers
have found an acne-prone genetic predisposition in 53% of
women with adult acne, with a positive first-degree family history
of AV.12 Although some women experience “acne breakouts”
throughout their adolescent life, some may have persistent acne
through their adult years, and others may note that their first
onset of acne occurred in their early, middle, or late twenties.
In order to distinguish the subsets of women with adult acne
based on onset, three distinct categories have been described.14
The first is continuous, with patients first having adolescent AV,
and then persistent post-adolescent acne through adulthood.
Late onset acne characteristically appears after 25 years of age
with no previous history of acne and is found in approximately
20% to 40% of women.12 Finally, there is a “relapsing” subtype
in women who had adolescent acne that disappeared for years
and then returned again.14 This may or may not be associated
with a high androgenic state or a syndrome. The most common
condition that can be associated with acne is PCOS. However, an
estimated 50% of women with acne in their adult years do not
have clinical or biochemical evidence of hyperandrogenism.15
