Adult female acne: Latest scientific information

  • 20min
  • May. 2022
  • Supported by
    • La Roche-Posay

Nowadays, we see more cases of acne after adolescence, with a higher prevalence in females than males. Adult female acne has a different clinical presentation and is associated with a number of specific pathophysiological characteristics and gender-specific triggers.

Adult female acne has a high negative impact on the patients’ QoL, even when they have mild to moderate acne. Due to all these particular aspects, adult acne treatment should be tailored to address the specific characteristics of this population, including other factors beyond acne severity.



Definition


Adult female acne (AFA) is defined as acne that affects women over the age of 25.
AFA may persist continuously from adolescence or with periods of relapse and remission or or manifest for the first time during adulthood.
Whether continuing from childhood or making its first appearance in adulthood, AFA is a severe issue, which has a profound psychosocial impact on adult women.[1]



Prevalence


Female patients account for two thirds of visits made to dermatologists for acne and one third of all dermatology office visits for acne are by women who are older than 25 years.[2]
According to differences in the design of the studies, with self-reported prevalence rates being higher than those from clinical studies, the prevalence of AFA varies:



Types


Clinically, there are three distinct sub-types of AFA[6, 7]:

  • Persistent acne: a continuation of the disease from adolescence into adulthood;
  • Relapsing acne: a regression after adolescence and recurrence in adulthood;
  • Late-onset acne: acne that begins after the age of 25 years. Mainly mild to moderate in severity, even though severe acne may be observed as well.[6, 8, 9]


Clinical signs and symptoms


The clinical signs of adult female acne differ from those of adolescent acne. AFA usually appears gradually and its severity ranges from mild-to-moderate whereas adolescent acne may develop swiftly and present as severe disease. Adult Female Acne lesions affects mainly the lower part of the face, the perioral region and the chin (deep-seated, long-lasting small nodules <0.5 cm), conferring a U-shape, the zone below the jawline, in addition to the anterior cervical region, and sometimes the chest.[10]
Localization of acne on the submandibular area, which is specific to AFA, is seen in only 11 % of adult women.[1] AFA lesions are inflammatory lesions (affecting 58% of women), papules, pustules and nodules, of mild to moderate intensity, with the presence of numerous open comedones and microcysts, few closed comedones.[11] Postinflammatory hyperpigmentation is common and scars can occur in 20% of affected women.[12] In one study of postadolescent acne, 85% of patients had mostly comedonal acne.[13]

Pathogenesis


The pathogenesis of acne in adult women is particularly complex and it includes genetic predisposition, androgenic hormone stimulation and microbiome factors. Genetic predisposition influences the number, size and activity of the sebaceous glands, the hormonal control, the process of follicular hyperkeratinization and the innate immunity. First-degree relatives with acne in adulthood may determine individual susceptibility to adult persistent facial acne.[16] Androgens, which stimulate sebum production via androgen receptors on the sebaceous glands, play a major role in adult women acne, as evidenced by the response of acne in adult women to hormonal treatments and the use of hormone-based therapies such as oral contraceptive and antiandrogen medications in women with normal androgen levels.[17-21] Cutibacterium acnes is the main bacterium involved in the pathogenesis of acne. C. acnes phylotypes IA preferentially colonizes the seborrheic areas of the skin while others (IB, II and III) are not or poorly present in acne lesions. C. acnes is involved in stimulation of follicular hyper-keratinization, alteration of the sebaceous composition and inflammatory response through Toll-Like receptors. C. acnes colonization may cause chronic stimulation of the innate immune system, initiation and exacerbation of inflammatory lesions.[11-22]



Factors


Several environmental actors have been cited for triggering or worsening acne in adult women. Such factors includes tobacco, exposure to sunlight, cosmetics, stress, medications and diet.[7-10, 23, 24] These environmental factors can then modulate the pathogenic factors (described in §5) and lead to the formation of acne lesions.

Flare-ups before menstruation appear to be more common in older women and are observed in about half of adult patients with acne[25, 26]. These flares are due to increased water content of the follicular wall in the last week of the menstrual cycle, and may be more marked in patients using androgenic, progesterone-derived oral contraceptives (first and second generation) than in patients using more recent formulations.[27, 28]



Quality of life


For adult women, acne can have a major impact on their live, regarding psychological well-being, social functioning and everyday activities, which can result in decreased self-esteem, anxiety, depression and even suicidal ideation. Even in women with mild clinical conditions, the impact on Quality of life (QoL) is high. [29] Therefore, effective management strategies aim also at improving patient’s QoL, at the earliest possible stage. QoL is a status of wellbeing in emotional, physical, social and functional dimensions of an individual. To measure QoL, the most common evaluation scales are :[30]

Classification Adult Female Acne Scoring tool


Traditional methods of assessing acne severity have been primarily developed to assess acne in adolescents.[31] However, these methods insufficiently consider adult women-specific acne issues, such as differences in severity of acne symptoms between facial areas or the use of oral contraceptives and cosmetics. Recently, a composite Adult Acne Evaluation Tool, AFAST, has been developed from the Global Acne Severity Scale.[32] The AFAST is composed by the GEA scale to assess acne on the full face, Score 1 (Table 1) and a second scale developed to assess acne on the mandibular zone, Score 2 (Table 2).

This new tool allows dermatologists to score both facial and mandibular acne more precisely, thus allowing for the most adapted therapy to be selected more easily.[33]



Treatment algorithm


Based on a clinical consensus between acne experts, Poli et al. have proposed an acne treatment algorithm which dermatologists can easily apply to their daily clinical practice.[34] The proposed algorithm includes the four main aspects of daily acne treatment: bacterial resistance, contraception, skin care and topical treatment use. The algorithm highlights the specificity of adult female acne. Indeed, the severity of mandibular acne is the main modulating factor for choosing the most adequate treatment (Table 3).

Treating the entire skin surface with a topical treatment in adult acne using a drug with a large spectrum of activity, with both anti-inflammatory and comedolytic properties is also important.[14] The algorithm does not include the management of secondary acne caused by endocrine disorders, which require specific hormonal treatment approaches. Acne recurrence is common. To minimize the likelihood of relapse after treatment completion, maintenance therapy is often needed. The duration of such maintenance therapy should consider its efficacy, tolerability and adherence. Recommended maintenance therapies include azelaic acid, tretinoin and adapalene.[35]



Skin care


Treatment for acne can cause dryness, irritation, impair the epidermal barrier, increase transepidermal water loss and inflammation and eventually reduce adhesion to prescribed treatment. Skincare products adapted for acne management include cleansing agents for oily or sensitive skin, sebaceous secretion regulators, antimicrobial products, product with anti-inflammatory properties or keratolytic abilities, moisturizers and sunscreens (useful for preventing post-inflammatory hyperpigmentation). All adult women with acne should use a gentle, non-soap cleanser with a pH close to 5.5 and a non-comedogenic, oil-free moisturizer. Moisturizers may contribute to reduce these adverse events of topical products and oral isotretinoin by avoiding the impairment of the epidermal barrier, which is essential to prevent or reduce inflammation. Patients should be informed about the role of comedogenic cosmetics such as powder make-up, may play by limiting the efficacy of acne drugs. However, corrective makeup and camouflage are useful and should be part of the therapeutic regimen as they improve the quality of life, contribute to sun protection and reduce the habit of inconsistency, very common in women.[36-38]



Adherence


According to the World Health Organization “Increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments.[7, 39] Indeed, adherence to acne therapy can be poor. [1] Long duration, psychological impact of acne, stress-related issues and low expectations of further treatment efficacy can make adult female patients more difficult to motivate and to maintain on treatment, which can explain the lack of treatment response.[40] A tailored treatment approach providing an easy, precise and specific management of adult female acne may help adult women to patients to adhere better and longer to their therapy.


This article has been written by Pr. Brigitte Dréno

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