What About Adult Acne? Is It Just Me?

Acne is a chronic, inflammatory-mediated disorder affecting the hair follicle and its associated sebaceous gland, resulting in distention (expansion) and obstruction (blockage) of the affected follicle.

Sebaceous glands normally function to keep hair shafts conditioned and prevent them from drying out; when these glands begin to produce excess oil (sebum), dead skin cells can become trapped within the pore, forming a plug.

This plug of oil and dead skin cells blocks the pore, trapping and creating an ideal environment for the proliferation of bacteria (Propionibacterium acnes) that normally exist on the skin, resulting in inflammation and the development of acne.

Factors that may contribute to the development of acne include certain medications, heredity, stress, and increases in androgenic hormones.

Most people (over 90%) suffer from some type of acne as a teenager; however, about 20% of women and 10% of men are affected by acne after the age of 25.

Causes of Acne

The causes of acne are the same regardless of age; acne occurs as a result of excess sebum production, resulting in the proliferation of P. acnes and subsequent inflammation.

Excess sebum combines with dead skin cells and obstructs pores, creating an ideal environment for the proliferation P. acnes.

The body then mounts an immune response to the bacteria, which is manifested in the skin as red bumps and pustules.

Progression of Acne in Hair Follicles
  • Fluctuations in hormone levels persist into adulthood, and elevated levels of androgenic hormones stimulate the sebaceous glands to secrete excess oil.
  • Stress causes an increase in the secretion of androgenic hormones, leading to excessive sebum production.
  • Excessively dry skin causes sebaceous glands to secrete increased amounts of oil in order to balance the dry skin.
  • Chemicals in some skin care products can irritate the skin, leading to inflammation, which causes acne.
  • Certain medications can precipitate outbreaks of acne:
    • Corticosteroids (prednisone, hydrocortisone) can increase yeast proliferation within the hair follicle.
    • Lithium.
    • Antiepileptic drugs (carbamazepine, phenytoin).
    • Barbiturates (phenobarbital).
    • Androgenic steroid hormones.
    • Halogated medications (iodides, bromides, chlorides).
    • Antituberculosis medications (isoniazid, rifampin).

Prevention of Acne

Although it is impossible to completely prevent acne, there are measures that can be taken to reduce the severity of acne outbreaks:

  • Avoid touching your face, which can increase oil production, encourage bacterial growth, and irritate the skin.
  • Wash your face twice a day and after profusely sweating (e.g., running, exercise).
  • Gently cleanse your skin:
    • Use your clean fingertips when washing your face.
    • Avoid scrubbing your face with abrasive cleansers.
    • Avoid products that contain alcohol (e.g., toners, astringents).
  • Rinse your skin with lukewarm water; hot or cold water can irritate the skin and precipitate outbreaks.
  • Make sure that your skin care products are:
    • non-comedogenic
    • oil-free

Acne Characteristics and Severity

Acne can cause a variety of characteristic lesions:

  1. Comedones (obstructed pores):
    • Blackheads: open clogged pores.
    • Whiteheads: closed clogged pores.
  2. Papules: small, red, elevated lesion.
  3. Pustules: papules containing pus.
  4. Nodules: large, solid, painful lumps beneath the surface of the skin.
  5. Cysts: nodules containing pus.
  6. Macules: flat, red areas of inflammation.

    Acne On the Face

Acne severity can be classified as mild, moderate, or severe based on the number of lesions that are present at a given time.

  • Mild acne: < 30 lesions.
  • Moderate acne: a lesion count between 30 and 125.
  • Severe acne: > 125 lesions.

Acne Treatment

  1. Mild Acne
    1. Keratolytic washes and toners containing salicylic acid can become concentrated inside obstructed pores, where they can dissolve dead skin cells and sebum to relieve the obstruction. Salicylic acid also has anti-inflammatory properties.
    2. Over the counter (OTC) topical agents:
      1. Washes and masks containing benzoyl peroxide (in concentrations of 10% or less) kill bacteria by peroxidation, decreasing the amount of surface bacteria on the skin. Benzoyl peroxide may also have anti-inflammatory properties, and it helps to break down keratin and unclog pores.
      2. Azelaic acid (in concentrations of 10% or less) has antimicrobial and anti-inflammatory properties, and it inhibits keratinization in hair follicles to decrease comedone formation.
      3. Adapalene (Differin) is a retinoid cream that was previously available only by prescription and is effective in the treatment of acne. It is often less irritating to the skin than tretinoin.
  2. Moderate Acne
    1. Topical antibiotics are effective at killing excess skin bacteria and reducing redness; they are often combined with benzoyl peroxide in order to decrease antibiotic resistance.
      1. Clindamycin and benzoyl peroxide (BenzaClin).
      2. Erythromycin and benzoyl peroxide (Benzamycin).
    2. Topical prescription retinoids such as tretinoin (Retin-A), adapalene (Differin), and tazarotene can be used to increase cell turnover, decrease inflammation, and prevent the adherence of keratinized epithelial cells in hair follicles.
    3. Topical dapsone gel has both antimicrobial and anti-inflammatory properties and can be effective in the treatment of acne.
  3. Severe Acne
    1. Severe cases of acne should be referred to a dermatologist for proper diagnosis and treatment.
    2. Systemic (oral) antibiotics can be given in combination with topical benzoyl peroxide creams in order to kill acne-causing bacteria and reduce inflammation.
    3. Systemic (oral) isotretinoin (Accutane, Claravis) works by decreasing the sebaceous gland size and sebum production. It can be very effective in the treatment of severe acne, but there are several side effects, and female patients must use two forms of birth control and take pregnancy tests for 30 days before, during, and for 30 days after treatment.
      1. Birth defects (in pregnant women).
      2. Depression (increased risk of suicide).
      3. Hepatitis.
      4. Osteoporosis.

You’re Not Alone

Treatment of adult acne depends on the severity of the breakouts and is often aimed at decreasing sebum production, reducing the amount of bacteria on the skin, decreasing associated inflammation, and removal of debris and dead skin cells.

Acne breakouts consist of different types of skin lesions, each having its own characteristic appearance.

Although there is no way to prevent the occurrence of acne breakouts, their frequency, and severity can be reduced by identification and avoidance of contributing factors.

The incidence of adults afflicted with acne seems to be increasing; however, effective OTC and prescription treatments are widely available, and consultation with your dermatologist will maximize your chance of success.

If you have struggled with adult acne or know someone who has, please leave a comment and let me know how you dealt with it and/or treated it.