Beat the blemishes: Tips for battling adult acne

It’s bad enough that many of us had to deal with acne during puberty and adolescence. Now that we're grown-up we'd expect our skin to behave in a more mature, blemish-free manner. But that’s not always the case. “Today” contributor Dr. Judith Reichman was invited to appear on the show to offer some insight on why some of us get adult acne and what we can do about it. Here are her thoughts:

What causes acne?
Contrary to common belief, it’s not poor skin hygiene or bad foods that can be faulted for causing acne. Our behavior is not to blame! The major acne culprit is the excess accumulation of a fatty substance called sebum that’s produced by the sebaceous glands in our skin. The sebum gets “stuck” and plugs the opening of the glands, causing whiteheads. After the bulging glands break open, they turn into blackheads. Sebum also nourishes the growth of bacteria that normally resides in the skin — propionibacterium acnes (P.acnes). Overgrowth of these bacteria then calls the skin’s immune cells into action in an attempt to defeat the bacterial invader, and inflammation and acne develop. This can take the form of closed, raised, red bumps or open pimples with infected fluids which course downward, causing deep lesions, or upward, to drain as open sores. Once healed, acne can leave darkened “footprints” (hyper-pigmentation).  It can also cause permanent scarring.

Male hormones cause an increase in sebum production and initiate this acne scenario. During puberty and adolescence, skin may respond to the sudden increase in ovarian production of testosterone that accompanies “ovarian awakening” (and promotes development of secondary sex characteristics as well as interest in sex) causing pimples to bloom. Those who develop severe acne may have large sebaceous glands, or their glands may simply be extremely sensitive to androgen (male hormone) fluctuations. In some girls, onset of moderate to severe acne is due to the secretion of too much male hormone. This is most likely due to a condition called polycystic ovarian syndrome or PCOS (which occurs in up to 10 percent of women). Excess insulin and male-hormone production cause irregular periods, weight gain, acne and excessive hair growth after puberty. There is also some evidence (from a study of twins) that a tendency to develop acne can be inherited. Your risk of adult acne is four times greater if you have a relative (parent or sibling) who had adult acne.

How does adult acne differ from that which occurs in adolescence?
“Adult acne” — that is, acne that occurs after the age of 25 — occurs in 12 percent of women and 3 percent of men. The lesions of adult acne typically appear in clusters around the lower cheek and jawline.  It’s called “persistent acne” if it continues after adolescence (and this is the most common type of adult acne, occurring in 70 percent to 80 percent of affected individuals).  “Late onset acne” is less common; it (as the name suggests) raises its ugly head for the first time in adulthood.

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We’re not sure why acne persists or suddenly develops as we get older. It may be that, with age, the sebaceous glands and ducts become more sensitive to male hormones or take longer to overcome inflammation. Endocrine (glandular) disorders, which can cause rising levels of male-type hormones, may develop at a later age and cause a persistence or new appearance of acne. Major stress can also cause an increase in the production of stress hormones from the adrenal glands. (Ever notice how you may develop a pimple or two when you are stressed or sick?) Many women complain about premenstrual acne. This too can be due to an increase in male hormone production after ovulation.

Should special tests be done?
If adult acne suddenly occurs or continues to be severe, blood tests should be performed to rule out elevated levels of male hormone from PCOS or the growth of tumors in the adrenal glands or ovaries. 

How can we treat blemished skin?
As we get older, our skin is more sensitive, so we have to be a little less aggressive in our use of drying or irritating topical acne therapies. It’s advisable to combine treatments that can target all of the causes of increased sebum production and infection. Most therapies take at least eight weeks to show results, and more dramatic improvement occurs only after three months. Unfortunately there is no instant gratification in the treatment of acne. 

The three basic types of therapies are:
Topical/vitamin A derivatives
There are three topical creams or gels that are made from vitamin A derivatives called retinoids. These increase turnover of cells around and in the glands and follicles of the skin, normalize the cells, and inhibit the development of pre-acne lesions. They also have an anti-inflammatory affect and help heal acne. Locally applied retinoids also help other medications, such as antibiotics, penetrate into the skin. The current FDA-approved retinoid products include:

• Trentinoin (Retin-A and generic)
• Trentinoin in special preparations (Retin-A Micro and Avita)

These products deliver the medication in a controlled manner, which may minimize irritation.

• Third-generation topical retinoids (Differin and Tazorac)

These products bind to specific receptors and have been found to cause less irritation. Moreover, they do not make the skin more sensitive to sunlight.

All these products can cause varying degrees of redness, dryness or irritation. Start with very small amounts (less than a pea-sized dollop for the face) and apply it at night, 20 minutes after you wash your face with a gentle cleanser. Apply sunscreen during the day.

Other topicals
These can be used in conjunction with the retinoids and include Benzoyl Peroxide. This kills P.acnes and helps treat infected lesions. It comes in over-the-counter and prescription strength, or in combination with antibiotics. 

Topical antibiotics
These kill the P.acnes. Solutions with erythromycin or clindomycin are most commonly prescribed. There has, however, been an increase in P.acnes’ resistance to erythromycin. (This is less of an issue if it’s used in combination with Benzoyl Peroxide.)

Oral medication/non-hormonal therapies
Oral antibiotics help combat moderate to severe acne. Usually they are used in combination with a topical retinoid. Tetracycline and erythromycin are the most frequently prescribed, but once more, we’re concerned about developing resistance to erythromycin. Don’t take tetracycline if you are pregnant or breastfeeding.

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Isotretinoin (Acutane) decreases the size of the sebaceous glands and decreases sebum secretion. It also inhibits P.acnes’ growth and has an anti-inflammatory affect. It is very potent and can be extremely drying, causing sores around the mouth or in the mucous membranes. It also is very toxic to a developing fetus. It should only be used for severe, recalcitrant acne, and if you take it you must use “fail-safe” contraception (usually two forms of contraception) and have a monthly negative pregnancy test.

Hormonal therapies
These are prescribed in order to decrease production and activity of male hormones. The easiest way to thwart the testosterone effect on your skin is to take birth-control pills: Most combination pills that contain estrogen will prevent excess male-hormone production. Ortho Tri-cyclin and Estrostep have been FDA-approved for acne treatment. Another birth-control pill, Yasmin, has a unique progestin which actually has anti-male hormone activity and so works to help prevent acne.

There are also anti-androgen medications that block male-hormone receptors. The one that is available in the U.S. is Spironolactone, a mild diuretic. Doses of 50 to 100 milligrams combined with other therapies may help, especially if you have deep cystic acne.

What kind of makeup should women with acne use?
Those that state they are “non comedogenic” may be less likely to contribute to acne. In general, powder blushes will be less acne-prone than creams, and creams/powder foundations are preferable to liquids. If you must use the latter, look for silicone-based products. Throw away old, used sponges and wash brushes to prevent infection. And use sunscreen daily.

We don’t have to accept acne at any age, so don’t hesitate to consult your dermatologist.  The right medical care can help “unblemish” your skin.

Dr. Judith Reichman, the “Today” show's medical contributor on women's health, has practiced obstetrics and gynecology for more than 20 years. You will find many answers to your questions in her latest book, "Slow Your Clock Down: The Complete Guide to a Healthy, Younger You," published by William Morrow, a division of Harper Collins Publishers.

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