Adult acne

By Caelia Corse

We're sorry to break the news to you but it's a myth that acne ends in your teens

Bad skin can make you anxious, obsessive and prone to wearing a motorbike helmet in public.

At least you’re not alone – acne in adult women is on the rise, although the cause is not clear, admits Dr Jo-Ann See, a Sydney dermatologist and chair of All About Acne (AAA), a group of medical experts with expertise in acne management. It’s frustrating and it’s confidence shaking – but acne can be fixed.

“This is not something you have to have for months or years,” says Dr See.

On that note, we took the mature, adult approach and badgered the bejesus out of the country’s leading experts for the latest solutions, so you can go back to taking your complexion for granted. The way it should be

Let’s go back to basics. Knowing what causes pimples is key to understanding why they appear in the first place and why certain treatments work when others don’t.

Ready for the science bit? Hormones make the body’s sebaceous glands, which are attached to the hair follicles in our skin, produce more sebum (oil). This is why acne is common in teenagers going through puberty whose hormones are, scientifically speaking, going apeshit. This increased oil production, combined with an increase in the number of cells (dead skin) sitting around the exit of the pore, creates clogging.

Once those pores are clogged, imagine an army of bacteria marching across your face and setting up camp in them. These bacteria, called Propionibacterium acnes, are anaerobic – meaning they hate oxygen; so clogged pores are a prime environment for them to settle in, get all cosy and multiply. This bacteria orgy results in inflammation.

Translation? A big, fat, painfully throbbing zit that makes you wish Marc Jacobs would do a balaclava line.

Under the surface

If you’ve ditched a date due to acne, you’re not alone. Dermatological social anxiety is now being recognised by psychologists and has opened up a new field called psychodermatology – the impact of a skin disorder on a person’s quality of life, relationships and psychological health.

POINTING THE FINGER

You probably associate pimples with ugly silver braces, training bras and New Kids on the Block posters, but it’s a myth that acne ends in your teens. Especially for women.

A study by the University of Alabama, US, found that after the teenage years, women were more likely to report having acne than men, with higher rates of women affected in all age groups 20 years and older.

Genetic predisposition is a strong factor – one study showed 50 per cent of patients had a first-degree relative who also had post-adolescent acne. Not scarred by your parents – in this case?

Stress and lifestyle could be to blame. Research from the University of Pennsylvania, US, has found acne is quite common in hard-working professional women in their 20s, 30s and 40s. Adult responsibilities (a big-deal job, kids, marriage, mortgage – or all of the above) cause adrenal glands to produce more of the stress hormone cortisol, which is then broken down into male hormones that stimulate the oil glands.

Relationship stress also impacts your skin – a UK dermatologist reported to the British Journal of Dermatology that he was noticing a particular pattern of stress-related acne in female patients: 13 women whose neck and jaw-line pimples appeared between the ages of 26 and 29 all linked the spots to the break-up of a relationship. Interesting.

Annoyingly zen and still breaking out?

“Acne can occur at other times of hormonal change, including menstruation, pregnancy and menopause,” says Dr Megan Mathews, naturopathic GP and author of Radiant Health, Radiant Skin.

Period-related spots tend to pop up the week before Auntie Flo arrives, or the week before ovulation.

“Women who have polycystic ovaries can also experience a much higher rate of acne, because they have more male hormones circulating, which stimulates oil glands,” says Women's Health health expert and GP Dr Ginni Mansberg. “That’s the reason they get hairier as well.”

Related: Adult acne questions answered

The root cause of acne could lie in the consumption of a typically high-GI Western diet, according to a report published in the Archives of Dermatology, with processed foods that raise insulin levels named as the main zit-causing culprit.

For women, emotional eating can also be a breakout trigger, as typically high-GI foods (biscuits, cakes etc) are the comfort food of choice. In the past few years there has been a lot of interest in the link between diet and acne, says Dr See.

Here at home, researchers from RMIT University in Victoria enlisted 50 spotty teenage boys and assigned half to a diet high in processed foods, and the other half to a low GI diet. The acne of the boys on the higher protein, low-GI diet improved dramatically.

While dermatologists see diet research as controversial and claim more credible studies are needed, Dr See admits she now suggests some of her patients try low GI along with conventional treatments.

From the point of view of complementary medicine, diet is key in treating hormonal acne.

“It’s important to eat a nutrient-rich, low-GI diet, as this will help to balance the hormones,” says Dr Mathews. “Avoid sugars and denatured fats like junk food and takeaway foods.”

On her healthy skin menu?

“I’d recommend every day eating 60 per cent vegetables of all colours, 20 per cent complete protein (eggs, fish, poultry, yoghurt), 15 per cent complex carbohydrates (wholegrains) and 5 per cent uncooked, first pressed organic oil (try flaxseed oil).”

Where body weight is a definite issue for acne sufferers? Obesity, PCOS and metabolic syndrome all cause the body to overproduce certain hormones, which stimulate the oil glands. It’s also thought fat tissue plays a role in the overproduction of oil, so weight loss could help.

TOPICAL TREATMENT

From supermarket cleansers to prescription medications, there’s plenty you can do to stamp out those damned spots.

Keratolytics “The first step in acne treatment is minimising or reversing the clogging process,” says cosmetic physician Dr Mary Dingley.

Supermarket and chemist products, like Clearasil, are called keratolytics; which means they break apart the bonds between the top layer of skin cells so that they shed more quickly, having the effect of unclogging pores.

Alpha hydroxy acids or AHAs (like glycolic acid, found in many cosmeceutical products) are also keratolytics, and some OTC products may contain benzoyl peroxide, which has an antibacterial action, too.

Prescription treatments If keratolytics don’t do the job, it might be time to speak to your doctor about prescription treatments. You may need to be on these for three months before you see results.

Related: More on adult acne

Here’s a quick rundown of acne-beating medications

Retinoids Topical retinol is a vitamin A derivative which unclogs pores. “It does this to a much better extent than the hydroxy acids,” explains Dr Dingley. It also has a regulating effect on oil production. “But they shouldn’t be used if you’re pregnant,” she cautions.

Antibiotics Once you go beyond the blackheady/clogged stage of acne and you’re getting red, inflamed pimples this means the bacteria orgy has set in. Your GP may prescribe a topical antibiotic lotion, which is antibacterial and anti-inflammatory to help heal and soothe.

Combination products There are a number of dual action treatments available which combine topical retinoids with benzoyl peroxide, or antibiotics. Epiduo is one popular new prescription acne gel that combines benzoyl peroxide and adapalene, which is a vitamin A derivative. Ask your doctor if this or another product is right for you.

ORAL TREATMENTS

The pill The contraceptive pill may be prescribed by your GP to stabilise hormone levels if acne flares with your period. It can also help women who overproduce male hormones, like those with PCOS. If you have hormone-related symptoms, like an irregular cycle, your doctor can perform a blood test to check your hormone levels.

Oral antibiotics Your doctor might prescribe these to lessen inflammation, and fight bacteria. Often oral antibiotics will be prescribed with a topical treatment. Again, it can take up to three months to see results. And if not…

Oral retinoids (prescribed by a dermatologist) If after six months of trying the above you’re still doing your best impersonation of a pubescent teenager, it’s time to ask for a referral to a dermatologist who can prescribe an oral retinoid, which will suppress oil production. Suppress is the key word here – oral retinoids are not a cure. You might be familiar with one brand name: Roaccutane.

Why can’t you get it from your GP?

“It’s extremely toxic in pregnancy, so we don’t want a lot of it around in the community,” says Dr Mansberg.

So toxic, in fact, that your dermatologist will make you take a precautionary pregnancy test, and then advise two forms of contraception while you’re on it.

Scarily, it’s also been linked with depression and suicidal thoughts, but experts say this is rare. The most common side effect of this oil suppressant is severe dryness – eyes, mouth, downstairs – making natural lubrication during sex a non-event.

For all these reasons oral retinoids are not officially encouraged, but they are popular because, “They work,” says Dr Mansberg.

SMART SKIN CARE

Many of the acne treatments on the market, both topical and oral, cause skin dryness – this is because they’re designed to reduce oiliness and the build up of dead skin cells in the pores. This dryness can cause confusion when it comes to your skincare regime; but the experts all agree – you still need to cleanse and moisturise your skin twice a day.

What about toner? Save it for the photocopier. “Toners tend to dehydrate, so your skin is actually encouraged to produce more oil to combat that,” says Dr Dingley.

THE DEAL ON SCARRING

If severe acne is present for a very long time (three years or more) there’s a much higher probability of scarring, says dermatologist Dr Greg Goodman.

How does scarring occur? Inflammation and infection in the second layer of the skin (the dermis) is expelled by the body as a pimple. Normally this pimple heals uneventfully, but the healing process in people with severe acne is less effective, and their body tends to wall this inflammation off. This causes a cyst that sits underneath the skin and can squash any surrounding healthy tissue. When the cyst heals it can draw the skin into the space it created, which is why acne scars often end up looking like little dents.

Fractionated lasers, such as Fraxel, are now being used to treat scarring. It’s expensive though – it can cost anywhere between $3000 and $5000 – and treatment can take months, so prevention is the best way to go.

“It’s imperative that acne is treated aggressively and early to prevent scarring, and products like Roaccutane are a tremendous boost in preventing scarring when used early in severe cases,” advises Dr Goodman.

So take heart, dear spotties. Even if you are plagued with acne now, by following the expert advice in this article, you should be smooth skinned and free of zits (and helmets) before you can say “pizza face”.

HELP FOR ACNE SUFFERERS: To find a dermatologist near you go to Acne or Australasian College of Dermatologists