Postadolescent Acne (Adult-Onset Acne)

Dermatologists regularly hear the lament “acne, at my age!” expressed by women in whom acne suddenly appears or in whom acne has not resolved by 20 years of age.
Adult-onset acne is overwhelmingly a condition of women and occurs when acne develops for the first time in the 20s or early 30s. In some cases, teenage acne persists into adulthood or disappears but then recurs later.
The prevalence of female adult acne has increased significantly in the past several generations.
Adult-onset acne in men has traditionally been unusual but it is now increasingly seen in men who participate in athletic activities particularly those who use hormonal supplementation.
There is little question that acne is influenced by hormones. Many women report premenstrual or (less commonly) midcycle flares of inflammatory acne. Pregnancy, oral contraceptives, and hormonal supplementation also appear to affect a woman's complexion and cause fluctuations in acne.

Acneiform lesions tend to appear and reappear like clockwork, typically recurring premenstrually or at ovulation.
Lesions may last several days or sometimes persist for a month or longer.
In some women, lesions occur without any pattern.

The diagnosis is made clinically.
In female patients whose acne is not responding to treatment, or for those who have other signs of hormonal excess such as male characteristics (e.g., facial hair) or irregular menstrual periods, hormonal tests are indicated. More often than not, these levels are normal, and it appears that these women may have an end-organ hypersensitivity to their endogenous androgens.

Differential Diagnosis

Rosacea/Perioral/Periorificial Dermatitis (see below)

Folliculitis

Acne Cosmetica

Traditional name for acne that is supposedly caused by cosmetics.
May look like inflammatory acne; however, it is often the result of skin irritation.

Management

Topical Treatment

Skin care should be kept simple and gentle with the use of mild soaps (Cetaphil gentle cleanser or Purpose facial wash).
Postadolescent acne in female patients is treated with many of the same agents used for adolescent acne; however, care should be taken in choosing a topical because aging skin is often more sensitive than teenage skin and may become dry or irritated more easily.

Systemic Treatment

Oral Antibiotics

Oral antibiotics are effective and commonly used for postadolescent acne (see the earlier discussion in this chapter and in Table 12.5).
Need to be used with caution in women of childbearing potential. Patients should be advised to stop the treatment if they become pregnant.

Hormonal Treatment

Indications include the following:

Oral Contraceptive Pills

By suppressing gonadotropins, reducing ovarian androgen secretion, and increasing sex hormone-binding globulin levels, oral contraceptives decrease serum testosterone concentrations. They also block the androgenic stimulation of sebaceous glands.
Ortho-Tri-Cyclen (ethinyl estradiol/norgestimate), Estrostep (ethinyl estradiol/norethindrone), and Yaz (ethinyl estradiol/drospirenone) are FDA approved to treat acne vulgaris. Alesse and Yasmin are other oral contraceptive pills (OCPs) that are effective for acne.
Antibiotics and the “Pill”—studies have shown that the antibiotics used to treat acne do not interfere with the efficacy of oral contraceptives.

Oral Antiandrogens

Before oral antiandrogens (androgen receptor blockers) are prescribed, a hormonal and gynecologic evaluation is appropriate for certain patients, particularly women who have treatment-resistant acne, women with the sudden onset of severe acne, virilizing signs or symptoms, irregular menstrual periods, or hirsutism.
Oral antiandrogens may also be considered for those women who are reluctant to take oral contraceptives for moral or religious reasons.

Spironolactone (Aldactone)

Spironolactone is the antiandrogen used most frequently to treat acne. It has potent antiandrogenic effects and works by decreasing sebum production.
Dosing: Usually started at 25 to 50 mg/day and then titrated upward according to response (dose range 50 to 200 mg/day).
It may take 3 months for any positive effects to become visible, but results may appear sooner. The dosage may need to be adjusted during the first 6 months of treatment.
Side effects: Most are dose dependent and include breast tenderness, irregular menstrual periods, headaches, and potential hyperkalemia (rare in young healthy patients).

Other Androgen Receptor Blockers

Cyproterone is an acetate steroidal androgen receptor blocker and competitively inhibits testosterone and dehydroepiandrosterone. It is not available in the United States but is sold outside the United States in combination with ethinyl estradiol as Diane-35.
Flutamide, a nonsteroidal androgen receptor blocker approved for prostate cancer, has been used for acne at doses of 62.5 to 500 mg/day.

Helpful Hints

A minimum of 3 to 6 months of therapy is required to evaluate the efficacy of oral contraceptives and antiandrogen agents in treating adult-onset acne.
The birth control patch and ring have an unpredictable effect on acne and can actually provoke acne. Depo-Provera, an injectable form of birth control-containing synthetic progesterone, can also worsen or trigger acne.
In women with predicable premenstrual flares of acne, a short course of an oral antibiotic can be given 5 to 7 days before her next menstrual period (“pulse therapy”).

Point to Remember

Every female patient with acne should be questioned about her menstrual history and possible virilizing symptoms.

Description of Lesions

Postadolescent acne is relatively free of comedones and consists of evanescent, inflammatory red papules and/or pustules.
In general, there are fewer lesions than in typical teenage acne.

Distribution of Lesions

In women, lesions occur on the face, most often in the perioral area, along the jawline, or on the chin, that is, the lower part of the face (Fig. 12.12). Also, the hairline, neck, and upper trunk may be affected.
In men, lesions tend to be limited to the trunk.

Outline
Description of Lesions
Distribution of Lesions