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Acne usually begins when the body starts to produce the hormones called androgens. When androgen production goes into high gear - about age 11 to 14 years - acne also goes into high gear. Androgens cause the sebaceous gland to enlarge, and this is normal. People who develop acne have sebaceous glands that are over-stimulated by androgens. Young women tend to have acne flare-ups that coincide with the hormonal changes associated with their menstrual cycle. These changes affect the sensitivity of their sebaceous glands to androgens.

Increased sebum production

After the sebaceous gland is stimulated by androgens, it produces more sebum. The oily sebum accumulate in the follicle, and travels up the hair shaft to the surface of the skin. As it travels up the hair shaft it also mixes with normal skin bacteria and dead skin cells that have been shed from the lining of the follicle.

The greater the sebum production, the greater the likelihood that the hair follicle will become clogged and result in comedowns.
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Changes inside the follicle

As androgen production increases and sebaceous glands enlarge, the inner lining of skin in the hair follicle also changes. Normally, dead cells inside the follicle shed gradually and get expelled onto the surface. However, during puberty these cells are shed more rapidly and tend to stick together. When they mix with sebum, they can clog the follicle--the cells and sebum form a plug in the follicle.

Bacteria

The clogged follicle becomes a breeding ground for bacteria. One type of bacteria specifically involved is Propionibacterium acnes or P. acnes for short. P. acnes ingests sebum and is a normal resident on skin even in people who don't have acne. However, when the sebaceous gland gets clogged, and sebum builds up inside the follicle, P. acnes multiplies rapidly. Chemicals produced by the bacteria can cause inflammation in the follicle and surrounding skin.

Can I be Genetically Predisposed to Acne?

While virtually everyone gets acne to some degree, some people are born with a predisposition to certain types of acne. There seem to be similarities in acne among family members regarding patterns of acne lesions, duration of acne, severity and so on. Acne occurs in all races, but there are ethnic variations that suggest genetic influences; Caucasian Americans, for instance, tend to be more affected than African Americans or people of Asian heritage. From a scientific standpoint, not much is known yet about the specific genetics involved in acne, but there seems to be a connection.

If a teenager's parents or older siblings have had severe acne, that teenager is likely to have severe acne, too. It is all the more critical for such teenagers to consider seeing a dermatologist before the acne becomes severe.

Can Cosmetics Give Me Acne?

Yes, comedones from certain cosmetics and toiletries may clog pores. Such products, which include makeup, foundations, night creams and moisturizers, are called comedogenic. People should look for "noncomedogenic" cosmetics and toiletries.

Cosmetic acne is usually minor and usually does not cause scarring. It: can be persistent, however, sometimes lasting for decades. Aggravating the problem, some young women try to cover up the pimples with even more makeup. Plus, normal teenage acne can occur at the same time.

Can the Environment Induce My Acne?

Yes. Acne may also be due to (or aggravated by) contact with a large variety of comedogenic substances. For example, the airborne grease in a fast food restaurant can be comedogenic, as can motor oil, which someone may be exposed to regularly at a job.

In fact, anything that can irritate acne-prone areas of the skin may make acne worse, including rubbing and friction from clothing, hair, sporting equipment and so on. Your dermatologist can best identify and treat these types of acne.

Why Do Adult Women Get Acne?

Hormonal Acne

Acne in females may be influenced by hormonal changes associated with menstruation, pregnancy, stress, ovarian disease or endocrine imbalance. Most of the hormonal changes are temporary. Sometimes they are caused by a condition that requires medical treatment. When a female has acne that (1) appears for the first time in adulthood or reappears in adulthood after clearing up earlier, (2) is unresponsive to acne treatments, (3) gets worse during pregnancy or menstruation, or (4) is associated with "masculine" patterns of hair growth or hair loss, darkening of skin in armpits or body folds, or central body obesity, she should be examined by a dermatologist. Indications of hormonal imbalance may require examination for adrenal, ovarian or pituitary abnormalities.

The hormones that have the most influence on acne are the androgens—so-called "male" hormones although they are present in both males and females. The androgens are a causative factor in acne because they have a stimulating effect on sebaceous follicles where acne lesions have their origin.

Androgens tend to be present in relatively large amounts during adolescence as the teenager matures. The androgenic influence on sebaceous follicles is substantial at this time—a reason that acne is often thought of as a "teenage condition." As the body matures and androgen levels stabilize in adulthood, acne clears in the majority of cases.

Adult women can be unpleasantly surprised when acne reappears in their 20s or 30s—or appears for the first time. While the acne is often mild to moderate, it may not respond to tried-and-true acne treatments that worked when the woman was a teenager. The cause of this adult acne is probably a hormonal change. The required treatment will be one that takes hormones into account. This type of treatment cannot be purchased over-the-counter at the pharmacy. It is a medical treatment prescribed by a dermatologist after appropriate medical examination.

Typical examples of hormonal acne in healthy adult women are:

  • Acne comes and goes during the menstrual cycle as hormonal balances go through many changes in the body.
  • Acne "flares" during pregnancy as the body’s hormonal balances shift to accommodate changing physiologic needs.
  • Acne may be associated with chronic emotional or physiologic stress. Stress may cause physiologic changes that affect hormone production.

Treatment of Hormonal Acne in the Healthy Female

Hormonal acne in a healthy female can be effectively treated by a dermatologist. An underlying disease of ovaries, adrenals or pituitary, or diabetes, should be treated by an appropriate specialist physician.

A variety of treatments are available for hormonal acne in the healthy female. The dermatologist selects the treatment best suited to the needs of the patient, based upon the patient’s medical history and examination. Treatment options include:

Oral contraceptive pills are estrogen-progestin combinations formulated to alter the female hormone pattern. Because of their effects in altering androgen production, low-dose oral contraceptives have been prescribed by dermatologists for many years in the treatment of hormonal acne. The Food and Drug Administration recently approved an oral contraceptive specifically for the treatment of mild to moderate hormonal acne. Oral contraceptives can be taken for extended periods of time to control hormonal acne if the woman has no plans to become pregnant. Side effects of low-dose oral contraceptives can include nausea, weight gain, menstrual spotting and breast tenderness.

Oral corticosteroids are anti-inflammatory drugs that belong to a class of drugs produced by the adrenal glands. When adrenal glands are overactive in producing androgens, oral corticosteroids such as prednisone and dexamethasone can be prescribed to suppress androgen production. Oral corticosteroids are also prescribed to suppress inflammation in severe acne. Side effects of oral corticosteroids can include weight gain and bone thinning.

Antiandrogens are a class of drugs that (1) reduce androgen production in ovaries and adrenal glands, and (2) block androgen reception by cells in sebaceous follicles. Reduction of excess androgen and reduction of androgen available in the sebaceous follicle are anti-acne effects. Antiandrogens used in the treatment of hormonal acne include spironolactone and, less commonly, flutamide. Side effects of irregular menstruation and breast tenderness may be eased by taking the drug together with an oral contraceptive.

References

AAD Press Release "Women and Acne: The Hormonal Connection (March 3, 2001)

Strauss JS et al. Diseases of the sebaceous glands. In: Freedberg IM et al (Eds.). Fitzpatrick’s Dermatology in General Medicine, 5th ed. New York: McGraw-hill; 1999:769-784.

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