Acne in Adult Women
By: James E. Fulton, Jr., M.D., Ph.D.

Published in Les Novelles Esthetiques October 1998

In dermatology, as in any field, practitioners often operate on assumptions organized around previously observed patterns. Such reliance upon conventional wisdom is important and necessary. However, our assumptions are often slow to change even long after the patterns have. It is important, then that we regularly challenge OUT assumptions by reexamining our patient population.

An example of such an assumption is the long-held belief that acne is chiefly a concern among adolescent males. It is true that until recently, acne was predominantly a problem of teenage and young adult males.

Eighty percent of the patients in our offices presenting with complexion problems twenty years ago were males ages 12 to 23. 'As these patients reached their early to mid-20s, the condition usually disappeared. In the 1990s, however, this pattern seemed to be changing. We were confronted with an apparent increase in the incidence of acne in adult women, many of whom continued to have mild to moderate acne conditions well into their 20s, 30s, even 40s. So in the summer of 1998, we conducted a study to explore the possible causes of this phenomenon.

Collecting the data
A review of our medical records revealed that 71% of the patients presenting with complexion problems were females over the age of 20. One hundred and fifty of these women were surveyed by means of direct interview and questionnaire. Researchers reviewed the history of acne in each patient's family and the severity of the patient's acne during her teenage years, and examined all factors to which past and present flare-ups were attributed.

We were able to classify the acne of 142 of the 150 women surveyed. Type I acne was characterized by open comedones, type II showed predominantly closed comedones, and type III consisted of inflammatory papules and pustules. Type IV was comprised of all cystic acne cases involving large inflammatory nodules of 1 cm or more in diameter, and also may have included a combination of type I, II, and III acne. We took photographs of the subjects and counted the lesions (open comedones, closed comedones, papules, pustules and cysts).

In 35 selected subjects with inflammatory acne, hormonal blood levels of leutenizing hormone (LH), follicle stimulating hormone (FSH), dehydroepiandosterone sulfate (DHEAS), free and bound testosterone (TI, and globulin binding factor (SHBG) were examined (Endocrine Sciences Laboratories, Calabasas Hills, California). Biopsies (2.5 mm punch excision of early inflammatory lesions were taken from six subjects with papulo-pustular acne and were examined microscopically.

The type of acne present in most of the adult female acne sufferers in our study (54%) was type III (papules and/or pustules). Two percent had type I (open comedones), 20% had type II (closed comedones), and 24% had type IV (cystic acne). A large majority of our female test subjects (70%)reported a history of mild to moderate acne as a teenager, and nearly three quarters (74%) had a family history of acne. Their brothers, usually suffered severe acne as teenagers, but most had outgrown the problem by approximately age 24. The women's acne, though milder, did not terminate but persisted well into their 20s and 30s. The follicles were apparently still susceptible and could react to aggravating factors. The subjects who had no significant acne in the teen years developed the condition later in life, often as a result of similar aggravating factors. Compared to the complexion problems of teenage males, specific aggravating factors played a more significant role in causing acne flare-ups in adult women.

The most common aggravating factor among the subjects was stress (75%), followed by hormonal changes, such as menstrual cycle flare-ups (68%), excoriations (53%), pregnancy (35%), oral contraceptive use (29%) and cosmetics (21%)). Other aggravating factors can be seen in this table below. .

Acne in Adult Women

Both acute and chronic stress were reported as causes of acne flare-ups. Acute stress arose from instances such as death in the family or academic problems in school. Such stress, in association with fluctuating hormone levels, led toan acute breakdown in the follicular walls around impacted comedones, resulting in a flare-up. The exact leukotoxic factor resulting in the inflammatory flare-up is unknown, but it has been suggested that bacterial by-products may leak into the dermis and stimulate the inflammatory reaction. With acute stress, the existing impactions break down, producing erythema and induration. With a return to a normal lifestyle, these foci may resolve, or they may become pustnlar and spontaneously drain.

A constant source of stress, such as employment, family responsibilities, marital problems, can lead to a chronic stress syndrome, which affects the pituitary and adrenal glands through the ACTH mechanism. This may result in an increased production of hormones, such as dehydroepiandosterone sulfate, and subsequently lead to an increase in inflammatory nodules, usually of the chin.

Acne comes from across the face like a wave. It begins on the nose, travel to the mid-cheek and ends up at the anele of the jaw.

Further, the majority of our patients aggravated their acne condition to varying degrees with the use of their fingernails, a behavior that increased as stress increased. Such excoriating of acne lesions can cause flare-ups, strip off pigment cells from the dermis leaving light and dark areas of the face and lead to secondary bacterial infections. All of these consequences were observed. Persuading these patients to stop the excoriation process was very difficult. The problem was treated as a ”bad habit,” and along with group therapy for stress management. therapy attempts to break the obsessive compulsive cycle included Prozac, along with group therapy for stress management.

Another common cause of acne flare-ups was the shift in hormonal blood levels associated with the initiation of discontinuation of oral contraceptives. A similar shift can occnr during early pregnancy and/or the postpartum penod. Ten to 20 years ago the use of oral contraceptives was associated with acne flare-ups, especially if the pills were androgen dominant.’ Oral contraceptives today have fewer androgens, and most acne patients either remain the same or improve with birth control therapy. Some women, in fact, take oral contraceptives to control their acne.

Acne usually travels across the face like a wave, starting on the nose, central forehead and chin area, and spreading out laterally to the jaw line over about a 10-year period.’Tbis progression appears to follow the mawation of the follicles. Oral contraceptive use interrupts this wave. Upon discontinuation of these contraceptives, then the acne simply resumes its progression until it has completed its natural course. The acne lesions associated with the discontinuation or oral contraceptives are similar in appearauce and distribution to those commonly seen three and four months after pregnancy.

Cosmetics are less of a problem than they were 20 years ago as more noncomedogenic products are now available? Still, certain hairspray;, conditioners, and pomades, as well as skin care moisturizers and treatment lotions, continue to be a problem for a signiscant number of acne sufferers. Many products contain the key offender isopropyl myristate, or its derivatives, such as isopropyl palmitate. These, depending on dose and concentration, are comedogenic ingredients 6, and chronic use may lead to the development of closed comedones in the facial area. Similar lesions on the forehead may result from the use of a comedogenic shampoo or hair pomade.

Interestingly, the tendency to associate acne with diet seems to have greatly diminished over the past 30 years. Once considered significant both by physician and patient ' , diet as an aggravating factor was rarely reported by our patients. One particular patient, however, attriiuted a flare-up to kelp powder, which she sprinkled liberally on her food at each meal. Kelp contains iodide, excessive levels of which the sebaceous ducts will excrete, causing irritation to the sebaceous follicle.' The patient's acne cleared rapidly when she discontinued the ingestion of kelp.

Another interesting finding involved a patient with elevated hormone blood levels who had hirsutism, irregular menstrual periods and IV acne. Upon further examination, she was found to have polycystic ovaries. Overall, however, the results of the hormonal studies were disappointing. We expected many patients with inflammatory lesions to have elevated testosterone or DHEAS levels!" Instead, hormone levels were normal or close to normal in most cases. The small number of hormonal elevations that were seen could not justify the routine use of hormone blood tests or extensive programs with systemic anti-androgens for this group of patients.

An acutely stressed patient may benefit from prednisone (5 mg/day) to block adrenal gland output of hormones, but in general, hormone therapy proved unnecessary among our subjects. This runs contrary to results reported from dermatology practices in medical school settings, where the referred patient population has a higher incidence of hormonal elevations. It is possible that our studies did not measure the acute stress-induced hop mone elevation at the appropriate time in the course of the condition, or that the appropriate stress-related hormone was not measured.

The biopsies revealed a white blood cell (leukocyte) migration into the follicular wall with an associated inflammation. There was no evidence of rupture of the follicular contents into the dermis. The leukocytes either destroyed the follicular epithelium deep in the follicle, producing an inflammatory nodule, or migrated to the surface between the follicular wall and comedo producing a a pustule. Often, there was residual scarring. The earliest pathological finding was the leukocyte migration into the follicular lining, with a subsequent innammation. The follicular lining could recover, leading to a remission of the clinical innammation. or the leukocytes could destroy larger segments of the lining, producing a nodule. The leukocytes could also migrate to the surface, producing a pustule.

Factors generally associated with sociological progress among women, such as increased access to the work place, were found to be associated with an increase in the incidence of acne.

Topical therapy
In our work with acne patients, we have found that the combination of topical therapy, exti-actions, intralesional injections of corticosteroids and ice compresses usually leads to significant improvement in three to four weeks and clearing in two to three months. The routine use of oral antibiotics, such
as tetracycliue or erythromycin, is generally not beneficial. The findings of our study were consistent with this. Most of our subjects had had numerous treatments with tetracycline and its derivatives over the years without significant improvement, but the topical treatments proved quite effedive.

The study's subjects underwent a standard topical treatment program using a granulated benzoyl peroxide scrub cleanser and vitamin A/glycolic conditioning lotions. This bleach kills yeasts, spores,
and bacteria lo, and is also a follicular irritant, sloughing out the impacted cells. The usual treatment protocol involved using the cleanser once in the morning and once in the evening.

After washing with the cleanser, subjects wiped the skin with normalizing tonic (glycolic acid) on a cotton ball. Then, they applied a vitamin A conditioning gel. Occasionally, in the more persistent cases, they also used a benzoyl peroxide 5% to 10% gel.

For acne sufferers we prefer the alcohol-based vitamin A preparations. We proceed cautiously with the benzoyl peroxide gels. With an adult woman, we usually start with only a one to two hour exposure to the gel in the evening, gradually increasing to three or four hours. Occasionally, patients will wear the gel through the night. We try to avoid excessive applications and use around the eyes as it may accentuate dryness.

For the purposes of our study, we counted lesions on the left side of the face monthly to document treatment progress. The results were tabulated for each patient, then averaged. In the majority of cases, the topical treatment program proved adequate. Withing three months of initial therapy, the lesion counts of these patients were reduced, on average by 74%. Had further treatment been required, isotretinoin (Accutane) may have been considered. However, in our study, as in our experience, there was no need for systematic therapy with tetracycline or isotretinoin in most cases.

A statement about society
Surprisingly, our study may have some sociological, as well as medical, implications. Factors that are generally associated with sociological progress among women, such as birth control and increased access to the work place, were found to be associated with an increase in the incidence of acne among adult women in our study. The dramatic rise in the number of women entering the work force in the past decade and a half offers two separate, plausible explanations for this phenomenon. On the one hand, the incidence of acne among adult women may have truly increased due to the additional stress associated with the workplace and the desire among working women to use cosmetics more frequently. On the other hand, what appears to be an increase in the incidence of acne may actually be an increase in access to care. In other words, the new income and increased availability of health insurance associated with employment may explain the rise in the number of women visiting our
medical office to seek help for their complexion problems. Some combination of these two scenarios probably offers the best explanation.

Whatever the reasons for it, the dramatic shift in the incidence of acne in recent years is real. As our findings confirm, teenage males have been replaced by adult women as the large majority of acne patients seen in our medical office. This has implications for the practice of dermatology now, and possibly into the future. Professionals involved in the treatment of acne would do well to give their attention to these current trends and watch for future changes in the population we serve.

"I would like to thank John Raash for contributing to writing this report, and Tim for putting up on this site". --Dr James E. Fulton, Jr.

References
1. Fulton JE, Black E. Step-ByStep program for clearing acne. New York Harper-Row; 1983.
2. Illigman A.M. Postadolescent Acne in Women. Cutis. 1991; 48 75-077.
3. Puhvel, Sakamoto M. The chemoattractant properties of comedonal components. ] Invest Dermatol. 1978;71:32409
4. Strauss JS and Pouchi PE. Effect of cyclic progestinestrogen therapy on sebum and acne in women. JAMA 1964;190:815-819.
5. Fulton JE, JR., Pay SR, Fulton JE, 111. Comedogenicity of current therapeutic products, cosmetics and ingredients in the rabbit ear. J A m Acad Dermatol. 1984;10:96-105.
6. Nton JE, Jr. Comedogenicity and initancy of commonly used ingredients in skin cae products.] Soc COP met Chem, 1989;40321-333.
7. Pilsbnry DM, Shelley WB, Illigman AM. Dermatology. Philadelphia: WB Saunders; 1956805.
8. Lucky AW McGnire J, Resenfield RL. Lucky PA, Rich BH. Plasma androgens in women with acne vulgaris. JInventDermato1. 1983;81:70-74.
9. Marynick SP, Chakmakjian ZH, McCaffree DL, Herndon JH, JR. Androgen excess in cystic acne. NEngl JMed. Adamosis 1983;17981-986.
10. Fulton JE. Shenk, Franks SB. Benzoyl peroxide therapy. In: Franks SB, ed. Acne Update For the Practitioner. City: York Medical Books; 1979141-147.

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