Acne is a very common skin condition that affects up to 85% of adolescents and can persist into adulthood. It often has significant psychosocial impacts. While acne was once considered a condition specific to youth, it is now widely recognized as a chronic inflammatory skin disease in adults, influenced by a complex interplay of hormones, genetics, microorganisms, and environmental factors.
In women, acne often appears around the lower face (jawline and perioral areas) and tends to flare cyclically before menstruation. Even without hyperandrogenism, acne may persist into the 30s and 40s.
Effective management requires a multifaceted approach that addresses not only the severity of the skin lesions, but also hormonal influences, lifestyle, and psychological stress. Treatment should be individualized, and in women, hormonal therapies are often used in combination with topical or systemic treatments.
Key Pathophysiological Factors:
- Increased sebum production (androgen-related)
- Follicular hyperkeratinization
- Proliferation of Cutibacterium acnes
- Inflammatory response
General Treatment Principles:
- Treatment is selected based on the severity of the condition
- Combining therapies generally improves effectiveness
- Both comedonal and inflammatory lesions should be addressed
- In women, if adult-onset acne or signs of androgen excess (e.g., PCOS) are present, hormonal therapy is important
First-line Treatments:
Topical Therapy (Mild to Moderate Acne)
- Topical Retinoids (Adapalene, Tretinoin): Normalize keratinization
- Benzoyl Peroxide (BPO): Antibacterial and keratolytic effects
- Topical Antibiotics (Clindamycin): Effective for inflammatory lesions; recommended to be used with BPO to prevent resistance
Note for Women:
Topical retinoids are contraindicated during pregnancy. BPO and azelaic acid are relatively safer options.
Systemic Therapy (Moderate to Severe Acne, or Inadequate Response to Topicals)
1. Oral Antibiotics
- Doxycycline: 50–100 mg/day
- Minocycline: 50–100 mg/day
→ Typically used for 3–6 months and must be combined with BPO to prevent resistance
Caution: Avoid during pregnancy and in children under 8 years. Monitor for photosensitivity and risk of candidiasis.
2. Hormonal Therapy (For Women Only)
Indicated in:
- Moderate to severe acne
- Adult-onset or persistent acne
- Signs of androgen excess (e.g., polycystic ovarian syndrome, menstrual irregularities, hirsutism)
Options:
A. Combined Oral Contraceptive Pills (COCP):
- Suppress androgen production and sebum secretion
- Effective progestins include:
- Ethinylestradiol + Cyproterone acetate
- Ethinylestradiol + Drospirenone
- Ethinylestradiol + Dienogest
- Avoid formulations containing levonorgestrel or norethisterone
- It may take 3–6 months for visible improvement
B. Spironolactone:
- Androgen receptor antagonist (off-label use)
- Dose: 50–100 mg/day (up to 200 mg/day)
- Can be used alone or with COCP
- Monitor serum potassium before starting and 1–2 months later
- Contraindicated during pregnancy due to risk of abnormal male fetal development
3. Oral Isotretinoin (Referral to Dermatologist Required)
- Reserved for severe or treatment-resistant acne
- Reduces sebum production, keratinization, and inflammation
- Usual dose: 0.5–1 mg/kg/day for 4–6 months
Important precautions for women of childbearing potential:
- Highly teratogenic
- Strict contraception and pregnancy testing are required
- In Australia, only dermatologists can prescribe isotretinoin
Summary
Acne is a common dermatological condition that affects both adolescents and adults, often with psychological and social consequences. If you are seeking advice or treatment for acne, please feel free to contact SkyArch Medical Clinic Brisbane.
Dr. Tatsuro Nagashima
References:
- Therapeutic Guidelines – Dermatology (eTG Complete)
🔗 https://www.tg.org.au - Australian Medicines Handbook (AMH)
🔗 https://amhonline.amh.net.au - RACGP – Clinical Guidelines for Adult Acne
🔗 https://www1.racgp.org.au/ajgp/2021/september/acne
