“It’s not fair!” I hear this from patients all over the country, especially women in their 30s, 40s, and 50s who thought that acne was a teenage malady. Though acne prevalence peaks at age 15, significant percentages of women in their 30s (35%), 40s (26%), and 50s (15%) complain of acne; male prevalence is roughly half that in women.
Acne occurs where the oil glands surrounding body hairs are particularly large, and in adult women, it particularly attacks the jawline and chin. Acne starts with testosterone — a hormone produced in both males and females once puberty begins — that stimulates oil gland and hair follicle lining cells to proliferate. Therefore, all acne at all ages is hormonal.
New cells and oil build up beneath the skin surface, forming whiteheads and blackheads that can’t escape through the pores, that is, unless patients squeeze them out! Increased oil in these plugs prevents oxygen from entering and provides ‘food’ for normal skin bacteria (P. acnes) that thrive in the absence of oxygen and convert oil into irritating byproducts. When a plug bursts into surrounding skin, it creates the redness, swelling, and pain experienced as annoying pimples.
Because dirt is not the cause of acne, vigorous scrubbing only serves to give sufferers a redder face.
As well, high glycemic index diets — sugar, white bread, white potatoes, candy — are linked to higher rates and more severe cases of acne; low glycemic index diets can improve acne.
And while smoking also increases acne severity in adults, quitting reduces the acne burden.
Though the cause of adult acne is the same as adolescent acne, adult women with acne are especially sensitive to testosterone. Standard treatment that works in adolescence and the early 20s often fails in older women, and 30% or more relapse after a course of isotretinoin, the “miracle drug” of acne treatment.
Furthermore, the FDA requires women on isotretinoin to sign a form stating they will use two forms of contraception to avoid pregnancy due to the 25-50% chance of severe birth defects in children conceived while mom is taking isotretinoin. While contraceptives can be morally used to treat acne, they cannot be morally used to prevent conception in patients using isotretinoin. Fortunately, most physicians are willing to prescribe isotretinoin if a woman promises to abstain from sexual intercourse during and one month after taking it.
However, a better option for women with moderate-to-severe acne is the noncontraceptive spironolactone, a hormonal treatment that blocks testosterone action at the oil gland-hair follicle unit. Spironolactone is both safer and more effective than oral contraceptives (and does not serve as a near occasion-of-sin as contraceptives do). More frighteningly, in 2005, the World Health Organization recognized oral contraceptives as a Group One Carcinogen (with cigarettes, radiation, and asbestos) for increasing the risk of breast cancer.
Spironolactone helps virtually every woman who tries it at appropriate doses and who patiently allows three to six months to reach maximal improvement. It even reduces oiliness and unwanted facial hair growth. For mild cases of adult acne with only whiteheads and blackheads — and maybe a few pimples and red bumps — the combination of over-the-counter adapalene (that unplugs pores) and benzoyl peroxide (that releases oxygen to kill P. acnes) is highly effective within three months. See a dermatologist for more details.
DR. THOMAS MCGOVERN is a dermatologist/Mohs surgeon member, Fort Wayne Chapter Legate, and Member of the National Board of the Catholic Medical Association – a national, physician-led community of healthcare professionals that informs, organizes, and inspires its members, in steadfast fidelity to the teachings of the Catholic Church, to uphold the principles of the Catholic faith in the science and practice of medicine.