Dr Anjali Mahto is a UK-trained consultant dermatologist who aims to bridge the gap between traditional medical dermatology, beauty, and cosmetic medicine. Her areas of specialist interest include acne and scarring, rosacea, moles, and anti-ageing therapies including injectable and laser treatments.

On February 28, 2018, Dr Mahto will take part in the IMCAS Academy webinar focusing on acne, Adult female acne - do we know why and how do we treat? She discussed this problem and its causes with the IMCAS Academy.

1. How much of a problem is adult acne?

Over the past decade we are noticing a documented increase in outpatient attendances for female adult acne. The exact cause of this is not entirely clear. In general terms, however, female adult acne sufferers can be divided into one of two groups. The first group consists of those with “persistent” acne. These are the people that suffered with acne as a teenager and this has persisted either intermittently or continuously into adult life i.e. they have never really “grown out” of the problem. The second group can be defined as the “late-onset” group. These individuals have no previous history of acne in their teenage years and it often develops for the first time around the age of 25. Late-onset acne has been reported to affect about 20% of women. This group seems to have higher treatment failure or relapse rates with conventional therapies.

2. Are there tests or underlying medical conditions that should be excluded?

Although raised androgen levels have a role to play in adult acne, most women do not have elevated hormone levels or clinical evidence of hyperandrogenism. This may be because the androgen abnormality is not a circulating problem but rather a localized problem in target tissue.

Acne as a result of an ovarian or adrenal tumour should be considered in the following scenarios:

- Persistent and/or treatment resistant acne

- Acne of sudden onset

- Signs of hyperandrogenism (androgenetic alopecia, seborrhoea, hirsutism, Cushingoid features, clitoromegaly, deepening of the voice, acanthosis nigricans)

The two most common medical conditions which can cause excess circulating androgen levels are polycystic ovarian syndrome (PCOS) and congenital adrenal hyperplasia (CAH). Checking hormonal profiles can be useful if these conditions are suspected in the luteal phase of menstrual cycle. Any oral contraceptives should be stopped at least one month prior to testing.

3. Does diet have a role to play in acne?

The diet and acne story is one that has caused much controversy over the decades. One of the main problems that exists is the lack of high quality scientific trials to prove a direct correlation between the two. There is some emerging evidence that foods with a high glycaemic load and to a lesser degree, dairy, may contribute to acne but the studies are largely observational and not of high enough scientific standards to make therapeutic recommendations. Acne should not be treated with diet alone, but reducing refined sugary foods can be useful from a general health point of view and may benefit a select group for their skin.

4. Should we be concerned about the use of oral antibiotics for treating acne?

The use of oral antibiotics should ideally be limited to a period of 3-4 months and they should never be used alone as monotherapy. There are concerns about bacterial resistance and topical therapy with benzoyl peroxide, retinoid, antibiotic or combination therapies should be prescribed at the same time as oral antibiotic treatment.

5. Does the skin microbiome have a role to play in acne?

Like the gut, the skin is also colonized by microbes living in symbiosis with us. Data shows differences between the skin microbiome on healthy skin versus acne-prone skin. The bacteria, P. acnes, has long been implicated as one of the factors in the development of acne. There is evidence to show that those with acne have different P. acnes strains compared to those without. The bacterial community in those with healthy skin were enriched with genes related to bacterial metabolism which are thought to be important in preventing harmful bacteria from colonizing the skin. Those with acne, however, had more diverse strains of P. acnes with enriched virulence associated factors. This is an emerging area of interest as it provides novel methods of treatment rather than unselectively killing all bacteria – both good and bad.

Register for the IMCAS Academy webinar now.