“I’m too old for acne!” Acne in adult women is frequent and poorly treated – Dr. J. Revuz

The frequency of consultations for acne in adult women has clearly increased in recent decades; the clinical aspect, scalable mode, risk factors, different therapeutic methods from those for adolescent acne; little is known generally and its treatment is difficult and often frustrating for patients.

Epidemiology

Prevalence

Arbitrarily, there is talk of acne in adult women over the age of 25. Increased frequency - or consultation frequency? - is undeniable: considered as rare in 1942¹, acne in adult women was common in 1994, the average age of all patients changed in 10 years from 20.5 to 26.5 years old². A French survey by questionnaire³ in 4,000 women aged between 25 and 40 found a prevalence of 41%, almost half of which corresponded to an acne “clinic”, i.e. justifying treatment. The strong predominance of female consultants may, as the increased frequency, lead to a greater propensity for women to consult, rather than a genuine higher prevalence compared to men; The Cunliffe team had thus noted, in clinical examinations, that the prevalence among hospital employees was 54% among women and 40% among men⁴, whereas the distribution of consultants for adult acne is between 3 to 5 women per one man. The same equality (or slight difference) of prevalence was noted in Australia in 1,500 adults examined: 13.6% in women, 11.8% in men⁵. In both cases, it was mainly “physiological” acne, i.e. made from rare intermittent lesions; “Severe” acne seemed more frequent in women; It is, however, not extremely reliable data. In these studies, 20 to 40% of female acne occurred in adult age (late-onset acne) without having occurred in adolescence. The prevalence of acne decreases with age: 63% between 20 and 29 years old, 43% between 30 and 39 years old, less than 10% among 50-59 years old⁶ (figure 1).

Risk factors

These have been barely and poorly studied; It is an area where groundless statements, based on preconceived ideas are frequently expressed; Many assertions about the role of stress, in particular that of executive women, hormones, the difficult life of women, living three days in 24 hours⁷ reflect more the concerns of authors than the data established. Being overweight would be negatively associated with acne in a study by Taiwan⁸. The role of tobacco, conversely, seems firmly established, at least for one of the varieties of acne in adult women; thus 150/226 (66%) of women with acne were smokers in a Italian study and this acne was especially comedonal in female smokers: 73% of women with comedonal acne were smokers, compared with 29% of women with inflammatory acne⁹. Some acnegenic cosmetics may be in question or, at least, aggravate acne. Genetics plays an important role: the existence of a history of acne in the mother multiplies the risk of having acne as an adult by 4¹⁰.

Clinical

Acne in adult women usually occurs in less seborrhoeic skin, and more readily affects the bottom of the face, the mandibular, sub-maxillary region and the chin (figure 2). This topographic particularity is in part currently being questioned¹¹. Acne on the cheeks and forehead was considered rare in the acne of European adult women; It seems frequent in African¹² and Afro-American¹³ women.
It mainly consists of inflammatory lesions sometimes with nodules on the chin; closed comedones (microcysts) are not unusual: Considered as less frequent than in teenage girls in a Korean study¹⁴, they would primarily be the mark of “smokers’ acne”⁹ (figure 3). Acne on the torso, the top of the back or the intermammary region is not unusual. Atrophic scars and consequent pigmentations are common: 49% in the French study³ (figure 4). In this same study, handling/excoriation of “spots” was almost universal without it falling in the severe and specific tables of excoriated acne (usually called «young girls’ acne» even if observed at any age and in both sexes). The social, psychological and quality of life impact are significant¹³. Acne is often considered as unfair and an anomaly by adult women: “It’s not my age any more”.

Acne in adult woman and hormonal status

60% to 70% of women with acne undergo a worsening during their period, usually in the 8 days before their period¹⁵, which is not linked to any hormonal anomaly: This type of phenomenon is common in all chronic skin or visceral disorders. The search for a hormonal induction by asking questions is, however, essential: many contraceptives (1^st and 2^nd generation oral contraceptives; intra-uterine devices with progesterone, implants, etc.) are likely to trigger or aggravate acne. We can even observe acne caused by 3^rd or 4^th generation oral contraceptives that “benefit” from an indication in acne. Acne treatment in an adult woman, therefore, always involves specific questioning on the contraceptive methods used and on the coincidences between amending this contraception and outbreaks of acne. Conversely, one spontaneous hormonal anomaly is extremely rare in women with acne without genuine clinical signs of hyperandrogeny: male alopecia, hirsutism, clitoral hypertrophy… polycystic ovary syndrome is rarely manifested by acne and never isolated acne¹⁶.

In practice, biological explorations are too often carried out in the absence of an indication, in particular in the absence of period problems. They are costly and destabilising for the patient without a diagnostic or therapeutic benefit; These hormonal explorations must remain exceptional and carefully justified.

Acne in adult women according to skin type and geography

Several studies have focused on the differences according to skin type and geography. An American study of 2,895 adult women¹⁷ compared the frequency and type of acne in women of different races (according to American terminology); Prevalence was highest among “African-American women” and “Hispanics”; Acne was more inflammatory among Asians and more comedonal among those of European descent (Caucasians); above all, essential data, hyperpigmentations were more frequent among African-American women (65%) and Hispanics (48%) than in the other categories. In another U.S. study¹⁸, the preferred location of the cheeks was noted among “African-American women” (48% vs 38% among Caucasians), the frequency of hyperpigmentations and the importance attached to their disappearance, confirming the daily experience of dermatologists faced with requests most often exclusively concerning pigmentations (figures 5 and 6). The Franco-African study by F. Polite et al. already cited¹² confirms these data and highlights the frequency of voluntary depigmentation practices of African women (in sub-Saharan Africa), source of setbacks and the worsening of facial acne lesions.

Treatment

Treatment is difficult: poor tolerance of local treatments, moderate effectiveness of oral treatments, explaining that less than a quarter of patients are treated³.

Elimination of aggravating factors

An essential first step!

• Giving up smoking is often difficult to achieve, it is necessary to at least try to cut down.
• The reduction of the acnegenic exogenous hormonal impregnation is essential; It is often confused with the hormonal acne treatment that does not have the same aim. Here, the fundamental issue is that of a contraception adjustment when it has androgenic effects (so-called 1^st and 2^nd generation progestins; Intra-uterine devices impregnated with a progestin with androgenic effects; implant. In France, the recent media-administrative explosion over 3^rd and 4^th generation oestrogen-progesterone and the danger of - real but manageable - thromboembolic events does not currently facilitate this contraception replacement management. When it is not denied by the patient, the use of oestrogen-progesterone with an antiandrogenic effect or simply non-androgenic leads to a modest improvement which is a help (more rarely therapeutic in itself) in acne treatment.

Local treatments

They are little used because of their poor efficacy and their poor tolerance in this field. Benzoyl peroxide is in particular effective on inflammatory lesions, but often poorly tolerated. Adapalene, better tolerated than tretinoin, may be tried if there are a lot of microcysts. The fixed combination dapalene/Benzoyl peroxide can be indicated here. Topical erythromycins, not very effective and desiccant, can be used as a stop button. Active antiacne cosmetics are a useful alternative when local treatments are difficult to use.

Systemic treatments

Systemic medical treatment is therefore essentially; there are tetracyclines, which are quite effective; the doses should be adapted to body weight: 50 to 100 mg for doxycycline (for a woman weighing 60-70 kg); 150 to 300 mg for lymecycline; the need for higher doses is rare. The risks of photosensitisation, especially with doxycycline, are most often easily prevented by taking medication in the evening and protection advice. Zinc gluconate is effective on inflammatory lesions. It can be prescribed during pregnancy. Finally, Isotretinoin treatment is legal in case of insufficient results with cyclins. All these treatments are purely suspensive: relapses usually occur when treatment is stopped; maintenance treatment with low-dose cyclins (50-75 mg/d) is sometimes effective, but not always well supported. 50-200 mg/day of Spironolactone is an interesting long-term treatment option for acne of adult women; it is usually combined with a contraception because of the risk of feminization of the male foetus. The optimal dose is reached in 25 mg stages from a 50 mg/d dose. The risk of hyperkalaemia is common, but in practice exceptional19. The biological monitoring of serum potassium is no longer regarded as essential20. Cyproterone acetate in antiandrogenic doses (25-100 mg/day) is used in the event of a well-documented hormonal anomaly.

Cosmetics

Cosmetics advice is important given the irritant effects of topical acne treatments: - gentle washing: make-up remover milk rinsed with water, gentle cleansing gel and micellar water are the best products; - moisturising and anti-inflammatory cream tested non-comedogenic for delicate skin; - cream containing keratolytic active substances and antibacterial agents for resistant skins in combination with drug treatments or used only for minor acne.
Make-up is common in this population. It is necessary to check that foundation and powders are non-comedogenic tested. In fact, it is not uncommon to observe many microcysts on the cheekbones and cheeks, the result of regular applications of powder.

Strengths

• Acne in woman aged between 25-40 is frequent: 10-20%. Nearly half has emerged without a history of acne in adolescence.
• Tobacco and family history are the only clearly established risk factors.
• Acne on the bottom of the face is frequent but the cheeks and forehead may also be affected. Smokers have often comedonal acne on their cheeks. Scars and blemishes are particularly frequent on pigmented skin.
• It is essential to find out the patient’s contraception history. Hormonal dosages are almost always useless.
• Treatments are above all systemic. Cosmetics can help provided that they are not comedogenic.

In practical terms

• Acne in adult women not only affects the bottom of the face but also the cheeks.
• Acne in smokers is very comedonal.
• Some contraceptives cause or worsen acne.
• Treatment is based on cyclins, spironolactone and sometimes isotretinoin.

This article has been written by Dr. J. Revuz, dermatologist (Paris, France)