Many people think acne affects only teenagers. On a daily basis, I encounter patients over the age of 20 who complain and ask: “Why am I still breaking out at my age? Shouldn’t I have outgrown acne?”
As acne is more prevalent in adolescents (affecting more than 85% of them), it has been miscategorized as an adolescence disease. It probably doesn’t help that most ads for acne target teens and young adults. However, in the physician’s office, the mean age of presentation for treatment is 24 years, with 10% of patients being between the ages of 35 and 44.
Who Gets Adult Acne?
While acne often spontaneously improves during the late teenaged or early adulthood years, many patients experience persistent or new onset adult acne. Genetics and sex seem to play a key role in its development. Most patients report at least one first-degree family member with acne. And, after age 20, women are more affected by it than men. (Many women do not realize they have acne until they stop their oral contraceptive pills, which have been treating their mild acne for years.) These findings have led to the conclusion that acne is often a chronic disease similar to eczema.
Regardless of age, acne involves the hair follicles, which proliferate excessively. These follicles produce excess sebum (an oily substance), leading to inflammation and the growth of bacteria (Propionibacterium acnes). Many studies show the psychological and emotional impact of acne is on par with that of diseases such as diabetes, asthma and arthritis. Fortunately, there are many treatment options available for patients suffering from acne.
Treatments
Depending on the severity and type of acne, a treatment regimen is typically available.
Topical Therapy
Topical therapy (medication applied to the skin) is the first-line treatment for acne.
1. Retinoids (vitamin A derivatives are typically tried first) help by preventing acne from forming.
2. Benzoyl peroxides and combinations with topical antibiotics are effective treatments. Major drawback: they bleach clothes, towels and sheets.
3. Antibiotics work better in combination with benzoyl peroxides to limit bacteria resistance.
4. Salicylic acid is moderately effective.
5. Azelaic acid has limited efficacy.
6. Sulfur and topical dapsone could also be effective.
Systemic Antibiotics
Systemic antibiotics (drugs that affect the whole body, usually taken in pill form) are the standard of care in moderate to severe acne. Bacterial resistance is a problem.
1. Doxycycline, minocycline and tetracycline are the first-line treatment, but cannot be used in pregnant and nursing women.
2. Erythromycin is safe for pregnant women and children under 8, whereas the tetracyclines are not due to potential skeletal and teeth damage.
3. Trimethoprim-sulfamethoxazole.
Hormonal Agents
1. Estrogen-containing oral contraceptives can be useful in some women.
2. Antiandrogens, such as spironolactone and cyproterone acetate, can help.
3. Corticosteroids injected into active lesions help the individual acne eruption clear more rapidly.
Isotretinoin (Accutane)
This is used as a last resort to treat severe, disfiguring nodular acne. It will cause birth defects if taken during pregnancy. Side effects include a possible increase in mood disorders, depression, suicidal ideation and suicide, although a causal relationship has not been established.
Other Treatments
Other treatments may include:
1. Laser therapy for treatment of acne, as well as acne scars.
2. Chemical peels, both glycolic acid-based and salicylic acid-based preparations. There is little evidence from clinical trials published in peer-reviewed literature.
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