Dr. Richard Fried Helps Us Sort the Facts About Adult Acne

New Harbinger Publications: Is it true that the age of onset of acne is increasing?

Richard G. Fried: It depends on what age group we are talking about. Adolescent acne is seeing a younger age of onset: age eight or nine is no longer uncommon. Adult acne can be a continuation of adolescent acne or may have onset any time during adulthood. There is no time that we can say for sure that people are out of the woods in terms of being at risk. [See prevalence data below.]

NHP: What do you feel are the reasons that more and more adults are suffering from acne?

RGF: That’s probably related to the more varied and volatile hormone changes that accompany the adult physiology and lifestyle. Also, subtle early pre-menopausal changes in estrogen and testosterone may contribute.

I believe that women are subject to more stress than perhaps at any other time in history. There are more concrete demands and more mixed messages demanding personal and professional perfection. The price is often physical and emotional exhaustion and emotional stress. How is it possible for the skin to not respond badly as well?

NHP : What is the difference between ‘adult acne’ and ‘teen acne’?

RGF: They are basically the same, but clinically adult acne tends to be deeper, more cystic, more often found along the jawline and central face.

NHP : Are the causes of acne different for men and women?

RGF: The final basic “cause” is the same: abnormal response of the follicle lining cells to androgens. However, I think there are many more potential and identifiable causes in women, i.e. hormone medications, menses, pregnancy, personal care products like cosmetics, and so forth.  

NHP: Do you know of recent statistics on how common adult acne is among women? And can you offer a comment on how prevalent it is in your practice?  

RGF: There are two studies of note on this subject. In 1999 a study was published in the Journal of the American Academy of Dermatology finding an acne prevalence of 54 percent among women (Cunliffe). However, most of this was considered physiologic (meaning breakouts before the menses rather than persistent acne.) Twelve percent of women and 3 percent of men had so-called clinical acne (persistent and clinically obvious lesions). Eighty-two percent of those with clinical acne reported that their acne had persisted since adolescence. This was a community-based study looking at 749 people older than twenty-five years of age.

A more recent study (2001) appeared in the Journal of the European Academy of Dermatology and Venereology in which a representative sample of French women aged twenty-five to forty years were sent a validated, self administered questionnaire. Total acne prevalence was 41 percent, 17 percent of women surveyed had clinical acne and 24 percent had physiologic acne. The most common perceived triggers were menstrual periods and stress. Thirty-four percent reported that they did not have adolescent acne suggesting a substantial portion of this population had new onset adult acne. (Poli, et al)

NHP: Does whether or not a person had acne as an adolescent affect whether or not they have acne as an adult?

RGF: Absolutely not. We can't ever be sure when acne is over or when it will begin — it’s one of life's unpredictable occurrences. Zits or wrinkles: we thought it would be one or the other, and it could be both…doesn't that suck!

NHP: The FDA has recently placed restrictions on Accutane. What are your thoughts on the medication?

RGF: The medication is a godsend! It prevents physical and emotional scarring. Since it became available in 1982 it has literally saved thousands of people from the ravages of scarring acne. There is nothing else like it. If they were to withdraw it from the market, we would return to the decades where people could not be helped.

The real issue is that Vitamin A in Accutane is a teratogen that can cause birth defects if taken during the first trimester of pregnancy. It has no effect on resting unfertilized eggs, fertility, or the ability to make normal babies. You just can't take the medication during the first trimester. The safety as been documented in two generations of people.

The problem is that there are contraceptive failures and failures to use contraception! Thus, I agree with education and warnings about pregnancy. Note that birth defects can occur with many medications including tetracycline and many OTC meds.

NHP: Please explain the link between acne and depression in adults.

RGF: Acne can cause or worsen depression in many ways. The demands of caring for the disease and associated physical discomfort alone can be depressing. The affected person's self-image can be diminished or impaired by the images that are seen in the mirror each day. Others’ social responses to acne can also be devastating, leaving the affected person feeling stigmatized, including the limitation of work opportunities and successes as a result of acne. Finally, opportunities for intimacy can be reduced by acne leading to more depression.

NHP: What would you say to someone with acne who thinks, “You know, I’ve had this all my adult life and there’s nothing that will work?”

RGF: I would say that I fully understand their frustration and hesitancy to try “yet another treatment” that will let them down.

However, I also would tell them with emphatic certainty that there is no one whose acne we cannot get substantially better or clear. Time for a new chapter in their lives: one without adult acne!

NHP : Any suggestions for parents of older teens with acne?

RGF: Yes. We know acne stinks. Make sure your kids know that they are not doing anything wrong. It's not how you wash, what you eat, what you drink, or impure thoughts. The over-the-counter, television, and internet “miracle cures” are too good to be true. REALLY. You need real therapy that can clear your skin.