Adult female acne: a guide to clinical practice

Overview

This guide, published in Anais Brasileiros de Dermatologia in 2019, was prepared by five Brazilian dermatologists with extensive experience in acne. They reviewed the main evidence and reached consensus on clinical practice for adult female acne, defined as acne in women over 25 that either persists from adolescence or appears for the first time in adulthood. It is often chronic, needs maintenance treatment, and is associated with anxiety, depression and reduced quality of life.

Clinical picture and causes

Lesions are typically inflammatory papules and pustules of mild to moderate severity, often on the lower face and jawline, with few comedones. Post-inflammatory hyperpigmentation is common and scars occur in about 20% of women, although many women also have lesions on other areas of the face and the trunk. Severity can be scored with the GEA scale or the AFAST tool. Causes are multifactorial: genetic predisposition, androgen sensitivity, sebum changes, follicular hyperkeratinisation, Cutibacterium acnes and innate immune inflammation. Stress, sleep loss, smoking, high-glycaemic and dairy-rich diets, some drugs and progestin-only contraceptives may aggravate it.

Investigation

Hormonal tests (free and total testosterone, DHEA-S, LH, FSH) are suggested when there are signs of hyperandrogenism such as hirsutism, menstrual disorders or alopecia. They are best taken in the early follicular phase, in the morning, and not during hormonal contraception. Polycystic ovary syndrome is the most frequent cause.

Treatment

Topical therapy is the mainstay for mild to moderate disease and for maintenance: retinoids, azelaic acid and benzoyl peroxide, with topical or oral antibiotics never used alone. Oral tetracyclines are the first-choice antibiotics but are avoided in pregnancy. Hormonal options include combined oral contraceptives and spironolactone, although evidence for spironolactone is limited. Oral isotretinoin is first line for nodulocystic acne and is used after failed conventional treatment, with strict pregnancy prevention because of its teratogenicity. Moisturisers, gentle cleansers and sunscreen are part of every regimen.