Background and Manifestations of Acne
The blemishes and lesions characteristic of acne arise when hair follicles in the skin become blocked with oils and particles such as dead skin cells, bacteria, or occasionally white blood cells (Bellew 2011; Beylot 2013). Sebaceous glands attached to hair follicles secrete an oil-based substance known as sebum. Sebum normally helps moisturize skin and keep it supple. However, if too much sebum is produced, the follicle can become blocked. Testosterone, the characteristic male sex hormone, stimulates sebum production and is a major contributor to the initial formation of acne lesions (Dawson 2013; Lee, Jung 2010; Bhatia 2004). This is a primary reason why acne is more common in adolescence, when sexual maturation coincides with a spike in testosterone production, especially in males.
A clogged pore may form a “blackhead,” which is called an open comedo, or a “whitehead,” known as a closed comedo (Dawson 2013). Sometimes, bacteria called Propionibacterium acnes (P. acnes) that normally reside in the skin interact with the sebum trapped in a clogged follicle and lead to inflammation (Lee 2013; Rebello 1986; Weldon 1998). Inflamed acne lesions, which are more severe than non-inflamed lesions and are more likely to lead to scarring, can be classified as follows (Webster 2002; Mayo Clinic 2011a; Beylot 2013; Hsu 2011):
- Papules - small, raised bumps that are inflamed and may be red and tender.
- Pustules - small, inflamed, pus-filled bumps that may have a white tip.
- Nodules - solid, irregular or dome-shaped inflamed lesions beneath the skin.
- Cysts - sac-like lesions containing white blood cells, bacteria, and dead cells in a liquid or semi-liquid state.
- Cysts and nodules often appear in conjunction to form nodulocystic acne, a severe form of the condition which can be very painful and often results in severe inflammation and acne scars.
Acne in Adult Women
Millions of adult women suffer with acne. Oftentimes, dermatologists simply prescribe a conventional acne treatment to these women and fail to assess for an important potential underlying cause in this population – hormonal imbalance (Kamangar 2012; Dreno 2013; Kim, Michaels 2012).
Conditions such as polycystic ovary syndrome (PCOS), which causes abnormal ovarian growths, can contribute to adult female acne by driving up testosterone levels. For adult women with persistent acne, blood tests to assess hormone levels may help identify an underlying hormonal cause such as PCOS (Kamangar 2012; Dreno 2013).
Identifying a hormonal problem in a woman with acne is important because typical acne treatments may not be effective if the cause is a hormonal imbalance (Kim, Michaels 2012). Moreover, declining hormone levels may contribute to dry skin among aging women, which in turn may increase propensity for conventional topical acne treatments to cause skin irritation (Kamangar 2012; Dreno 2013; American Academy of Dermatology 2012). Women with acne who experience irregular menstrual periods or have unusually oily skin should especially consider a potential hormonal imbalance (American Academy of Dermatology 2012).
Oral contraceptives may relieve acne for some women, but may cause abnormal vaginal bleeding and can potentially increase risk for blood clots. Anti-androgen drugs such as spironolactone may also be coupled with oral contraceptives to treat acne in women, especially those with evidence of excess male hormone levels (American Academy of Dermatology 2012). Considerations such as a woman’s desire to become pregnant, personal or family history of breast cancer, and presence of concurrent skin conditions such as rosacea should be taken into account when determining if hormonal treatment is appropriate.