Treat the Skin and the Psyche

by Cynthia Cobb, NP

Women are more likely to experience adult acne than men: 50% of women experience acne sometime in adulthood, but only 25% of men are affected.^1,2

The sequelae of the disease are not limited to the skin. Depression, social withdrawal, decreased self-esteem, reduced self-confidence, poor body image and higher rates of unemployment have all been documented in adults with acne. Acne is not a serious threat to physical health, but it has a significant effect on the psyche.³

Causes of Adult Acne

Adult acne is typically caused by a combination of factors, including medication side effects, cosmetic products, excessive sweating, stress, genetics and hormones.⁴Hormones seem to be the primary offender in adult women.⁵Hormonal acne is most often linked to androgens that stimulate the sebaceous glands and hair follicles of the skin. When the sebaceous glands are overstimulated by androgens, acne flare-ups can occur.^1,6Nearly half of all women experience acne flare-ups and increased facial oiliness during the week preceding menstruation.⁵

Androgen levels should be evaluated in women who have persistent acne accompanied by hirsutism or thinning hair, since these could be indicators of polycystic ovary syndrome or adrenal hyperplasia.

Treatment Options

Acne is a chronic disease that may not respond to the same over-the-counter treatments that work for adolescents.

The treatment of adult acne should be multifaceted. Time and persistence are required to clear acne.⁷

All acne should be treated topically. Popular topical treatment choices include one or a combination of the following: ^1,4,5,6,7

• retinoids (tretinoin [Retin-A], adapalene [Differin], tazarotene [Tazorac])

• macrolides (clindamycin [Cleocin], erythromycin [Benzamycin])

• salicylic acid (multiple products)

• azelaic acid (Azelex)

• benzoyl peroxide (multiple products)

• benzoyl peroxide-clindamycin (Benzaclin).

Treat according to the worst lesion for best response. If nodular lesions or a large number of lesions are present, oral antibiotics and an androgen blocker such as spironolactone should be added to the topical treatment.⁷

Treatment with oral medications may include one or a combination of the following:^1,4,5,6,7

• antibiotics (minocycline, doxycycline, tetracycline, erythromycin)

• spironolactone (Aldactone)

• oral contraceptives (Ortho Tri-Cyclen, Yasmin [contains a spironolactone analogue], Yaz [contains a spironolactone analogue and helps with premenstrual dysphoria])

• isotretinoin (Accutane, Sotret)

Patients should also gently wash with a mild facial cleanser twice daily. Toners that contain glycolic acid or salicylic acid may help decrease surface oils.⁵Cleansing and toning should be followed by application of the following substances in this order: topical products, noncomedogenic sunscreen and makeup. Retinoids should be applied at bedtime only.

Other treatment options include microdermabrasion, chemical peels and laser therapy.⁴

References

1. DeNoon D. WebMD Acne Health Center: Acne É Again? Available at: http://www.webmd.com/skin-problems-and-treatments/acne/features/adult-acne. Accessed April 24, 2008.

2. Adult acne. Available at: http://www.acne.org/adult-acne.html. Accessed April 24, 2008.

3. American Academy of Dermatology. AcneNet. The social impact of acne. Available at: http://www.skincarephysicians.com/acnenet/socimpct.html. Accessed April 24, 2008.

4. Nelson L. Adult acne. Available at: http://www.yourplasticsurgeryguide.com/facial-rejuvenation/adultacne.htm. Accessed April 24, 2008.

5. American Academy of Dermatology. Millions of women facing adult acne. Available at: http://www.medicalnewstoday.com/printerfriendlynews.php?newsid=11514. Accessed April 24, 2008.

6. Northrup C. Midlife acne. Available at: http://www.drnorthrup.com/womenshealth/healthcenter/topic_details.php?topic_id=55. Accessed April 24, 2008.

7. Webster G. Putting your best face forward: practical approaches to acne and rosacea management. Presentation at the American Academy of Nurse Practitioners annual conference, Grapevine, Texas, June 2004.

Cynthia Cobb is a women's health nurse practitioner who specializes in aesthetics at Coccolare Spa in Lafayette, La. She is a test administrator for the Association of Medical Esthetic Nurses' certification exam for medical esthetic practitioners and the author and publisher ofÊthe Study Guide for the Medical Esthetic Practitioner Certification Examination.

Clinical Pearls For Topical Therapy

• Prescribe retinoids cautiously with benzoyl peroxide because the redness and peeling associated with retinoids tend to increase with benzoyl peroxide use.

• Use retinoids at the start of any and every acne treatment regimen.

For Oral Therapy

• Antibiotic treatment may be required for 3-6 months. Full-dose therapy decreases antibiotic resistance.⁷

• Topical retinoids work slowly and must be used along with antibiotics so that antibiotics may be discontinued.⁷

• Some women benefit from oral contraceptives, some see no change, and others actually experience worsened acne.⁶

• Acne treatment options are limited for pregnant patients due to penetration of active medication through skin. Topical antimicrobial agents may be a good choice for these patients.⁵

• Isotretinoin should be started sooner rather than later to prevent disfiguring physical and psychological scars.⁷