Acne Vulgaris in Adults

  • Inês Vieira da Costa Aluna do 6ºano do Mestrado Integrado em Medicina, Instituto De Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
  • Glória Maria Cardoso da Cunha Velho Assistente Graduada de Dermatologia e Venereologia, Professora Auxiliar Convidada de Dermatologia da Disciplina de Clínica Médica do Mestrado Integrado em Medicina no Instituto Ciências Biomédicas Abel Salazar/Centro Hospitalar do Porto, Porto, Portugal
Keywords: Acne Vulgaris/epidemiology, Acne Vulgaris/etiology, Acne Vulgaris/physiopathology, Acne Vulgaris/therapy, Adulto


Introduction: Acne vulgaris is a chronic inflammatory disease of the pilosebaceous unit, of multifactorial etiology. It is one of the most common dermatological diseases. It affects more than 85% of teenagers, especially of the male gender. Despite being infrequent in adulthood, recent epidemiological data show a growing prevalence, around 40%, mainly in the female gender, with a negative impact on quality of life. Acne in adulthood or late acne is present after the age of 25 and is classified as late onset acne or persistent acne. The persistent type, which is the most common, represents 70% - 80% of all cases, and is characterised by the persistence of the teenage acne, while late onset acne is defined by the onset after the age of 25, with a prevalence of about 20% to 30%.

Objective: To review current scientific literature, especially focused on the pathophysiology of late acne, triggering and aggravating factors, as well as particularities of the therapeutic approach.

Methodology: The MEDLINE-PubMed database was used to select original and review articles published between 2001 and 2017.

Discussion: Acne can be a clinical sign of systemic disease, mainly with endocrinological abnormalities, as polycystic ovary syndrome, adrenal hyperplasia and virilising tumours. It is important to consider these etiologies into account, especially in women and in the presence of other signs of hyperandrogenism. Several studies point to other triggering or aggravating factors, namely genetic factors, stress, smoking, exposure to ultraviolet radiation, obesity, hyperglycaemic diet, drugs, cosmetics and colonisation by resistant strains of Propionibacterium acnes.

Conclusion: In most cases, adult acne affects the face, has mild to moderate clinical severity and is associated with normal hormonal levels. The exclusive location on the lower third of the face is most often associated with other signs of hyperandrogenism and endocrinological disease, as well as with a predominance of inflammatory lesions. Late acne is described as potentially refractory to the conventional therapy and is very relapsing. Thus, it is a therapeutic challenge, which requires an individualized approach.


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Preneau S, Dreno B. Female acne – a different subtype

of teenager acne? J Eur Acad Dermatol

Venereol. 2012;26:277-82. doi: 10.1111/j.1468-


Poli F, Dreno B, Verschoore M. An epidemiological study

of acne in female adults: results of a survey conducted in

France. J Eur Acad Dermatol Venereol. 2001;15:541-5.

James WD. Acne. N Engl J Med. 2005;352:1463-72.

doi: 10.1056/NEJMcp033487.

Capitanio B, Sinagra JL, Bordignon V, Cordiali Fei P, Picardo

M, Zouboulis CC. Underestimated clinical features of

postadolescent acne. J Am Acad Dermatol. 2010;63:782-

doi: 10.1016/j.jaad.2009.11.021.

Dréno B, Thiboutot D, Layton AM, Berson D, Perez M,

Kang S. Large-scale international study enhances understanding

of an emerging acne population: adult females. J

Eur Acad Dermatol Venereol. 2015;29:1096-1106. doi:


Jansen T, Janßen OE, Plewig G. Acne tarda. Akne im

erwachsenenalter. Hautarzt. 2013;64:241-51. doi:


Dréno B, Layton A, Zouboulis CC, López-Estebaranz JL,

Zalewska-Janowska A, Bagatin E, et al. Adult female

acne: a new paradigm. J Eur Acad Dermatol Venereol.

;27:1063-70. doi: 10.1111/jdv.12061.

Rivera R, Guerra A. Management of acne in women over

years of age. Actas Dermosifiliogr. 2009;100:33-7.

Teixeira V, Vieira R, Figueiredo A. Impacto psicossocial da

acne. Rev Soc Port Dermatol Venereol. 2012;70:291-6.

Tanghetti EA, Kawata AK, Daniels SR, Yeomans K, Burk

CT, Callender VD. Understanding the burden of adult

female acne. J Clin Aesthet Dermatol. 2014;7:22-30.

Khunger N, Kumar C. A clinic-epidemiological study

of adult acne: Is it different from adolescent acne? Indian

J Dermatol Venereol Leprol. 2012;78:335-41. doi:


Kokandi A. Evaluation of acne quality of life and clinical

severity in acne female adults. Dermatol Res Pract.

;2010:1-3. doi: 10.1155/2010/410809.

Perkins AC, Maglione J, Hillebrand GG, Miyamoto K,

Kimball AB. Acne vulgaris in women: prevalence across

the life span. J Womens Health. 2012;21:223-30. doi:


Da Cunha MG, Fonseca FL, Machado CD. Androgenic

hormone profile of adult women with acne. Dermatology.

;226:167-71. doi: 10.1159/000347196

Collier CN, Harper JC, Cafardi JA, Cantrell WC, Wang

W, Foster KW, et al. The prevalence of acne in adults 20

years and older. J Am Acad Dermatol. 2008;58:56-9.

doi: 10.1016/j.jaad.2007.06.045

Di Landro A, Cazzaniga S, Cusano F, Bonci A, Carla C,

Musumeci ML, et al. Adult female acne and associated

risk factors: Results of a multicenter case-control study

in Italy. J Am Acad Dermatol. 2016;75:1134-41. doi:


Schmitt JV, Masuda PY, Miot HA. Padrões clinicos de acne

em mulheres de diferentes faixas etarias. An Bras Dermatol.


McCarty M. Evaluation and management of refratory

acne vulgaris in adolescent and adult men. Dermatol

Clin. 2016;34:203-6. doi: 10.1016/j.det.2015.11.007.

Rosenfield RL. Clinical practice. Hirsutism. N England J

Med. 2005;353:2578-88.

Danby FW. New, relevant information and innovative interventions

in the management of acne. G Ital Dermatol

Venereol. 2011;146:197–210.

Kim GK, Del Rosso JQ. Oral spironolactone in post-teenage

female patients with acne vulgaris: Practical considerations

for the clinician based on current data and

clinical experience. J Clin Aesthet Dermatol. 2012;5:37-

Ghosh S, Chaudhuri S, Jain VK, Aggarwal K. Profiling and

hormonal therapy for acne in women. Indian J Dermatol.

;59:107-15. doi: 10.4103/0019-5154.127667.

Harper JC. Evaluating hyperandrogenism: a challenge in

acne management. J Drugs Dermatol. 2008;7:527-30.

Gowri BV, Chandravathi PL, Sindhu PS, Naidu KS. Correlation

of skin changes with hormonal changes in polycystic

ovarian syndrome: A cross-sectional study clinical study.

Indian J Dermatol. 2015;60:419. doi: 10.4103/0019-


Schmidt TH, Khanijow K, Cedars MI, Huddleston H, Pasch

L, Wang ET, et al. Cutaneous findings and systemic associations

in women with polycystic ovary syndrome. JAMA

Dermatol. 2016;152:391-8. doi: 10.1001/jamadermatol.


Uysal G, Sahin Y, Unluhizarci K, Ferahbas A, Uludag

SZ, Aygen E, et al. Is acne a sign of androgen excess

disorder or not? Eur J Obstet Gynecol Reprod Biol.

;211:21-5. doi: 10.1016/j.ejogrb.2017.01.054.

Seirafi H, Farnaghi F, Vasheghani-Farahani A, Alirezaie

NS, Esfahanian F, Firooz A, et al. Assessment

of androgens in women with adult-onset acne. Int J

Dermatol. 2007;46:1188-91. doi: 10.1111/j.1365-


Ianosi S, Ianosi G, Neagoe D, Ionescu O, Zlatian O, Docea

AO, et al. Age-dependent endocrine disorders involved in

the pathogenesis of refractory acne in women. Mol Med

Rep. 2016;14:5501-6. doi: 10.3892/mmr.2016.5924.

Geller L, Rosen J, Frankel A, Goldenberg G. Perimenstrual

flare of adult acne. J Clin Aesthet Dermatol. 2014;7:30-

Yang YS, Lim HK, Hong KK, Shin MK, Lee JW, Lee SW, et

al. Cigarette smoke-induced interleukin-1 alpha may be

involved in the pathogenesis of adult acne. Ann Dermatol.

;26:11-6. doi: 10.5021/ad.2014.26.1.11.

Da Silva JP, Velho GM. Influência do índice de massa corporal

e da dieta na fisiopatologia da acne vulgaris. Rev

Soc Port Dermatol Venereol. 2017;75:241-9.

Melnik BC. Linking diet to acne metabolomics, inflammation,

and comedogenesis: an update. Clin Cosmet

Investig Dermatol. 2015;8:371–88. doi: 10.2147/CCID.


Adalatkhah H, Pourfarzi F, Sadeghi-Bazargani H. Flutamide

versus a cyproterone acetate-ethinyl estradiol combination

in moderate acne: a pilot randomized clinical

trial. Clin Cosmet Investig Dermatol. 2011;4:117-21.

doi: 10.2147/CCID.S20543.

Kaur S, Verma P, Sangwan A, Dayal S, Jain VK. Etiopathogenesis

and therapeutic approach to adult onset acne.

Indian J Dermatol. 2016;61:403-7. doi: 10.4103/0019-


Dessinioti C, Antoniou C, Katsambas A. Acneiform eruptions.

Clin Dermatol. 2014;32:24-34. doi: 10.1016/j.


Knaggs HE, Wood EJ, Rizer RL, Mills OH. Post-adolescent

acne. Int J Cosmet Sci. 2004;26:129-38. doi:


Adityan B, Kumari R, Thappa DM. Scoring systems

in acne vulgaris. Indian J Dermatol Venereol Leprol.

;75:323-6. doi: 10.4103/0378-6323.51258.

Choi CW, Lee DH, Kim HS, Kim BY, Park KC, Youn

SW. The clinical features of late onset acne compared

with early onset acne in women. J Eur Acad Dermatol

Venereol. 2011;25:454-61. doi: 10.1111/j.1468-


Kamangar F, Shinkai K. Acne in the adult female patient:

a pratical approach. Int J Dermatol. 2012;51:1162-74.

doi: 10.1111/j.1365-4632.2012.05519.x.

Ozdemir S, Ozdemir M, Görkemli H, Kiyici A, Bodur S.

Specific dermatologic features of the polycystic ovary

syndrome and its association with biochemical markers

of the metabolic syndrome and hyperandrogenism.

Acta Obstet Gynecol Scand. 2010;89:199-204. doi:


Kubba R, Bajaj AK, Thappa DM, Sharma R, Vedamurthy

M, Dhar S, et al. Acne in India: guidelines for

management-IAA consensus document. Indian J Dermatol

Venereol Leprol. 2009;75:1-62.

Zouboulis CC. Acne as a chronic systemic disease. Clin

Dermatol. 2014;32:389-96. doi: 10.1016/j.clindermatol.


Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus

Workshop Group.. Revised 2003 consensus on diagnostic

criteria and long-term health risks related to polycystic

ovary syndrome (PCOS). Hum Reprod. 2004;19:41-7.

Nast A, Dréno B, Bettoli V, Bukvic Mokos Z, Degitz K,

Dressler C, et al. European evidence-based (S3) guideline

for the treatment of acne - update 2016 - short version.

J Eur Acad Dermatol Venereol. 2016;30:1261-8.

doi: 10.1111/jdv.13776.

Savage LJ, Layton AM. Treating acne vulgaris: systemic,

local and combination therapy. Expert Rev Clin Pharmacol.

;3:563-80. doi: 10.1586/ecp.10.27.

Thiboutot D, Gollnick H, Bettoli V, Dréno B, Kang S, Leyden

JJ, et al. New insights into the management of acne:

an update from the global alliance to improve outcomes

in acne group. J Am Acad Dermatol. 2009;60:S1-50.

doi: 10.1016/j.jaad.2009.01.019.

Layton A. The use of isotretinoin in acne. Dermatoendocrinol.


Rademaker M, Wishart JM, Birchall NM. Isotretinoin 5

mg daily for low-grade adult acne vulgaris-a placebo-

-controlled, randomized double-blind study. J Eur Acad

Dermatol Venereol. 2014;28:747-54. doi: 10.1111/


Ebede TL, Arch EL, Berson D. Hormonal treatment of acne

in women. J Clin Aesthet Dermatol. 2009;2:16-22. doi:


Katsambas AD, Dessinioti C. Hormonal therapy for acne:

why not as first line therapy? Facts and controversies. Clin

Dermatol. 2010;28:17-23. doi: 10.1016/j.clindermatol.


Husein-ElAhmed H. Management of acne vulgaris with

hormonal therapies in adult female patients. Dermatol

Ther. 2015;28:166-72. doi: 10.1111/dth.12231

Koltun W, Lucky AW, Thiboutot D, Niknian M, Sampson-

-Landers C, Korner P, et al. Efficacy and safety of 3 mg

drospirenone/20 mcg ethinylestradiol oral contraceptive

administered in 24/4 regimen in the treatment of acne

vulgaris: a randomized, double-blind, placebo-controlled

trial. Contraception. 2008;77:249-56. doi: 10.1016/j.


Krunic A, Ciurea A, Scheman A. Efficacy and tolerance of

acne treatment using both spironolactone and a combined

contraceptive containing drospirenone. J Am Acad Dermatol.

;58:60-2.doi: 10.1016/j.jaad.2007.09.024

Fernandes CE, Rennó Jr J, Nahas EA, Melo NR, Ferreira

JA, Machado RB, et al. Síndrome de insuficiência androgénica

- critérios diagnósticos e terapêuticos. Rev Psiquiatr

Clín. 2006;33:152-61.

Kronenberg HM, Melmed S, Polonsky KS, Larsen PR. Williams

Textbook of Endocrinology. 11th ed. Philadelphia

Elsevier; 2008.

How to Cite
Vieira da Costa, I., & Cardoso da Cunha Velho, G. M. (2018). Acne Vulgaris in Adults. Journal of the Portuguese Society of Dermatology and Venereology, 76(3), 299-312.
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