Treatment challenges in adult female acne and future directions

ABSTRACT

Introduction: Acne is a chronic, inflammatory, and immune-mediated disease of the pilosebaceous unit, highly prevalent in adolescents. However, an increasing number of adults over 25 years old with facial acne, particularly women, have been observed. It is considered a different disease when compared to acne vulgaris. Face is the mainly involved area with inflammatory lesions and more sensitive skin, pointing out the need of a holistic approach.

Areas covered: We performed a comprehensive literature search on PubMed database, up to January 2021, regarding adult female acne. We synthesized data about pathogenesis; differences compared to acne vulgaris; and treatment, with focus in the management challenges and perspectives.

Expert opinion: It is essential to value the negative impact on quality of life of adult female acne, independently of severity. The disease has prolonged evolution, and patient might be resilient once the improvement, regardless of the treatment option, will just be noticeable after 3 months. Aggravating factors should be clearly discussed, such as the need of changing many habits, especially lesions manipulation. The therapeutic regimen includes make-up and tailored skin care (considering proneness to sensitivity), while anti-acne drugs should be chosen in accordance with desire to be pregnant, presence of pregnancy or breastfeeding.

KEYWORDS:

• Acne
• adult
• dermatosis
• dermatology
• female

Article highlights

• Adult female acne (AFA) has been demonstrating an increasing prevalence all over the world. It is an impacting disease for adult women, in their social, and professional life. Quality of life and patients’ suffering should be valued.

• In accordance with the available data from more recent international observational study, lesions may have different distributions from adolescent acne in about 10% of the cases, when there is predominance of mild to moderate inflammatory papules along mandibular and perioral areas of the face, in a ‘surgical mask-like’ pattern. The presence of comedones and inflammatory papules, with a full-face involvement, is the most commonly clinical picture in AFA; and more than 50% of the affected women have truncal lesions.

• The pathogenesis is similar to acne vulgaris, but additional factors trigger and aggravate the disease chronic evolution, including high level of stress, sleep deprivation, picking habit, sensitive skin, pollution, and diet. It seems that peripheral production of androgens, at sebaceous gland level, is responsible for its prolonged duration.

• It is important to treat AFA as early and as effectively as possible to avoid scars and psychological sequelae, taking into account the desire to be pregnant. The majority of patients have normal androgen levels in the serum. However, other signals of hyperandrogenism, mainly hirsutism and menstrual irregularities, should be addressed and hormonal investigation, as well as transvaginal ultrasound, requested.

• There are many topical but only three different systemic drugs (antibiotics, antiandrogens, and isotretinoin) available for treatment, usually in combination for inflammatory acne.

• For mild acne, topical treatment, always combined with adjuvant measures (gentle cleanser, moisturizer, sunscreen, and dermocosmetics), may be sufficient for disease control, in prolonged periods of time. For this reason, topical antibiotics should be avoided.

• Oral hormones represent the most important drugs for AFA, especially spironolactone and contraceptives, containing ethinyl estradiol and cyproterone acetate, drospirenone, or chlormadinone as progestins.

• Oral isotretinoin might be considered in severe and refractory disease as it is highly effective and safe for acne vulgaris. Off-label low daily doses and variable duration of the treatment are the best approach, always associated with contraception methods, starting 1 month before the treatment up to 1 month after drug interruption. This regimen promotes less mucocutaneous side effects, same efficacy, and better adherence. Lab tests (lipid profile, transaminases, gamma-GT, total blood count) should be requested at baseline and repeated after 2 months, as well as beta-HCG monthly. Serious adverse events, including depression and inflammatory bowel disease, are rare and individual and do not justify excessive warning and concern.

• Topical clascoterone (androgen blocker) and new anti-inflammatory substances, as well as new use of oral nonsteroidal anti-androgen, such as bicalutamide are interesting perspectives for AFA control.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

One reviewer has declared recieving research, speaking and/or consulting support from a variety of companies including Galderma, GSK/Stiefel, Almirall, Alvotech, Leo Pharma, BMS, Boehringer Ingelheim, Mylan, Celgene, Pfizer, Ortho Dermatology, Abbvie, Samsung, Janssen, Lilly, Menlo, Merck, Novartis, Regeneron, Sanofi, Novan, Qurient, National Biological Corporation, Caremark, Advance Medical, Sun Pharma, Helsinn, Arena, Forte, Informa, UpToDate and National Psoriasis Foundation. They have also consulted for others through Guidepoint Global, Gerson Lehrman and other consulting organizations. They have also declared employment at www.DrScore.com. and Causa Research, a company dedicated to enhancing patients’ adherence to treatment. Another reviewer has declared being involved in clinical research (FDA clinical trials) with many of the agents that are in this review. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

This paper was not funded.