SAN FRANCISCO – Dermatologists are seeing an increasing incidence of adult women with acne in their offices and they are a clear challenge to treat, Dr. Hilary E. Baldwin said.
Compared to teenagers, women in their 30s, 40s and 50s and their acne lesions can be more resistant to treatment, Dr. Baldwin said at a seminar on women’s and pediatric dermatology sponsored by the Skin Disease Education Foundation (SDEF).
"One of the problems of treating moderate-to-severe acne in the adult woman is that topical medications may not work particularly well. It may be that she is a little harder to treat, but also she has acne on the neck and the jaw, which is more sensitive skin, and the topical products tend to be quite irritating," Dr. Baldwin said.
Acne after adolescence also can be more psychosocially devastating. Unlike a teenage girl, an affected woman may have no one else in her social group who has acne. And "because teenagers are supposed to have acne," Dr. Baldwin said, "people will question: What is she doing wrong? Is she not eating right?"
Acne can have a detrimental effect on sexuality, motherhood, and/or returning to the workplace, and can deepen a midlife crisis, said Dr. Baldwin, vice chair of the Department of Dermatology at SUNY-Downstate in Brooklyn, N.Y.
With fewer topical agents in their armamentarium for the adult woman with acne, dermatologists tend to prescribe oral medication, Dr. Baldwin said.
Oral antibiotics are an example, such as anti-inflammatory dose doxycycline (acne is an off-label indication). This agent does not kill Propionibacterium acnes, but can improve acne through an anti-inflammatory effect similar to full-dose doxycycline, Dr. Baldwin said.
One caveat: if you prescribe an oral antibiotic, you may experience pushback from some patients, Dr. Baldwin said. "I have women who say that they get a yeast infection every time they get an antibiotic." Strategies include antibiotic treatment through a yeast infection; a simultaneous prescription to prevent yeast growth; and/or selection of an antibiotic less likely to cause this effect. For example, extended-release minocycline may be less likely to spur yeast growth than traditional minocycline, she said.
Non-antibiotic alternatives for moderate-to-severe acne are limited, especially in women of child-bearing potential.
Oral hormonal contraceptives also can improve acne in adult women, Dr. Baldwin said. In the United States, ethinyl estradiol/norethindrone acetate (Estrostep, Warner Chilcott); drospirenone/ethinyl estradiol (Yaz, Bayer); and ethinyl estradiol/norgestimate (Ortho Tri-Cyclen, Ortho McNeil Janssen) are FDA-approved for acne treatment "and others with estrogen may be effective."
Because their full acne-fighting effects can take up to six months, Dr. Baldwin recommended prescription of oral contraceptives in combination with a quicker onset agent. "For me it’s a medication on top of a medication that is going to give more immediate improvement, one I can take them off when I start to see the oral contraceptive kick in."
"The difference becomes significant with Yaz at about 6 months," Dr. Baldwin said. "But waiting for six months for this to happen is not something most of our patients will do."
Keep potential adverse effects of oral contraceptives in mind. Evidence in the literatures suggests there is no increased cardiovascular risk among non-smokers, Dr. Baldwin said. In addition, studies indicate no increase risk of breast cancer. An increased likelihood for a thrombolic event is elevated during the first year then becomes normalized, she said.
The FDA added a black box warning to labeling for spironolactone (Aldactone, GD Searle, plus generics) in 2008 that cites an increased risk for tumors based on animal studies. The warning recommends use only for approved indications, "which acne is not," Dr. Baldwin said. There have been five cases of breast cancer reported in women taking spironolactone and other medications, but there was "no clear link to the medication." Also, a review article found no evidence of risk (J. Clin. Aesthet. Dermatol 2009;2:16-22). Still you "need to discuss this risk with your patients," Dr. Baldwin said.
"A recent Cochrane review on spironolactone which concluded that, although it was very helpful for hirsutism and for alopecia, that it had no evidence-based medicine to support its use in the treatment of acne," Dr. Baldwin said in an interview (Cochrane Database Syst. Rev. 2009;(2):CD000194). "Now that flies in the face of numerous small studies which have demonstrated clearly over the years that spironolactone in doses from 50 to 200 mg per day are very helpful in the treatment of acne, especially in the adult woman."
The number of participants in these studies was "so small that it didn’t pass muster for the Cochrane review," Dr. Baldwin said. "I still believe spironolactone is an incredibly useful drug in the treatment of acne."