ACNE IN THE ADULT FEMALE PATIENT : A PRACTICAL APPROACH

Armando VSLM 41090026

BACKGROUND

Acne vulgaris is a common skin condition with 85% lifetime prevalence.

Adult acne is a common reason for patients to present for dermatological evaluation, and adults in fact make up a large portion of the patient population seen by dermatologists for acne.

Various studies have reported acne prevalence in

the range of 4154% in women and 3440% in men
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BACKGROUND

Several studies suggest that women are more likely to report acne than men.

Acne in adult women has also been shown to have

a late onset and become persistent.

PATOGENESIS

Pathogenesis of acne in adult women is complex, involving androgens in addition to other important factors well accepted for their role in the

pathogenesis of acne:

Sebum Production; follicular plugging; genetics; Propionibacterium Acnes; diet; medications; innate

immunity; and alterations In follicular keratinization and

differentiation.
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PATOGENESIS

The role of androgens in adult women with acne has been well supported in the literature, and four clinical

observations highlight this important role.

1. 2.

3. 4.

Androgen-insensitive individuals do not produce sebum and do not develop acne. Conditions of hyperandrogenism, such as polycystic ovary syndrome (PCOS), are associated with acne that is highly responsive to hormonal therapies. Hormonal-based therapies such as oral contraceptives and anti-androgen medications are effective treatments for acne. Rising levels of dehydroepiandrosterone sulfate (DHEA-S) are associated with the onset of acne in pre-menarchal girls, and higher levels in pre-menarche may predict the development of more clinically severe acne in puberty.

CLINICAL FEATURES

Especially at the jaw line and chin, with a broad clinical spectrum of :
Comedones Papules Pustules Cysts, and/or nodules

DIFFERENTIAL DIAGNOSIS

The common differential diagnosis of adult female acne includes:

1. 2. 3. 4.

Rosacea Seborrheic dermatitis Acne Cosmetic Pomade acne

5.

Medication included acne (Danazol, Testosterone,

progestins, glucocorticoids,ect.)
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POLYCISTIC OVARY SYNDROME

The most recent consensus criteria defines a diagnosis of PCOS as two of the following three criteria:
1. 2. 3.

amenorrhea or oligomenorrhea biochemical or clinical hyperandrogenism ultra-sonographic documentation of increased follicle

count (>12) or follicular volume (>10 cm ) per ovary.

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PCOS

Acne is an important and common cutaneous sign of PCOS. dermatological associated include androgenic nigricans. with Other signs PCOS alopecia, hirsutism,

seborrhea, and acanthosis

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PCOS

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PCOS

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TREATMENT

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OCP

OCPs work by several mechanisms to reduce acne.

OCPs stimulate hepatic synthesis of sex hormonebinding globulin, which bind circulating androgens, decrease free testosterone and DHEA-S, and likely

reduce sebum production. OCPs also inhibit 5-areductase, decreasing peripheral conversion of testosterone, as well as decreasing production of

ovarian and adrenal androgens. OCPs are effective in

the treatment of acne, with studies demonstrating 40 70% reduction in lesion counts.
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SPIRONOLACTONE

Spironolactone is a highly effective treatment for acne in adult women and may surpass the efficacy of OCPs.

Spironolactone

is

safe

and

well-tolerated

medication, yet patients should be counseled on potential side effects.

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OTHER HORMONAL TREATMENT FOR ACNE

Flutamide Cyproterone acetate (CPA)

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ALGORITHM FOR THE HORMONAL TREATMENT

OF ACNE

Combination treatment of spironolactone and OCPs is likely the safest approach, reducing adverse effects, and is supported by evidence that it is the most effective treatment for acne.

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THERAPEUTIC ALLIANCE AND SPECIAL

CONSIDERATIONS

It is imperative to build a strong therapeutic alliance with the patient and set realistic goals of treatment.

Patient concerns regarding treatment and cosmetic

practices should also be addressed.

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TREAATMENT OF ACNE DURING PREGNANCY

If possible, treatment during the first trimester should be avoided.

Recommended topical agents include azelaic acid, metronidazole, erythromycin, clindamycin, and glycolic acid. Systemic therapies with adequate safety data in pregnancy include penicillins, cephalosporins, erythromycin.

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CONCLUSION
Acne is common in adults and especially in women. It may also be a sign of an underlying systemic disorder such as PCOS.

Hormonal

therapies

such

as

OCPs

and

spironolactone are effective even when other

standard therapies for acne have failed, including antibiotics and isotretinoin.

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TERIMA KASIH

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