Individualized Treatment Considerations for Adult Women With Acne

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Acne vulgaris affects approximately 12-22% of women in the United States. At the 2023 Society of Dermatology Physician Assistants (SDPA) Annual Fall Dermatology Conference, Allison Arthur, MD, a board-certified dermatologist practicing at Sand Lake Dermatology Center in Florida, presented a session on acne in adult women.¹

Arthur emphasized the importance of understanding underlying causes of acne, particularly when it comes to decision-making in treatment and therapeutics.

The Pathogenesis of Acne

Arthur started her session by delving into the underlying causes of acne. She questioned whether "acne" might be a misnomer, suggesting that all acne is hormonally mediated and can be seen as a manifestation of end-organ hypersensitivity.

Differential Diagnosis

When dealing with patients suffering from acne, it is essential to consider differential diagnoses, Arthur said. These may include rosacea, perioral dermatitis, acne cosmetica, and acne medicamentosa, which can be triggered by substances like testosterone, prednisone, progestin, or lithium.

Comprehensive Evaluation

Understanding a patient's history is crucial in diagnosing and treating acne effectively, Arthur said. She recommends a comprehensive evaluation, which includes prior and current treatments, medical history, menstrual history, smoking history, and a review of systems that encompasses issues such as hirsutism and alopecia.

Polycystic Ovary Syndrome (PCOS)

Polycystic Ovary Syndrome (PCOS) can often be linked to acne, with cutaneous manifestations such as seborrhea, acanthosis nigricans, and alopecia. PCOS is associated with insulin resistance (40%), diabetes (10%), obesity (40%), fatty liver, and obstructive sleep apnea. These are all underlying factors in a patient's medical history that may contribute to the decision of treatment.

Recognizing Hormonal Disorders

Arthur stressed the importance of recognizing hormonal disorders in women with acne, particularly if they exhibit signs like hirsutism, acanthosis, and fewer than 8 menstrual periods a year. Acne can be stubborn and challenging to treat, making a correct diagnosis even more critical, she said.

Treatment Options

Treating acne necessitates a multifaceted approach. Arthur explored various treatment options:

Hormonal Treatments

Hormonal treatments should be considered in cases of hypoandrogenism, jawline acne distribution, and when acne proves resistant to conventional therapies, Arthur said. Discussing family planning before therapy initiation is advisable.

Considerations for Oral Contraceptive Pills (COCs)

Before starting a combined oral contraceptive pill, health care providers should consider factors such as checking blood pressure, screening for thromboembolic risk factors (including family history of clots, age, smoking, obesity, malignancy, trauma, and immobilization), conducting a workup for hypoandrogenism, and evaluating contraindication, Arthur noted. Patients may experience adverse events, including melasma, when using COCs.

Hormonal Intrauterine Device (IUD) and Spironolactone

Hormonal IUDs and spironolactone both can improve acne vulgaris and reduce sebum excretion, Arthur explained. However, it is crucial to monitor potassium levels. Additionally, it is important that spironolactone be avoided in use in male patients, as it may lead to gynecomastia. Once-daily dosing can enhance compliance, but it may take over 3 months to see acne improvement.

Integrative Treatments

Arthur also emphasized the role of integrative treatments, including dietary changes and light/laser therapies. She highlighted an Italian study that linked low consumption of vegetables, fruits, and fish to acne. Focusing on a low glycemic index diet is recommended, as high-glycemic diets can increase insulin and IGF-1, exacerbating acne pathogenesis.

Arthur suggests educating patients that specific foods can cause spikes in blood sugar, leading to increased oil production. Dairy products, especially milk, can elevate insulin and IGF-1. Patients should be asked about whey protein supplementation, as some individuals have developed severe acne after using such supplements for bodybuilding.

Additionally, spearmint tea, known for its antiandrogen properties, can be consumed in moderation. Though a study suggested a reduction in androgen levels, safety during pregnancy or lactation is not established, and patients should consume no more than 2 cups per day without adding honey.

Light and Laser Therapies

Blue light therapy can effectively kill C. acnes bacteria and serve as an adjuvant treatment for inflammatory acne. Two lasers, Accure and AviClear, have been found safe for all skin types, with reported lasting results, Arthur said. The goal is to target and minimize sebaceous glands. However, long-term concerns about dry skin should be considered.

Acne Management During Pregnancy

Arthur also addressed the challenges of managing acne during pregnancy. There is limited data on the safety of topical retinoids during pregnancy, she said, and use of spironolactone poses a risk of feminization of the male fetus. Isotretinoin, tazarotene, and tetracycline family antibiotics are contraindicated during pregnancy.

However, topicals like clindamycin (with benzoyl peroxide wash), azelaic acid, salicylic acid (in concentrations less than 2% and applied in limited areas for a limited time), glycolic acid, and benzoyl peroxide can be used safely during pregnancy. Oral antibiotics like amoxicillin, cefadroxil, and cephalexin (for short-term use) are also viable options.

In general, if a treatment is safe during pregnancy, it is also safe for breastfeeding, Arthur said.

Reference

1. Arthur A. Acne in Adult Women. Presented at: 2023 SDPA Annual Fall Dermatology Conference: October 26-29, 2023; Nashville, TN.

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