"All of us want to know more about what's causing adult female acne; we really don't know,” observes dermatologist Julie C. Harper, MD. “We do know that we see it in our clinics and many of us would say that we're seeing it more and more in our clinics.”

Adult female acne has a unique presentation. “Along the jaw line and the neck that is so classic for an adult female— we never see that in the male,” Dr. Harper notes. That leads experts to question whether adult female acne may be a unique “kind” of acne, different than that kind seen in adult males, or adolescents of both sexes, she says. “They may be very, very distinct. They may have a different pathogenesis; they likely have a different treatment.”

Topical treatment options for acne in non-pregnant adult females generally include the same formulations used for other patient groups. Benzoyl peroxide (BPO) is commonly used, but adult patients may be concerned about tolerability. Using lower concentrations can help reduce irritation without sacrificing efficacy. “Lower percentages, like 2.5% BPO, seem to work as well as higher percentages and are associated with less irritation,” says Dr. Harper. Formulations such as the combination adapalene and benzoyl peroxide 2.5% (Epiduo, Galderma) offer lower concentrations of BPO. Fixed combination products may increase adherence by simplifying regimens. Nonetheless, stand-alone agents are still used.

Like benzoyl peroxide, topical retinoids are also considered standard treatment options for acne. Topical retinoids primarily function to regulate hyperkeratinization and prevent the formation of microcomedones. They also confer anti-inflammatory effects. Next-generation retinoids, such as adapalene (Differin Cream, Gel, or Lotion, Galderma) target different retinoid receptors than does tretinoin, providing potentially better tolerability. Furthermore, these next-generation formulations may be more appealing to adult patients who may have already tried tretinoin to treat adolescent acne. There is also recent evidence suggesting that adapalene may be better tolerated on darker skin types (J Cosmet Dermatol.12(2):103-7).

A relative newcomer to the acne treatment scene, topical dapsone (Aczone, Allergan) has been shown to have antiinflammatory effects and it shows superior efficacy in female patients.

Oral contraceptive pills remain an option for the management of acne in women, despite concerns about their risks. “All birth control pills carry with them some increased risk, so basically a woman's baseline risk of having a clot if they're not on a birth control pill is about three per 10,000 woman years. If you take a birth control pill, maybe six per 10,000 woman years,” according to Dr. Harper.

The oral birth control pills commonly used to treat acne contain the progestin drospirenone, such as Yaz (Bayer Healthcare). “Drospirenone now we know may be associated even with a little bit higher risk than some of the other pills,” Dr. Harper says. “But to put that into perspective, instead of three or six per 10,000 woman years, now we're talking about nine or 10 per 10,000 woman years.”

Skincare and Education

In addition to providing an effective treatment regimen, patients require education, including tips on skincare. “Skincare is very important in acne for a couple of reasons. It's a very important part of actually treating and managing acne, but it's also important to help patients to tolerate the topical medications that we're prescribing…Patients who are irritated from topical medications don't use them and then they don't get the results,” Dr. Harper insists. In addition, sunscreen is a must.

Advise patients to expect at least minor irritation upon initiating topical acne therapy so that they will be prepared for mild peeling or erythema, Dr. Harper says. Excessive reactions warrant a call to the office.

Dr. Harper spoke with our editors for upcoming coverage in Practical Dermatology. For more on acne, visit: http://bmctoday. net/practicaldermatology/2012/07/supplement/.