|Year : 2021 | Volume
| Issue : 1 | Page : 71-77
A clinicoepidemiological study of adult acne among females: Is it surpassing the adolescent acne?
Harish Muddanahalli Rajegowda, BS Suman, Shashi Kumar Basavapura Madegowda, Deepadarshan Kalegowda, Bhagya Shree Shettar Rajendra
Department of Dermatology, Mandya Institute of Medical Sciences, Mandya, Karnataka, India
|Date of Submission||25-Feb-2020|
|Date of Decision||23-Nov-2020|
|Date of Acceptance||19-Dec-2020|
|Date of Web Publication||19-Feb-2021|
Shashi Kumar Basavapura Madegowda
Department of Dermatology, Mandya Institute of Medical Sciences, Nehrunagar, Mandya - 571 401, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Acne is usually recognized as an adolescent skin disorder, but recently prevalence among adults is increasing. There are not many studies on adult acne in Indian population. Objectives: To study the various clinico-epidemiological factors and assess laboratory investigations for underlying hormonal imbalance in patients with adult acne. Objectives: To study the impact of adult acne on psychological stress and patients quality of life. Materials and Methods: In our prospective observational study, female patients over the age of 25 years presenting with acne in a tertiary care hospital were included. All patients were assessed for hormonal imbalances both clinically and with laboratory investigations. Patients were asked to fill questionnaires to assess stress and impairment in quality of life. Statistical analysis used: Descriptive statistics like percentage ,mean, range were used. Inferential statistics like chi square test was used. The statistical significance was evaluated at 95% confidence level (P<0.05). Results: Out of 150 female patients included in the study, the mean age of the patients was 30.19 years. Persistent acne was observed in 77.3%, while it was late onset in 22.7%, with inflammatory acne (76%) being most common. Most patients showed clinical signs of hyperandrogenism but raised total testosterone levels was seen in only 1.3%. Scarring was observed in a majority of patients (76%), and psychological stress in 46.7% patients. Conclusions: Adult acne is predominant in women which can be of late onset or persistent type, is usually inflammatory with predominant distribution involving cheeks, mandible and chin as compared to adolescent acne. Psychological stress assessment and dermatological quality of life index helps in assessing the severity and providing appropriate treatment.
Keywords: Adult acne, Homeostatic Model Assessment of Insulin Resistance, lateonset acne, persistent acne, stress.
|How to cite this article:|
Rajegowda HM, Suman B S, Basavapura Madegowda SK, Kalegowda D, Shettar Rajendra BS. A clinicoepidemiological study of adult acne among females: Is it surpassing the adolescent acne?. Clin Dermatol Rev 2021;5:71-7
|How to cite this URL:|
Rajegowda HM, Suman B S, Basavapura Madegowda SK, Kalegowda D, Shettar Rajendra BS. A clinicoepidemiological study of adult acne among females: Is it surpassing the adolescent acne?. Clin Dermatol Rev [serial online] 2021 [cited 2021 Jun 13];5:71-7. Available from: https://www.cdriadvlkn.org/text.asp?2021/5/1/71/309772
| Introduction|| |
Acne vulgaris is a chronic inflammatory disorder of the pilosebaceous unit, caused due to increased sebum, abnormal follicular differentiation, microbial hypercolonization of the follicular infundibulum, and increased inflammation. These various etiological factors include genetic predisposition, stress, smoking, cosmetics, hormone imbalance, dietary factors, and drugs.
Although primarily a disorder of adolescence, the prevalence of adult acne is increasing. “Adult acne” defined as the presence of acne beyond the age of 25 years, is of two distinct types – persistent acne where adolescent acne persists and late-onset adult acne developing for the first time after 25 years. The main complications include psychological and physical scarring. Adult acne has a 40% prevalence of psychiatric comorbidities.
The present study was conducted to observe the prevalence, clinical features, type of acne, various etiological factors, hormonal imbalance, insulin resistance, and to see if there is any correlation with adult acne.
To assess the impact of adult acne on psychological stress and patient's quality of life (QOL).
| Materials and Methods|| |
- Study design: This was a prospective observational study.
The study was conducted over a period of 3 months from November 2019 to January 2020, in the Outpatient Department of the Department of Dermatology, Mandya Institute of Medical Sciences, after obtaining ethical clearance. A total of 18,000 patients had visited the outpatient department during the study period. Among them, 150 female patients above 25 years of age with acne, fulfilling the inclusion and exclusion criteria were included in the study.
- Inclusion criteria: Female patients above the age of 25 years with acne of all grades were included in the study
- Exclusion criteria: Patients who are immunocompromised, pregnant, lactating, and on oral contraceptive pills were excluded from the study.
A detailed history about age, sex, occupation, location, age of onset of lesions, distribution, duration of lesions, presence of acne during puberty and severity of the lesions, menstrual and obstetric history (including history of infertility), and family history was taken. History of other aggravating factors such as stress, sun exposure, cosmetics, drugs, seasonal variations, and premenstrual flare was noted. A thorough clinical examination was done to determine the type of lesions, distribution, and severity of lesions. Types of scars were also noted. The patient's height and weight were recorded for the purpose of body mass index calculation.
Acne vulgaris was graded using a simple grading system:
- Grade I: Comedones, occasional papules
- Grade II: Papules, comedones, few pustules
- Grade III: Predominant pustules, nodules, abscesses
- Grade IV: Mainly cysts, abscesses, widespread scarring.
Associated conditions indicating hormonal imbalance such as features suggesting hyperandrogenism such as hirsutism, alopecia, acanthosis nigricans, obesity, and seborrhea, were also noted. Investigations such as serum total testosterone, fasting insulin, prolactin, follicular-stimulating hormone (FSH), luteinizing hormone (LH), fasting blood sugar, fasting lipid profile, and ultrasound of the abdomen and pelvis were done. The polycystic ovarian disease was detected on ultrasonography of the abdomen and pelvis using established Rotterdam criteria.
Insulin resistance was assessed using the Homeostatic Model Assessment of Insulin Resistance (HOMA-IR) which was calculated using the formula: fasting insulin (μU/L) × fasting glucose (nmol/L)/22.5. The patients were classified on the basis of HOMA-IR readings as, normal (<2), borderline (2–2.2), moderate (2.2–3), and severe (>3). Stress was evaluated through the Perceived Stress Scale (PSS) using the validated English questionnaire, which was answered by the patient.
Dermatology Life Quality Index (DLQI) of every patient was assessed using a validated English questionnaire, filled by the patient. The scoring of each question was as follows:
- Very much - 3
- A lot - 2
- A little - 1
- Not at all or not relevant - 0
DQLI is calculated by summing the score of each question to obtain a total score, which ranges from 0 to 30. The higher the score, the more is the impairment in QOL. It is interpreted as below:
- 0–1: No effect at all on patient's life
- 2–5: Small effect on patient's life
- 6–10: Moderate effect on patient's life
- 11–20: Very large effect on patient's life
- 21–30: Extremely large effect on patient's life.
Data were entered into Microsoft Excel sheet and analyzed using IBM Corp. Released 2016. IBM SPSS statistics for Windows, Version 24.0. Armonk, NY: IBM Corp., trial version. Descriptive statistics such as percentage, mean, and range were used. Inferential statistics like the Chi-square test were used. The statistical significance was evaluated at 95% confidence level (P < 0.05).
| Results|| |
The study included 150 female adult acne patients. The prevalence of adult acne in females was found to be 0.83% (150 patients out of 18,000 patients attending the OPD during the study duration). The age of the patients ranges from 26 to 45 years, with a mean age of 30.19 years. Majority of the patients are aged between 26 and 30 years (65.3%). The proportion of the population of different age groups and the type of acne is detailed in [Table 1]. Among each group, persistent type of acne was most common except in the age group of 41–45 years, where the late-onset acne is the most common type. The total duration of acne varied from minimum of 2 weeks to maximum of 16 years. Most of the patients were housewives by occupation (50.66%).
|Table 1: Distribution of prevalence among the age groups in study subjects|
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Inflammatory lesions and noninflammatory lesions were seen in 76% (114 patients) and 24% (36 patients) patients, respectively. Majority of the patients were having acne Grade 2 accounting to 46.6% with the face being involved in all the patients, followed by trunk involvement in 18.6%. On the face, the cheek was the most common site involved (62.6%), followed by the chin (58.6%), mandibular area (58.6%), and forehead (25.3%).
Regular use of cosmetics was present in 84 (56%) patients, with aggravation due to cosmetics in 52 (61.9%) patients. Exposure to sunlight was also responsible for aggravation in 76 patients (50.7%). Seasonal variation was observed in 62 patients (41.3%), of which 44 patients (71%) noticed exacerbation in summer, while 18 patients (29%) noticed an increase of acne in winter. The rest 88 patients (58.7%) had no seasonal variation. The premenstrual flare was seen in 112 (74.7%) patients.
History of drug usage was present in 40 patients (26.7%). A total of 14 patients (35%) gave a history of systemic intake, while 26 patients (65%) gave a history of topical application. The topical steroid was found to be the most commonly used drug in our study (65%). Other systemic drugs used were antipsychotic agents in 8 patients (20%), antithyroid drugs in 4 (10%) patients, and oral steroids in 2 patients (5%).
History of acne during puberty was found in 116 patients (77.3%). Family history of acne was present in 48 patients (32%). Most patients showed signs of hyperandrogenism such as seborrhea in 106 patients (70.6%), hirsutism in 46 patients (36%), acanthosis nigricans in 32 patients (21.3%), and alopecia in 24 patients (16%). Only 6.6% (10 out of 150) of patients showed no such signs.
Obesity was prevalent among 24 out of 150 of the patients (16%), while 58 patients (38.7%) were overweight [Figure 1].
|Figure 1: Bar diagram demonstrating the relation between body mass index and type of adult acne|
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Laboratory evidence of hyperandrogenism in the form of raised testosterone levels was seen in 18 out of 150 patients (12%). Serum prolactin was not deranged in any patient. Increased LH:FSH ratio (>2:1) was seen in 44 (29.3%) patients, which is statistically significant [Figure 2]. Twelve patients (8%) had raised levels of insulin, indicating insulin resistance. Laboratory evidence of hyperandrogenism and insulin resistance among different grades of acne is depicted in [Table 2].
|Figure 2: Bar diagram demonstrating grade of acne in relation to the type of adult acne|
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We also observed some of the differences between persistent and late-onset acne, which are depicted in [Table 3]. Among the following parameters studied, statistically significant differences were observed with respect to body mass index (BMI) and HOMA-IR values [Figure 3].
|Table 3: Comparison between persistent and late-onset acne with various laboratory parameters|
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|Figure 3: Bar diagram demonstrating the relation of Homeostatic Model Assessment of Insulin Resistance values to the type of adult acne|
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Complications of acne studied included scarring and psychosocial stress. Postinflammatory hyperpigmentation following healing was seen in 80 patients (53.3%). Acne scarring was found in 42 patients (28%). These included rolling scars in 28 patients (18.6%), ice pick scars in 8 patients (0.05%), and box scars in 6 patients (0.04%). Psychological stress due to acne was reported in 56 (37.3%) patients.
Psychological stress was observed in 70 patients (46.7%). The box-whisker plot showing the correlation between stress and grades of acne is depicted in [Figure 4].
|Figure 4: A box-whisker plot demonstrating the correlation of stress with grade of acne|
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According to DLQI scores, acne showed no effect in 6.7% of patients, small effect in 26.7% of patients, moderate effect in 30.7% of patients, and very large effect in 36% of patients. The relationship between DLQI and grades of acne is depicted in [Figure 5].
|Figure 5: A box-whisker plot correlating Dermatology Life Quality Index with the grade of acne|
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| Discussion|| |
Acne vulgaris is a skin disorder which primarily affects adolescents. The peak age of incidence in males is considered as 16–19 years, while in females, it is 14–17 years. However, the prevalence of acne in patients above 25 years is increasing and has become a growing concern. Despite the increasing prevalence, there are very few studies or reports on post adult acne, making it a challenge to treat. Many studies reported that adult acne is more common in females. Furthermore, several predisposing features, such as hormones, increased use of cosmetics, and exposure to hot and humid conditions during cooking are present in females. Hence, we recruited only female patients in our study.
We observed that adult acne accounts to 0.83% of cases presenting to the dermatology outpatient department. This is comparable to Khunger and Kumar who reported a prevalence of 0.38% in their study. The age of the patients was found to be in a range of 26–45 years with a mean age of 30.19 years. Majority of the patients are aged between 26 and 30 years (65.3%). There were no cases of adult acne reported during the study period beyond the age of 45. This is similar to Khunger and Kumar, but they observed that 2.1% of patients, who presented with acne, were above the age of 45 years. The duration of acne ranged from minimum of 2 weeks to 16 years in the patients observed in our study, but some studies showed duration as long as 30 years.
Adult acne can be classified as persistent acne and late-onset adult acne. In our study, we found that the persistence of adolescent acne was found in majority of patients (77.3%) than late-onset acne (22.7%). This is in concordance with the observations made by Khunger and Kumar Swathi and Kusagur and Abrol and Sharma who reported 73.2%, 70%, and 82.7% of persistent acne, in their studies, respectively.
Overall, inflammatory lesions and noninflammatory lesions were seen in 76% and 24% of patients, respectively. Similar proportions were obtained in late-onset and persistent type individually. Although there were differences in terms of distribution, grade, and onset of acne, no differences with respect to inflammation among both the types of adult acne were found. These findings are similar to the study conducted by Khunger and Kumar.
Majority of patients had Grade II acne accounting for 46.6%, followed by Grade I (26.6%), Grade III (21.3%), and Grade IV acne for 0.05%. These results were comparable to Goulden et al., but Grade I acne was found to be very rare in their study. These findings correlate with the fact that inflammatory lesions were more common.
The face was involved in all the patients, but truncal involvement was seen in 18.6% of patients. This might be due to fact that lesions on the face are cosmetically more distressing and patients seek treatment early. On the face, the cheek was the most common site involved (62.6%), followed by the chin and mandibular area (58.6%) and forehead (25.3%). Khunger and Kumar and Swathi et al. observed similar findings in their study. This was in contrast Goulden et al., and Poli et al., who reported that the lower face is the most common site on the face, in adult acne. This might be due to the racial differences.
Etiopathogenesis of adult acne is very complex and several factors have been postulated to cause it. Many studies have stressed on the importance of hormonal imbalance in pathogenesis, whereas some have reported that hormones have a minor role and other factors such as stress, cosmetics, drugs, or topical preparations to be significant.
Hyperandrogenism is postulated as one of the etiological factors of acne. Signs of hyperandrogenism were observed clinically, and certain laboratory investigations such as serum testosterone, FSH, LH, prolactin, and ultrasound of the abdomen were done to evaluate the same. We observed such signs in many patients. The most common finding was seborrhea, which was seen in 70.6% of patients, followed by hirsutism in 30.6%, acanthosis nigricans in 21.3%, and alopecia in 16% of patients suggesting a hormonal influence both in persistent and late-onset acne. Only 6.6% of patients showed no such signs. Goulden et al. reported that 37% of women had at least one feature of hyperandrogenism as hirsutism (24.2%), alopecia (7.2%), or menstrual disturbance (17.7%) which were comparable to our study, thus suggesting a role of hormonal imbalance in the pathogenesis of adult acne.
Menstrual disturbances were seen in 6% of patients. The premenstrual flare was observed in 74.7% of patients. In a study conducted by Swathi and Kusagur et al., Stoll et al., and Goulden et al., premenstrual flare was observed in 46%, 44%, and 37% of patients, respectively.
Laboratory evidence of hyperandrogenism in the form of raised total testosterone levels was seen in only 18 out of 150 patients (1.3%). The raised LH/FSH ratio is an important finding, which is considered consistent with the pathophysiology of the polycystic ovary. The ratio of LH:FSH was >2:1 in 44 (29.3%) patients, favoring polycystic ovarian syndrome. Ultrasonography report of 58 patients (38.7%) had features of the polycystic ovarian disease (PCOD). These findings are in contrast to a study by Khunger and Kumar where only 2 out of 230 patients had increased LH:FSH ratio and 2 out of 230 female patients showed features of PCOD on ultrasonography, suggesting a stronger role of hyperandrogenism in the pathogenesis of adult acne in our study. It is surprising to see that majority of who had no clinical features suggestive of hyperandrogenism showed polycystic ovaries on ultrasonography suggesting the importance of routine screening in patients with adult acne.
Obesity and insulin resistance also are known to play important role in the pathogenesis of adult acne. In our study, we observed that 16% of the patients were obese, and 12 (8%) had raised the level of insulin, compared to a study by Abrol and Sharma where 37.8% of patients had obesity. Among 150 patients, HOMA-IR values showed severe resistance in 30.7% (46) of patients, moderate resistance in 10.7% (16), and borderline resistance in 6.7% (10), and the rest 52% (78) of patients had no insulin resistance. The study by Balta et al. showed no correlation between the postadolescent acne and HOMA-IR values. This suggests the importance of insulin resistance and its relation with PCOD in patients with adult acne.
Steroids have been implicated in the causation of acne by inducing hypercornification of the upper portion of pilosebaceous unit. In our study, the most commonly used drugs were observed to be steroids (28 patients), followed by antipsychotics (8 patients), and antithyroid drugs (4 patients). 14 patients gave a history of systemic intake, while 26 patients (17.3%) gave a history of topical application which was similar in a study by Khunger and Kumar (11.8%).
Cosmetics contain several components such as petrolatum, lanolin, and vegetable oils, which are responsible for the causation of acne. In our study, we found that 56% (84 of 150) of patients had a history of use of cosmetics. Among them, 52 (62%) patients gave a history of aggravation of acne due to cosmetics which warrants an in-depth study to identify the comedogenicity of the products used or patch testing to identify the causative ingredients.
No seasonal variation was noticed in 58.7% of patients and among the 41.3% patients who noticed a seasonal exacerbation, majority noticed it in summer (71%). Exposure to sunlight was also responsible for aggravation in 76 patients (50.7%). These findings are comparable to Khunger and Kumar and Sardana et al., who also reported aggravation of acne in summer. Increased squalene peroxidase, humidity, and excessive sweating during summer are attributed to cause this flare. This disproves the traditional belief that acne is aggravated during winter.
In our study, family history of acne was present in 32% of patients. These findings are consistent with Khunger and Kumar and Goulden et al., who also reported similar observations in their study with family history positive in 38.8% and 50%, respectively.
Complications of adult acne include both facial scarring and psychosocial stress. Scarring is more common in adult acne than adolescent acne. The reasons for scarring in adult acne are that the lesions are predominantly inflammatory, delayed presentation to treatment, and resistant to treatment. Scarring was observed in 114 patients (76%) with majority of the scars being persistent pigmented macular scars (53.3%), followed by rolling (18.6%), icepick (0.05%), and box scars (0.04%) type. Our results were comparable to the study done by Khunger and Kumar who also observed scarring in 76.4% of the patients. Facial scarring is more common which emphasizes the importance of adequate therapy.
Psychological stress due to acne was reported in 56 (37.3%) patients. There are not many studies where the relation between stress and acne has been studied. Many mechanisms have been proposed such as the role of hypothalamic–pituitary–adrenal axis and substance P production by sebaceous glands. Hence, behavioral intervention along with management of acne would be beneficial. In our study, an association with stress-induced exacerbation of acne was seen in 46.7% (70) of patients, which was intermediate with respect to studies by Khunger and Kumar where 25.7% of patients showed an exacerbation with stress and Goulden et al., where 71% patients showed an exacerbation.,
Psychological impairment in acne is considerable and is comparable with certain chronic diseases such as asthma, epilepsy, diabetes, and arthritis. Patients with acne are prone to low self-esteem, low self-confidence, and social dysfunction leading to various psychiatric symptoms including anxiety, depression, obsessive-compulsiveness, and sometimes suicidal ideation. Hence, increased awareness and early intervention for the psychological and psychiatric sequelae of acne can be beneficial to patients.
According to DLQI scores, acne showed no effect in 6.7% of patients, small effect in 26.7% of patients, moderate effect in 30.7% of patients, and very large effect in 36% of patients.
Our study had patients with Grade II acne being the most common (46.6%) and scarring in 76% of patients, which was comparable to the study done by Hazarika and Rajaprabha where 73% of patients had scarring and Grade II acne in 67.5% patients. We also observed that facial acne was the most common and can cause a major impact on QOL since facial acne and scarring is more cosmetically distressing compared to acne at other sites.
The differences between persistent and late-onset acne with respect to clinical features and laboratory parameters have been studied in detail which shows the significant difference with respect to BMI and HOMA-IR values indicating hormonal influence in pathogenesis of adult acne. Objective assessment of stress and QOL using standardized questionnaires was done, but there was no significant difference with respect to either type of adult acne or the grade of acne indicating that the impairment was subjective and hence requires individual assessment which helps in proper treatment.
Male patients with adult acne were not included in our study.
The duration of the study could be longer with the assessment of treatment response. Transvaginal ultrasound was not used in our patients. Quality check of cosmetics should be vigilant in order to avoid side effects since majority of patients (61.9%) in our study gave a history of exacerbation following regular use of cosmetics.
| Conclusion|| |
Adult acne is predominant in women, is usually inflammatory with the predominant distribution involving the cheeks, mandible, and chin as compared to adolescent acne. Facial scarring occurs in a majority and associated stress is common. Even patients with no clinical symptoms and signs of hyperandrogenism may have deranged laboratory parameters warranting a thorough screening of all patients with adult acne to reduce the sequelae. Psychological stress assessment and dermatological QOL index done at the first visit help in assessing the severity and providing appropriate treatment to all patients.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3]