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Spotting why acne is spreading to later life

Did you breathe a sigh of relief when adolescence retreated, leaving your skin relatively intact? Or are you one of the growing number for whom acne persisted or even appeared for the first time during adulthood?

Although acne is often viewed as a teenage problem, it is increasingly occurring later in life and may require treatment well into your mid-40s.

Adult acne affects one in four men and one in two women at some time. One third of those with facial acne will also have acne on their body.

The psychological distress, isolation and discrimination associated with adult acne is considerable, so it is important to identify any underlying triggers, and to prescribe the most effective treatment to minimise both physical and psychological scarring.

Around 80 per cent of teens with significant acne are male. Among adults, however, the ratio is reversed and 80 per cent of those affected are female. In both cases, the same underlying mechanism may be involved – an increased sensitivity to male androgen hormones.

Each hair follicle is linked to a sebaceous gland whose oily secretions (sebum) keep your hair sleek and waterproof. Androgens stimulate both sebum production and the division of overlying skin cells. If these rapidly dividing cells stick together, rather than being shed, the hair follicles become blocked. This traps sebum inside, resulting in the classic, enlarging comedones we all love to squeeze.

Excess sebum and changes in skin acidity encourage colonisation with the skin bacterium, propionibacterium acne, and this sets the scene for an inflammatory reaction and an outbreak of pustules. 

There are three main types of acne: 

Mild acne: comedones predominate, appearing as whiteheads when closed or open blackheads in which sebum is oxidised;

Moderate acne: inflammatory lesions predominate with pustules and papules (raised pimples with an underlying, deeper infection);

Severe acne: nodules and cysts develop along with inflammatory papules and pustules, and there is a high risk of scarring.

In males, the highest level of androgens occurs during the teens and early-20s. Production then gradually reduces which may partly explain why acne is less common in adult males.

Females produce significantly less androgens than men, but their relative influence, compared with female oestrogens, can increase in some situations.

Adult acne affects one in four men and one in two women at some time

According to consultant dermatologist Professor Nick Lowe, hormonally-driven acne in adult women can be associated with polycystic ovary syndrome (PCOS). “There is also a subset of women without full-blown PCOS, whose sebaceous glands are unusually sensitive to normal androgen levels,” says Professor Lowe. Starting or stopping some oral contraceptive pills, contraceptive implants and pregnancy can also be potential triggers.

“Although many women find their skin improves, some women develop worsening acne during pregnancy or after giving birth,” he adds. “It is said this is more common when carrying a male foetus, but this is far from proven. Whatever the cause, it is important to select treatments that are safe during pregnancy and breast feeding.” Oestrogen levels fall as the menopause approaches and the increased relative significance of circulating androgens can also cause outbreaks of spots, although these are not usually so severe.

In some people with very severe, persisting acne, genetic causes can also play a role.

Is diet to blame? Diet is at the root of many health problems and acne is no different. There is strong evidence that androgen sensitivity is associated with insulin resistance. This is also linked with obesity, and eating a diet that contains too much sugar and refined carbohydrates may make acne worse.

The hormones present in cows’ milk and dairy products may also play a role. Try goats’ milk and butter and switch from milk chocolate to dark chocolate.

Dr Nyjon Eccles also advises eating more fruit, vegetables, oily fish and less meat to reduce inflammation. He says: “Gut dysbiosis, where there is an abnormal balance of bowel bacteria, may play a role, in which case probiotic supplements may help. Food sensitivities are perhaps an under-estimated and under-tested cause, which may need investigation.”

What about stress? Stress can exasperate acne and may be one of the factors in the rise of its incidence in adults. “When female undergraduates were followed during an academic year, the incidence of acne increased in the weeks following the end-of-term exams”, says Professor Lowe. “The delay occurs because stress triggers the production of adrenocorticoid hormones which have an androgenic action – just like the steroid-related acne associated with long-term oral corticosteroid drugs and using steroid creams on the face. Other medications that can trigger an acne response include some sedatives, anti-epileptic drugs and lithium-related antidepressants, so a full medical history is vital.”

How is adult acne treated? After taking a careful medical history and excluding triggers, dermatologists recommend anti-acne skin cleansers containing benzoyl peroxide or salicylic acid and oral antibiotics as the mainstay of treatment for mild to moderate acne. External therapies, such as suction dermabrasion, vacuum extraction, intense pulsed light and vascular lasers can also help. For more severe acne, topical retinoids, such as adapalene or tretinoin, are needed.

Although your primitive, grooming instinct may be strong, Dr Eccles warns against squeezing. “It is of major importance that you don’t pinch or squeeze lesions, as manipulation of any type worsens acne, producing longer-lasting pimples that are more likely to scar,” he says.

But the good news is that you can still use make-up, as long as you remove it scrupulously with a non-irritant cleanser, and look for cosmetics and skincare products that are labelled as “non-comedogenic”.