Post-Adolescent Acne in Women: More Common and More Clinical Considerations
June 2012 | Volume 11 | Issue 6 | Original Article | 708 | Copyright © June 2012
AbstractCurrent evidence suggests that post-adolescent acne in women is on the rise. Acne in this subgroup of patients commonly follows a specific pattern that can often be treatment resistant and/or prone to relapse, including after oral isotretinoin therapy. With a plethora of medications to choose from for acne treatment, many of which have been used in the past by patients without success, dermatology practitioners often find oral contraceptives and spironolactone to be of benefit in otherwise healthy adult females. Also, some of these patients may have concurrent hormonal anomalies such as polycystic ovarian syndrome or other underlying endocrine disorders, which should also be appropriately worked up by the clinician and managed accordingly. This article reviews some of the underlying pathophysiological factors, available treatment options, and screening guidelines to assist clinicians in the management of acne in adult females.
J Drugs Dermatol. 2012;11(6):708-713.
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
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