Drug Therapy

Status Report From the American Acne & Rosacea Society on Medical Management of Acne in Adult Women, Part 1: Overview, Clinical Characteristics, and Laboratory Evaluation

Cutis. 2015 October;96(4):236-241

James Q. Del Rosso, DO

Julie C. Harper, MD

Emmy M. Graber, MD, MBA

Diane Thiboutot, MD

Nanette B. Silverberg, MD

Dawn Zhang Eichenfield, PhD

Lawrence F. Eichenfield, MD

Acne presenting in adult women is commonly encountered in clinical practice. Many affected women have had acne during their teenaged years, have tried several therapies in the past, and are seeking effective treatment. Others are frustrated by the inexplicable emergence of acne as an adult when they never had it as a teenager. Both groups seek an explanation of why they have acne, are often psychosocially affected by its effects on appearance and self-esteem, and all are wanting effective and safe treatment. Clinicians are  encouraged to connect favorably with each patient through careful history and physical examination and to consider underlying causes of androgen excess. Practical approaches to examination and laboratory evaluation are discussed.

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Practice Points

Acne in adult women is common and may persist beyond the adolescent years or may be late in  onset with emergence usually during the early to mid-20s.
Adult women with acne often are frustrated, as they perceive it as a disorder of teenagers and are perplexed by its presence later in life. They often are distressed by unpredictable flares as well as difficulty with covering lesions and associated dyschromia and scarring.
Clinical patterns of acne in adult women are mixed inflammatory and comedonal facial acne or a U-shaped pattern of inflammatory lesions involving the lower face and neck.
Laboratory testing is not considered mandatory in all cases. The clinician is encouraged to carefully evaluate each case and determine if further evaluation to detect a cause of androgen excess is warranted.

References

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2. Collier CN, Harper JC, Cafardi JA, et al. The prevalence of acne in adults 20 years and older. J Am Acad Dermatol. 2008;58:56-59.

3. Lucky AW, Biro FM, Huster GA, et al. Acne vulgaris in premenarchal girls. an early sign of puberty associated with rising levels of dehydroepiandrosterone. Arch  Dermatol. 1994;130:308-314.

4. Mancini AJ, Baldwin HE, Eichenfield LF, et al. Acne life cycle: the spectrum of pediatric disease. Semin Cutan Med Surg. 2011;30(suppl 3):S2-S5.

5. Tanghetti EA, Kawata AK, Daniels SR, et al. Understanding the burden of adult female acne. J Clin Aesthet  Dermatol. 2014;7:22-30.

6. Goulden V, Stables GI, Cunliffe WJ. Prevalence of facial acne in adults. J Am Acad Dermatol. 1999;41: 577-580.

7. Marks R. Acne and its management beyond the age of  35 years. Am J Clin Dermatol. 2004;5:459-462.

8. Preneau S, Dreno B. Female acne—a different subtype  of teenager acne? J Eur Acad Dermatol Venereol. 2012;26:277-282.

9. Kim GK, Del Rosso JQ. Oral spironolactone in post-teenage female patients with acne vulgaris: practical considerations for the clinician based on current data and clinical experience. J Clin Aesthet Dermatol. 2012;5:37-50.

10. Thiboutot D, Chen W. Update and future of hormonal therapy in acne. Dermatology. 2003;206:57-67.

11. Villasenor J, Berson D, Kroshinsky D. Treatment  guidelines in adult women. In: Shalita AR,  Del Rosso JQ, Webster GF, eds. Acne Vulgaris.  London, United Kingdom: Informa Healthcare; 2011:198-207.

12. Del Rosso JQ, Zeichner J. What’s new in the medicine cabinet? a panoramic review of clinically relevant information for the busy dermatologist. J Clin Aesthet Dermatol. 2014;7:26-30.

13. Del Rosso JQ, Kircik L, Gallagher CJ. Comparative efficacy and tolerability of dapsone 5% gel in adult versus adolescent females with acne vulgaris. J Clin Aesthet  Dermatol. 2015;8:31-37.

14. Dreno B, Layton A, Zouboulis CC, et al. Adult female acne: a new paradigm. J Eur Acad Dermatol Venereol. 2013;27:1063-1070.

15. Choi CW, Lee DH, Kim HS, et al. The clinical features of late onset acne compared with early onset  acne in women. J Eur Acad Dermatol Venereol. 2011;25:454-461.

16. Dréno B, Thiboutot D, Layton AM, et al; Global  Alliance to Improve Outcomes in Acne. Large-scale international study enhances understanding of an emerging acne population: adult females. J Eur Acad Dermatol Venereol. 2015;29:1096-1106.

17. Kane A, Niang SO, Diagne AC, et al. Epidemiologic, clinical, and therapeutic features of acne in Dakar,  Senegal. Int J Dermatol. 2007;46(suppl 1):36-38.

18. Callender VD, Alexis AF, Daniels SR, et al. Racial differences in clinical characteristics, perceptions and behaviors, and psychosocial impact of adult female acne. J Clin Aesthet Dermatol. 2014;7:19-31.

19. Davis SA, Narahari S, Feldman SR, et al. Top dermatologic conditions in patients of color: an analysis of nationally representative data. J Drugs Dermatol. 2012;11:466-473.

20. Rendon MI, Rodriguez DA, Kawata AK, et al. Acne treatment patterns, expectations, and satisfaction among adult females of different races/ethnicities.  Clin Cosmet Investig Dermatol. 2015;8:231-238.

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It was not long ago that acne vulgaris (AV) was commonly considered to be a skin disease that affected teenagers with little attention given to preadolescent and postadolescent AV. This perspective has changed, with more attention being given to AV across a broad range of affected  age groups, including preadolescent, adolescent, and postadolescent subgroups.^1-5 Earlier onset of adrenarche has led to earlier development of AV in many young girls, with a higher range of dehydroepiandrosterone sulfate (DHEAS) levels observed overall in those with AV as compared to a normal age-matched population.^3,4 At the other end of the age spectrum, AV is a common phenomenon in adult females, with at least half of women estimated to exhibit some form of AV.^1,2,5-8 Based on a  large survey of females and males (N=1013), the prevalence of AV in adult females has been reported to be 50.9%, 35.2%, 26.3%, and 15.3% among women aged 20 to 29 years, 30 to 39 years, 40 to 49 years, and 50 years and older, respectively.² Acne vulgaris that persists beyond adolescence into adulthood is termed persistent acne, or early-onset acne, and the development of AV in women 25 years and older who have not previously been affected by AV has been termed late-onset acne.^6,8,9 Publications on the management of AV in adult women have focused primarily on systemic hormonal therapies; however, topical therapies more recently have received greater attention in this subpopulation^9-12 and will be discussed in part 2 of this series. Because data on AV in women are  limited primarily to involvement of the face and neck region, this article does not address truncal AV unless otherwise specified. Table 1 depicts factors that can influence the management of AV in adult women.

Visible Patterns and Considerations for Clinical Evaluation  

Clinical Patterns

Although epidemiologic and demographic data are limited in the subpopulation of women with AV, it is reported that females account for up to 82% of adults with AV, with approximately 75% presenting with AV that is clinically similar to their disease course in adolescence.^2,5,13 Among those women with persistent AV, some state that their AV is worse compared to adolescence, while others report it is not as severe. The pattern of AV often is similar to that seen in adolescence, presenting as mixed comedonal and inflammatory papular/pustular lesions diffusely distributed on the face; in other cases, a more selectively distributed U-shaped pattern is noted, characterized predominantly by inflammatory papules and/or nodules involving the lower cheeks and jawline margin, with lesions also commonly noted on the anterior and lateral neck.^5,8,9,13-16 A U-shaped pattern is believed to be more common in late-onset AV, often with persistence into the mid-40s.^1,15,17 It is important to emphasize the need for additional studies on the demographics and clinical characteristics of AV in adult females, especially correlations between onset, age, and clinical patterns of AV.

An international, prospective, observational study assessed the clinical characteristics of AV in adults (aged ≥25 years) at a dermatology visit for acne (N=374).¹⁶ Participants who were under management for their AV showed severity grades of mild (clear/almost clear) in 47.3% of cases. Involvement of multiple facial sites—cheeks, forehead, mandibular region, and temples—was noted in 89.8% of women, often with both inflammatory and comedonal lesions, which is a pattern similar to adolescent AV. Inflammatory lesions alone were observed in 6.4% of women, 17.1% had comedonal AV only,  and truncal AV was present in 48.4%.¹⁶ Additional well-designed studies are needed to determine if this study reflects an accurate qualitative and  quantitative depiction of the spectrum of AV in adult females.

Mandibular Pattern

In the observational study of AV in adults, AV localized to the mandibular area was noted in only 11.2% of participants.¹⁶ Women with localized mandibular AV were more likely than women without localized AV to be employed, noted greater daily stress levels, and tended to report more psychologically stressful jobs. Interestingly, the subgroup with mandibular acne alone was much less likely  to exhibit a global severity grade of moderate or higher (7.1% vs 50.1%), truncal acne  (19.0% vs 51.9%), postinflammatory hyperpigmentation (23.8% vs 51.9%), and erythema (19.0% vs 48.4%), suggesting a unique subset of AV presentation.¹⁶

Ethnicity/Skin Color

Women of all ethnicities and skin types may be affected by AV.^1,18-20 Earlier age of onset of AV has been suggested in white women; however, earlier onset of adrenarche may be more frequent in black girls, which supports an earlier age of onset of AV in this subpopulation.^15-17 Women with skin of color usually express greater concern with persistent dyschromia at sites where lesions have resolved, and presence of acne scars is a concern among women regardless of skin color, ethnicity, or race.^18,20-22