JOURNAL READING

JOURNAL OF CLINICAL AND AESTHETIC

DERMATOLOGY JANUARY 2017 .VOLUME 10

EMERGING ISSUES
I N AD U LT F E M A L E AC N E
Oleh:
Assa Ayu Marsitha, S.Ked

Kepaniteraan Klinik
Stase Ilmu Penyakit Kulit dan Kelamin
RSUD Abdul Aziz Singkawang
2017
 BACKGROUND

Acne vulgaris is A common skin disease and

is increasingly seen in adult women.
Almost twice as many women seek help for
their acne than men
One third of total acne office visits are
made by women over 25 years old
 Adult female acne has been traditionally
defined as acne in women over 25 years of age
and is broadly divided into persistent, new-
onset, or recurrent disease.
Persistent acne represents disease that
presented in adolescence and continues into
adulthood.
New onset acne presents for the first time in
adulthood.
Recurrent disease is acne that is present in
adolescence, clears for a variable amount of
time, then returns in adulthood
 SURVEYS

Clinically based, multicenter surveys with

high numbers of patients and global
representation provide the best insights
into skin diseases.
Unfortunately, there is no definitive,
prospective study categorizing the severity,
distribution, type, or differential response
to therapy for adult female acne.
 SURVEYS
investigators found that 61.9 % of acne patients
were over 18 years of age, with the average age
being 25 years old. Two-thirds of visits (65.2%) were
made by women.
Depression was reported in 10.6 % of females,
compared with 5.3 % in men, and seen most
commonly in patients over 36 years old. While it is
unclear whether acne is the precipitating factor for
depression, it is important to address it as a part of
patient management.
 SURVEYS
A community-based survey of 749 patients at least
25 years old also found that acne affected women
more frequently than men.
54 % of women and 40 % of men reported having
some form of acne. moreover, acne was more severe
in women.
Using the leeds Acne grading scale, acne with at
least grade 0.75 was seen in 12 % of women, as
compared to 3 % of men (P<0.001).
They also noted that acne persisted into middle age,
with no substantial decrease in prevalence until
after 44 years old (P<0.001)
 SURVEYS

A university-based survey of 1,013 subjects ages 20

years and older (mean age 48.016.7) reported that
73.3 % of patients suffered some form of acne in
their lifetime.
The study showed that women were more likely to
report having had acne than men, with statistically
significant differences across all age groups studied.
The majority of women (53.3%) reported that their
acne improved after their teenage years. However,
50.9 % of women 20 to 29 years old and 35.2 % of
women 30 to 39 years old reported acne.
 SURVEYS

Increased severity in postteenage years was

reported in 13.3 % of women.
Of the group of premenopausal women surveyed
(n=225), 62.2 % noted that their acne got worse
around the time of menstruation
Results of a self-administered, dermatologist-
validated questionnaire of 3,305 women ages 25 to
40 years in France suggested that total acne
prevalence was 41 % of the population. Adult onset
acne was reported by 41 % of women. stress was
listed as a precipitating factor for acne in half of the
women surveyed.
 SURVEYS

A photo-based survey of 2,895 women in the general

population ages 10 to 70 years showed that 55 % of
patients had some form of acne. Of those judged to
have clinical acne, half had predominantly
inflammatory lesions and the rest predominantly
comedonal acne.
Women with inflammatory acne tended to be
younger than those with comedonal acne (P=0.001).
Postmenopausal women had less acne than their age
matched peers (P<0.0001). While acne peaked in
teenage years, 45 % of women aged 21 to 30, 26 %
aged 31 to 40, and 12 % aged 41 to 50 had clinical
acne
 SURVEYS
Clinical acne was also more prevalent in people of
color than those with lighter skin types. It was also
suggested that Asian women may have predominantly
inflammatory acne, and caucasians comedonal acne.
Patients were evaluated in only four cities, with some
ethnicities from only a single city. moreover, being a
photographic study, acne in skin of color may have
been over represented because of the presence of
hyperpigmentation in photos.
Acne is the most common diagnosis seen in united
states dermatology ambulatory practices. The authors
perceive a higher prevalence of adult female patients
compared to the past in their practices. They also
observe a higher prevalence of hormonal issues,
specifically polycystic ovary syndrome (Pcos)
PATHOGENESIS AND ETIOLOGY

Four main pathogenic factors:

1. Sebum production
2. Propionibacterium acnes colonization
3. Follicular hyperkeratosis
4. Inflammation
 CLINICAL PRESENTATION

An international observational study concluded that the

clinical presentation of acne in adult women is
commonly characterized by low levels of mixed
comedones and inflammatory papules cross all facial
zones.
374 adult female acne patients (=25 years) found that
almost 90 % of cases were similar to those seen in
adolescent acne, with lesions on the cheeks,forehead,
mandible, and temples, with a range of acne severity.
Only 6.4 % of women had inflammatory lesions,
And a minority of patients had acne localized
specifically to the mandibular area. While facial acne is
most common, truncal lesions are found in up to 50 %
of women
 BURDEN OF DISEASE

Acne confers a significant impact on quality of life.

Adult female patients in particular often report
frustration, embarrassment, and distress over acne.

In fact, acne may have a more significant impact on

quality of life in adult female acne patients as
compared to younger acne patients
 TREATMENT OF ADULT FEMALE
ACNE

1. TOPICAL THERAPIES
2. ORAL AGENTS
 TOPICAL THERAPIES

A post hoc analysis of two Phase 2 and 3 studies with

adapalene 0.3% gel (n=74) showed greater efficacy than
vehicle in reducing total lesion counts in women aged 18
to 41 years (P=0.045), similar to the results seen in the
overall study population. The median % reductions in
inflammatory and comedonal lesions (61.2% and 50.7%)
favored Adapalene 0.3% gel, but differences were not
significant
In addition, a subgroup analysis of the pooled results
from three pivotal studies with clindamycin 1.2%-
tretinoin 0.025% gel in patients over 18 years old
reported greater median % reductions in inflammatory
and comedonal lesions in adult female patients compared
to adult male patients (72.4% and 55.2% versus 66.7%
and 53.3%, respectively)
 TOPICAL THERAPIES

In females patients (n=471), clindamycin 1.2%-

tretinoin 0.025% was significantly more effective
than the monads or vehicle in reducing inflammatory
lesions (P<0.03), but only significantly more
effective than clindamycin in reducing comedonal
lesions (P<0.02)
Subpopulation analysis of the pivotal Phase 3 clinical
trial with clindamycin 1.2%-benzoyl peroxide 3.75%
gel found statistically greater improvements in
female compared to male patients.
 TOPICAL THERAPIES

A meta-analysis of 254 patients from three Phase 2

and 3 clinical studies with adapalene 0.1%benzoyl
peroxide 2.5% gel evaluated use in adult women
ages 25 years and up (n=130). A median %
reduction in inflammatory and comedonal lesions of
73.0 % and 70.0 % was found in adult women at 12
weeks (P<0.001 and P=0.016, versus vehicle)
A pooled analysis of two Phase 3 studies with
dapsone 5% gel reported statistically significant
lesion reductions in women compared to men. in
women 18 years and up, the mean % reductions in
inflammatory and comedonal lesions were 46.6 %
and 39.8 %.
 TOPICAL THERAPIES

In addition, a post hoc analysis of the female

patients compared efficacy in adolescents (1217
years) to adult female (>18 years old) patients.
reductions in comedonal lesions were greater in the
adult female patients compared to adolescent
female patients (P<0.0001), but there was no
statistical differences in inflammatory lesion
reductions between the subpopulations
 ORAL AGENTS

Oral antibiotics, isotretinoin, and hormonal therapies

are all commonly used agents to treat acne in adult
women.
Here, the authors focus on hormonal options, both
oral contraceptive pills and spironolactone.
ORAL CONTRACEPTIVE PILLS (OCPS)

Several large studies have documented the

usefulness of oral contraceptive pills (ocPs)
containing ethinyl estradiol in combination with
several different progestins to treat acne in women.
increase risk of DVT (deep vein thrombosis) the
(2 4/10,000, compared to 1 in 10,000 for non-users)
Products containing drospirenone, desogestrel, and
gestodene appear to increase the risk of DVT slightly
more than other ocPs. However, their DVT risks are
still lower than the DvT risk in pregnant women.
 SPIRONOLACTONE

While spironolactone is not FDA approved to treat

acne, it has been used off-label for decades in
treating adult women.
It is a weak diuretic with anti-androgen properties
that competes with testosterone for binding the
androgen receptor on the sebaceous gland. Typical
dosage ranges from 50 to 200 mg per day, taken
with food to enhance absorption.
Common side effects include dose related breast
tenderness and menstrual irregularities. When
spironolactone is used along with ocPs, the OCP
mitigates any effect on the menstrual cycle.
 CONCLUSION

Adult female acne is common in dermatology

practice. Unfortunately, clinical studies specifically
evaluating prevalence, presentation, and treatment
of this population are lacking in the literature.
The authors suggest that adult female acne should
be subcategorized into the following two distinct
groups: post-adolescent patients ages 25 to 44 years
and older and perimenopausal patients, ages 45
years and older.
Treatment outcomes rely heavily on drug tolerability
and adherence to a prescribed regimen.
THANK YOU
LEEDS ACNE GRADING SCALE
LEEDS ACNE GRADING SCALE
LEEDS ACNE GRADING SCALE
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GRADING ACNE
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