Much has changed in our approach to treating the adult female with acne over the last decade or so. The major difference is recognizing that they are a distinct entity who deserve to be considered independently of younger women and men with acne. The type and morphology of acne present, therapeutic considerations, and the psychological impact of the disease in adult women is distinctly different than in the general population of acne patients.
The difference begins early. Girls often go through puberty earlier than boys and may start to develop acne as early as six to seven years of age. By age 16-18, acne is equally prevalent in both genders. Acne in boys may be more severe during this time period, often involving the back and chest. After 18 years of age, acne becomes less common in men, usually resolving in their early 20s. Women are often not as lucky. An old statistic estimated that about 13-15 percent of adult women had acne, but current surveys suggest that it is 25-50 percent or more. Most of these women feel that their acne is as bad or worse as adults than it was in their teenage years. Is that because acne is more prevalent now in adult women than it was 20 or 30 years ago, or is it because women are coming in to see dermatologists more frequently in 2014? Perhaps women are presenting more frequently because they've read in magazines or seen first hand while taking their children to the dermatologist that acne medications we have now are better than they were when they were teenagers. Acne in adult women can present for the first time, recur after resolution during their teenage years, or be a continuous disorder from when they were teens through to adulthood.
No discussion of acne in adult women is complete without recognizing that the psychologic overlay can be as bad or worse than it is in teenagers. During the teenage years acne is pervasive; patients are one in a crowd. Adult women, however, are often the only one in the workplace or social gathering with acne. This leads to isolation, loss of self esteem and depression. Such feelings of inadequacy may persist even after successful therapy.
ACNE PRESENTATION IN ADULT FEMALES
Acne in adult women presents in two, often distinct varieties— all over the face or in a”T-zone” location similar to what is seen in teenagers, or in a U-shaped area of the lower face and jaw, which may include the neck. Acne that presents in the U shape is usually devoid of comedones and comprised of red, often deeper, larger, more inflammatory papules. The back, chest, and arms are less commonly involved in these patients. Treatment needs for this type of acne may be considerably different. Topical medications can be a challenge as the thinner, less sebaceous skin of the neck may be less able to tolerate otherwise efficacious medications. Skin may also be drier in older patients leading to further tolerability issues. The acne is also inherently more difficult to treat.
The combination of these factors mean that adult women often require oral therapy to bypass the skin and render more aggressive therapy. Oral antibiotics, hormonal therapy, and isotretinoin are often needed.
The adult female with acne should be evaluated for the possibility of hormonal imbalance. The presence of alopecia, hirsutism, acanthosis nigricans, or other signs of androgen excess in combination with dysmenorrhea or amenorrhea may be an indication that you're treating an adult female who has an underlying medical condition that needs to be addressed. Blood tests including testosterone, DHEAS, FSH, and LH would be appropriate screening tests.
SAFETY AND EFFICACY OF HORMONAL THERAPIES
When treating moderate-severe acne in adult women, oral contraceptives and anti-androgens, specifically spironolactone, often offer good control especially for the U-shape form of acne.
Safety and efficacy of oral contraceptives have been extensively studied. Four branded pills are FDA approved for acne specifically, although all newer formulations are probably effective: Estrostep, Ortho-Tricyclen, Yaz, and Beyaz. The biggest problem in terms of efficacy with oral contraceptives is they take a very long time to work—it's often three to even six months before they really kick in. Oral contraceptives may be more effective in women who have noticeable premenstrual acne flares.
The most common side effects of oral contraceptives are primarily nuisance side effects. Spotting between periods, amenorrhea, breast swelling, weight gain, and headaches may be experienced. Oral contraceptive pills are specifically contraindicated in women who have bad coronary artery disease, refractory hypertention, migraines with auras, and a personal history of thrombophlebitis or breast cancer. Smoking is a relative contraindication.
Spironolactone is another choice for hormonal therapy. It has anti-androgenic activities and as such has been shown to have utility for women with hirsutism, alopecia, and acne. It is not FDA approved for any of these indications but can be highly effective. Like birth control pills, spironolactone often takes three to six months to demonstrate efficacy. Doses of 50-200 mg QD are used. In my practice, I find spironolactone to be particularly effective in older women, in women who have U- shaped acne, and also women who have uncommon but intolerably large, noticeable, and pain painful lesions. This last group is generally difficult to treat since topical medications are not particularly effective for occasional severe lesions. It is impractical to suggest to a female patient who has one or two very bad pimples a month that she go on oral antibiotics for the entire month or isotretinoin to treat something that is infrequent. However if she is in the workplace or in the public eye, such lesions may preclude her ability to function. It is important to recognize that spironolactone and oral contraceptives should not be limited only to women with evidence of elevated androgens. Studies have shown that they are also effective in women who have normal androgen levels. This may be due to end-organ hypersensitivity.
The most common side effects of spironolactone in this patient population are menstrual irregularities and breast tenderness. Hyperkalemia is possible as spironolactone is also a potassium-sparing diuretic. However, hyperkalemia with this drug is primarily seen in patients in whom it is used as third or fourth line antihypertensive—patients who are older with severe refractory hypertension and poor kidney function—not the typical acne patient. It is perhaps prudent to obtain a screening potassium level and to evaluate dietary intake of potassium rich foods. (The recent craze of coconut water bears specific mention, as potassium levels are inordinately high in such products.) In a woman of child-bearing potential the possibility of pregnancy should be addressed as spironolactone is capable of causing testicular feminization in a male fetus although the literature does not include case reports. The package insert for spironolactone does include a black-box warning recommending that, due to concerns about carcinogenesis, it not be used for off-label indications, which, of course, includes acne. Spironolactone has been available since 1950 and investigation into the source of this recently added warning show that it is based on Phase I toxicology results in male rats. The literature does not support similar concerns in humans.
TOPICAL THERAPY IN ADULT WOMEN WITH ACNE
Little is known about differences in topical therapy unique to the adult woman. Recently topical dapsone has been shown to be more efficacious in women than in men.
In a post-hoc analysis of the pivotal Phase III trials,1 it was shown to be clearly more effective across the board in women than it was in men. One plausible explanation for this finding, adherence to medication use, does not appear to be the cause. What does that mean? Does it mean that the medication has a different or additional mechanism of action of which we're unaware? Is it because the U-shaped acne is more hormonally mediated, or more inflammatory than T-zone acne making it more amenable to the anti-inflammatory effects of dapsone? Or does this finding suggest that there is something inherently different about adult female acne that we don't really understand?
Evaluations of other topical products specifically in adult women have been carried out or begun. Post-hoc analyses of pivotal Phase III trials of some medications have so far shown that although they weren't more effective in adult females than other patients, they were as efficacious and no more intolerant on the U-shaped area of the face compared to the entire population of the studies.
Questions that remain to be answered perhaps outnumber the questions already answered. Is acne more common in 2014 or are more women presenting with acne than ever before? Is this a reflection of an increased percentage of women in the workplace? Are there other medications that are particularly effective in the adult woman? What role, if any, does diet, stress, or hormones in milk and meat play? We look forward to a better understanding of what drives acne in this patient population and how best to help them.
- Tanghetti E1, Harper JC, Oefelein MG. The efficacy and tolerability of dapsone 5% gel in female vs male patients with facial acne vulgaris: gender as a clinically relevant outcome variable. J Drugs Dermatol. 2012 Dec;11(12):1417-21.