According to a recent review, the quality of life (QOL) burden caused by adult acne in women (AFA) requires aggressive treatment regardless of acne severity, according to a recent reviews. In particular, its authors recommend adopting a holistic approach that addresses lifestyle-related factors and using anti-hormonal treatments where possible.first
Study co-author Marco Alexandre Dias da Rocha, PhD, dermatologists must improve their understanding of AFA because they have the potential to reduce its significant impact on QOL. He is a volunteer professor of dermatology at the Federal University of De São Paulo in São Paulo, Brazil.
“These patients have a major negative impact on quality of life, even with mild illness,” says Rocha. Dermatology Times®. “It’s not about the number of lesions, the extent or the pustules and nodules.”
Teens with acne often know many of their peers with acne. However, according to Rocha, adult women with acne often feel alone with their struggles and wonder why they develop acne later on. Since AFA manifests on the face, often along the lower third, it causes problems with everyday problems like makeup as well as ongoing psychological challenges related to self-esteem, he points out. that women with AFA may have difficulty in romantic relationships, professional situations, and socializing with friends, he adds. They often suffer from depression and anxiety.
Most women with acne do not have a hormonal problem such as polycystic ovary syndrome (PCOS) or adrenal gland disease. According to Rocha, the problem lies in the sebaceous glands, which can produce testosterone from cholesterol and dehydroepiandrosterone (DHEA).
Peripheral androgen production promotes long duration of AFA, he added.
“Adolescent acne usually stops when the innate immune system restores balance in the sebaceous glands,” says Rocha. “But in the group of adult women, the immune system is over-activated. It never stops”.
He recommends that dermatologists talk to women with adult acne about the need to be patient in dealing with the chronic, often relapsing nature of AFA. The study authors add that the phases of damage reduction and maintenance treatment are equally important in this population.
“I don’t believe antibiotics are a great way to treat these patients because we know we have to take these drugs for a long time and we have a problem with them,” Rocha said. antimicrobial resistance of bacteria to the microbiota”. Among topical antibiotics, the authors write that it remains unclear whether sarecycline (Seysara; Paratek Pharmaceuticals and Almirall) offers better efficacy and safety than older tetracycline antibiotics. However, its narrower spectrum of activity may reduce drug resistance. Like the older tetracyclines, it is contraindicated in women who are pregnant, nursing or trying to conceive, they point out.
Hormonal treatments block or reduce sebaceous gland function, disrupting sebum production. The study authors recommend considering androgen blockers such as spironolactone. “We hope to use the new topical androgen blocker clascoterone, in combination with different topical agents, to better treat these patients,” says Rocha. Combining clascoterone (Winlevi; Cassiopea) with spironolactone, he notes, may allow a reduction in the dose of spironolactone. Switching to a topical androgen blocker such as clascoterone in the morning and retinoids in the evening can also improve outcomes, Rocha adds. “There are possibilities with this new drug to block the androgen receptors in the sebaceous glands.”
Combined oral contraceptives (COCs) have been shown to block the androgen system, thereby reducing the number of inflammatory and non-inflammatory lesions. In a meta-analysis, COCs demonstrated as effective as oral antibiotics over the course of 6 months.2 Of the COC formulations, combining ethinyl estradiol with a progestin worked best in AFA.3
Nonsteroidal AR blockers include flutamide, enzalutamide, and bicalutamide. With better safety than flutamide, bicalutamide has been used off-label to treat acne and other manifestations of PCOS, even at low doses, the authors write.
“It is important to understand that these drugs can be taken 1 to 2 times per week because they have a longer plasma half-life than spironolactone,” says Rocha. “Perhaps we can use bicalutamide [Casodex, AstraZeneca] twice weekly to reduce acne in adult women as it is a powerful androgen blocker. Bicalutamide does not cause menstrual disturbances, which may be related to spironolactone use, he added.
Understanding AFA also requires an appreciation of the influence of environmental and socioeconomic factors. Pollution, stress, insomnia, a sedentary lifestyle, poor eating habits and overuse of cosmetics and skin care products can all trigger or worsen AFAs, he said.
In contrast, the authors wrote, over-the-counter interventions such as sun protection, gentle skin care, and appropriately selected makeup should be considered part of the AFA regimen. “It’s important to take care of your skin when you have acne,” says Rocha. “But for the adult female population, it’s one of the most important factors.”
Because ceramide levels in the skin decrease with age, women with AFA have very sensitive skin. “When you have low levels of ceramides, the skin can’t hold water,” Rocha points out. In the absence of an adjunctive skin care regimen, the treatment of adult female patients with acne vulgaris with topical agents such as retinoids, azelaic acid, or dapsone may result in irritation, eczema, and/or skin inflammation. “We need to use gentle cleansers, oil-free moisturizers, and oil-free sunscreens to prevent post-inflammatory hyperpigmentation,” Rocha advises.
In addition, Rocha suggests that the diet can produce powerful therapeutic effects. In this regard, the consensus favors a low glycemic index diet combined with oral probiotics, the latter of which can modulate the immune system.
Rocha said additional research is needed in many areas, including comparing drugs for AFA in different populations, such as women with and without PCOS, and comparing spironolactone with spironolactone along with other topical medications. “We still have a lot to learn about this population. We are only just beginning to gain knowledge to better treat adult female acne,” he noted.
1. Bagatin E, Rocha MADD, Freitas THP, Costa CS. Challenges in the treatment of adult female acne and future directions [published online ahead of print, 2021 May 12]. Expert Rev Clin Pharmacol. In 2021; 1-15. doi: 10.1080 / 17512433.2021.1917376 Retrieved June 4, 2021
2. Koo EB, Petersen TD, Kimball AB. Meta-analysis comparing the effectiveness of antibiotics versus oral contraceptives in acne. J Am Acad Dermatol. 2014; 71 (3): 450-459. Accessed June 4, 2021
3. Arowojolu AO, Gallo MF, Lopez LM, Grimes DA. Combined oral contraceptives for the treatment of acne. Cochrane Database Syst Rev. 2012; (7): CD004425. Published 2012 Jul 11 doi: 10.1002 / 14651858.CD004425.pub6 Retrieved June 4, 2021