For all too many women, the acne that they once feared would flare up just in time for prom as a teenager has resurfaced into their adult years - causing anxiety for events from weddings to job interviews. The reason? Chronic, persistent acne is a common medical condition for women who either have suffered with it since adolescence or for those who first develop it during adulthood. Either way, the physical and emotional toll that acne causes can be devastating.
Speaking at ACADEMY '04, the American Academy of Dermatology's summer scientific session in New York, dermatologist Diane S. Berson, M.D., an assistant professor of dermatology at the Weill Medical College of Cornell University in New York, N.Y., discussed the causes of adult acne in women and various treatment options.
"When adult women experience acne outbreaks, hormones are usually the primary culprit," said Dr. Berson. "Hormonal acne can be particularly frustrating because it may not respond to the same over-the-counter treatments that worked for some women during their teenage years."
Hormones and Acne
While acne typically first appears during adolescence, hormonally influenced acne usually begins in the early-to-mid twenties and can persist well into adulthood. The cause of hormonal acne is most often linked to androgens, which are the hormones that stimulate the sebaceous - or oil - glands and hair follicles in the skin. When the sebaceous glands are over-stimulated by androgens, acne flare-ups can occur. Nearly half of all women experience acne flare-ups and increased facial oiliness during the week preceding menstruation.
Dr. Berson emphasized that while most women with acne have normal androgen levels, some women may have a more serious medical condition for which acne is just one symptom.
"When persistent acne is accompanied by excess facial hair, known as hirsutism, and hair loss or thinning hair, it could signal increased androgen production common in conditions such as polycystic ovaries and adrenal hyperplasia," said Dr. Berson. "In addition, women with hormonal acne also may experience irregular menstrual cycles, obesity, infertility or diabetes. It's vitally important for these women to consult with their physician, as a blood test can determine the cause of these symptoms and the best treatment option."
Treating Hormonal Acne
There are several treatment options available for women with hormonal acne, including topical retinoids, topical antimicrobials (such as benzoyl peroxide and antibiotics), and oral antibiotics that are prescribed when the inflammation is more severe. A dermatologist also may prescribe isotretinoin for women with cystic acne that is accompanied by scarring.
For women with hormonal acne who still develop premenstrual flares, oral contraceptive pills (OCPs) can be used successfully. OCPs contain an estrogen and progestin. They regulate the menstrual cycle and decrease the androgen activity responsible for acne, leading to decreased breakouts. Dr. Berson explained that most women who take OCPs to control acne can continue them for extended periods, especially if they are not currently planning to have children.
Another medication that may be prescribed in conjunction with an oral contraceptive is spironolactone, an anti-androgen. Spironolactone prevents excessive oil production by blocking androgen receptors and decreasing androgen production in both the ovaries and adrenal glands. The result is fewer acne flares.
While OCPs are effective in treating hormonal acne, they can cause side effects. Mild side effects, which usually subside after the first month or two after starting the medication, include breast tenderness, bloating and nausea. However, more serious complications such as blood clots or strokes are now less common with the newer formulations that contain less estrogen.
"Women prone to the more serious side effects of OCPs are those with existing hypertension, a history of blood clots or those over the age of 35 who also smoke," said Dr. Berson. "On the other hand, women taking OCPs actually may benefit from a decrease in developing osteoporosis and protection against endometrial and ovarian cancer. That's why it's important for women considering taking OCPs to control their acne to discuss the pros and cons with their dermatologist."
Dr. Berson also explained that women who are pregnant often experience bouts of acne, but treatment options are limited due to concerns regarding potential penetration of active medication through the skin. In this instance, topical antimicrobial agents are usually prescribed. In addition, it is not uncommon for women to develop post-menopausal acne due to a decrease in estrogen levels. However, traditional acne therapies, as well as antiandrogens, are good treatment options.
The Importance of Proper Skin Care
Since women with acne often have drier and more sensitive skin than they experienced during their adolescent years, Dr. Berson advised that they should talk to their dermatologist about appropriate skin care. Gently washing the face with mild facial cleansers is usually recommended and vigorous scrubbing should be avoided, as it can irritate the skin and make acne worse. In addition, toners containing glycolic acid or salicylic acid may help remove surface oils during the premenstrual period, which can contribute to acne flares, or for those with oily skin. Since some acne therapies can cause dryness, Dr. Berson recommended that women use a light moisturizer.
"Making slight modifications to your daily skin care regimen can go a long way in improving the appearance of your skin," said Dr. Berson. "For instance, daily sun protection is essential as some acne medications can increase the skin's sensitivity to sunlight. Also, when buying cosmetics or other skin or hair care products, look for ones labeled noncomedogenic - meaning that they do not clog pores and are less likely to cause acne. Your dermatologist is the best source of information when choosing skin care products that can work in tandem with your acne therapy to improve the overall appearance of your skin."