Adult Female Acne: Recent Advances in Pathophysiology and Therapeutic Approaches

Abstract

Adult acne is a chronic inflammatory disease of the pilosebaceous unit characterized by the excessive production of abnormal sebum favoring an imbalance of the skin microbiota and the hyperproliferation of Cutibacterium acnes and other virulent microbial strains, leading to an inflammatory environment, innate immunity overactivation, and keratinocyte hyperproliferation in hair follicles pores. Degraded keratinocytes plug the pores, consequently forming microcomedons, which can later evolve to papules, nodules, pustules and scars. Distinct from juvenile acne, in adult female acne (AFA) the symptomatology occurs or persists in postadolescence (after age 25). Although hyperandrogenism or the excessive sensitivity of androgen receptors are the main causes, AFA can be triggered by multiple factors, either including or not including androgen disturbances. The prevalence in adult women is 15–20%. Hyperandrogenism is present in 50% of cases; 70% of hyperandrogenism cases feature polycystic ovary syndrome (PCOS), a complex endocrine and metabolic condition. Genetic susceptibility occurs in 80% of acne cases, often with familial inheritance. Beyond classical stepwise therapeutic protocols (topical agents, isotretinoin, antibiotics, hormonal therapy with estrogens, progestins, spironolactone), novel approaches include the highly effective topical antiandrogen clascoterone, the management of insulin resistance by diet, exercise, stress avoidance, and adjuvant therapies such as berberine. Vaccines against the pathogenic proinflammatory C. acnes hyaluronidase A are in development.

Acne in Transmasculine Patients

“…This relationship suggests that factors besides exogenous testosterone (genetic, hormonal, or social) may play a role in the development of acne for transmasculine patients. Unlike in cisgender women, [50][51][52] there is not substantial evidence to show an association between serum testosterone level and acne in transmasculine patients. Results indicate that stabilization of testosterone levels leads to the stabilization of acne, and a larger net change in testosterone level may correspond to higher odds of acne.…”

Acne in Transmasculine Patients

“…This relationship suggests that factors besides exogenous testosterone (genetic, hormonal, or social) may play a role in the development of acne for transmasculine patients. Unlike in cisgender women, [50][51][52] there is not substantial evidence to show an association between serum testosterone level and acne in transmasculine patients. Results indicate that stabilization of testosterone levels leads to the stabilization of acne, and a larger net change in testosterone level may correspond to higher odds of acne.…”

Acne Vulgaris Associated with Metabolic Syndrome: A Three-Case Series Highlighting Pathophysiological Links and Therapeutic Challenges

“…Interventions such as metformin, statins, and structured lifestyle modifications played a crucial role in breaking this resistance, leading to notable improvement in lesion counts and treatment tolerance. Supporting this, cohort studies found that patients with IR had a significantly lower response rate to antibiotics alone, whereas metabolic correction enhanced therapeutic efficacy [ 32 , 33 ].…”

The Epidemiology of Acne in the Current Era: Trends and Clinical Implications

“…The human skin microbiome consists of the community of microorganisms colonizing the tegument, and it is composed of bacteria, fungi, viruses, and mites [45,46]. Bacteria of the commensal flora structure commonly colonize the tegument, digestive tract, upper respiratory tract, and genital organs, and they play an important role in protecting the body from the pathogens with which they come into contact [45].…”

“…The human skin microbiome consists of the community of microorganisms colonizing the tegument, and it is composed of bacteria, fungi, viruses, and mites [45,46]. Bacteria of the commensal flora structure commonly colonize the tegument, digestive tract, upper respiratory tract, and genital organs, and they play an important role in protecting the body from the pathogens with which they come into contact [45]. The microenvironment of the tegument is grouped into three main categories, which are directly related to the number of sweat and sebaceous glands in the area; therefore, we distinguish the following:“Seborrheic” areas (forehead, scalp, chest, back);“Wet” areas (armpit, cubital fossa, groin, inguinal fold, popliteal fossa, umbilicus (navel), buttock fold, soles, inner finger spaces);“Dry” areas (upper and lower limbs, except folds) [47,48].…”

Acne in Transmasculine Patients

“…This relationship suggests that factors besides exogenous testosterone (genetic, hormonal, or social) may play a role in the development of acne for transmasculine patients. Unlike in cisgender women, [50][51][52] there is not substantial evidence to show an association between serum testosterone level and acne in transmasculine patients. Results indicate that stabilization of testosterone levels leads to the stabilization of acne, and a larger net change in testosterone level may correspond to higher odds of acne.…”

Acne Vulgaris Associated with Metabolic Syndrome: A Three-Case Series Highlighting Pathophysiological Links and Therapeutic Challenges

“…Interventions such as metformin, statins, and structured lifestyle modifications played a crucial role in breaking this resistance, leading to notable improvement in lesion counts and treatment tolerance. Supporting this, cohort studies found that patients with IR had a significantly lower response rate to antibiotics alone, whereas metabolic correction enhanced therapeutic efficacy [ 32 , 33 ].…”

The Epidemiology of Acne in the Current Era: Trends and Clinical Implications

“…The human skin microbiome consists of the community of microorganisms colonizing the tegument, and it is composed of bacteria, fungi, viruses, and mites [45,46]. Bacteria of the commensal flora structure commonly colonize the tegument, digestive tract, upper respiratory tract, and genital organs, and they play an important role in protecting the body from the pathogens with which they come into contact [45].…”

“…The human skin microbiome consists of the community of microorganisms colonizing the tegument, and it is composed of bacteria, fungi, viruses, and mites [45,46]. Bacteria of the commensal flora structure commonly colonize the tegument, digestive tract, upper respiratory tract, and genital organs, and they play an important role in protecting the body from the pathogens with which they come into contact [45]. The microenvironment of the tegument is grouped into three main categories, which are directly related to the number of sweat and sebaceous glands in the area; therefore, we distinguish the following:“Seborrheic” areas (forehead, scalp, chest, back);“Wet” areas (armpit, cubital fossa, groin, inguinal fold, popliteal fossa, umbilicus (navel), buttock fold, soles, inner finger spaces);“Dry” areas (upper and lower limbs, except folds) [47,48].…”

Acne in Transmasculine Patients

“…This relationship suggests that factors besides exogenous testosterone (genetic, hormonal, or social) may play a role in the development of acne for transmasculine patients. Unlike in cisgender women, [50][51][52] there is not substantial evidence to show an association between serum testosterone level and acne in transmasculine patients. Results indicate that stabilization of testosterone levels leads to the stabilization of acne, and a larger net change in testosterone level may correspond to higher odds of acne.…”

Acne Vulgaris Associated with Metabolic Syndrome: A Three-Case Series Highlighting Pathophysiological Links and Therapeutic Challenges

“…Interventions such as metformin, statins, and structured lifestyle modifications played a crucial role in breaking this resistance, leading to notable improvement in lesion counts and treatment tolerance. Supporting this, cohort studies found that patients with IR had a significantly lower response rate to antibiotics alone, whereas metabolic correction enhanced therapeutic efficacy [ 32 , 33 ].…”

The Epidemiology of Acne in the Current Era: Trends and Clinical Implications

“…The human skin microbiome consists of the community of microorganisms colonizing the tegument, and it is composed of bacteria, fungi, viruses, and mites [45,46]. Bacteria of the commensal flora structure commonly colonize the tegument, digestive tract, upper respiratory tract, and genital organs, and they play an important role in protecting the body from the pathogens with which they come into contact [45].…”

“…The human skin microbiome consists of the community of microorganisms colonizing the tegument, and it is composed of bacteria, fungi, viruses, and mites [45,46]. Bacteria of the commensal flora structure commonly colonize the tegument, digestive tract, upper respiratory tract, and genital organs, and they play an important role in protecting the body from the pathogens with which they come into contact [45]. The microenvironment of the tegument is grouped into three main categories, which are directly related to the number of sweat and sebaceous glands in the area; therefore, we distinguish the following:“Seborrheic” areas (forehead, scalp, chest, back);“Wet” areas (armpit, cubital fossa, groin, inguinal fold, popliteal fossa, umbilicus (navel), buttock fold, soles, inner finger spaces);“Dry” areas (upper and lower limbs, except folds) [47,48].…”