acne in the adult female patient a practical

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ACNE IN THE ADULT FEMALE PATIENT :A PRACTICAL APPROACH

Armando VSLM

41090026

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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 41–54% in women and 34–40% 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.

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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. Androgen-insensitive individuals do not produce

sebum and do not develop acne.2. Conditions of hyperandrogenism, such as polycystic

ovary syndrome (PCOS), are associated with acne that is highly responsive to hormonal therapies.

3. Hormonal-based therapies such as oral contraceptives and anti-androgen medications are effective treatments for acne.

4. 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.

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CLINICAL FEATURES

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

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DIFFERENTIAL DIAGNOSIS

The common differential diagnosis of adult

female acne includes:

1. Rosacea

2. Seborrheic dermatitis

3. Acne Cosmetic

4. 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. amenorrhea or oligomenorrhea

2. biochemical or clinical hyperandrogenism

3. ultra-sonographic documentation of increased

follicle count (>12) or follicular volume (>10

cm3) per ovary.

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PCOS

Acne is an important

and common cutaneous

sign of PCOS. Other

dermatological signs

associated with PCOS

include hirsutism,

androgenic alopecia,

seborrhea, and

acanthosis nigricans.

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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 hormone-

binding globulin, which bind circulating androgens,

decrease free testosterone and DHEA-S, and likely

reduce sebum production. OCPs also inhibit 5-a-

reductase, 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 a 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