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Case Report. A Case Report of Adult Acne


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Acne vulgaris is among the commonest inflammatory skin diseases affecting pilosebaceous units. It occurs mainly in puberty and affects adolescents at the age of 14-19 years both females and males, in relation to sebum production of hair follicles under the action of sex hormones. Clinically the disease is presented with comedones, papules, pustules, nodules and scars in some cases. Seborrheic areas face, chest and back are affected. Recent epidemiologic studies have shown significant number of female patients aged over 25 years with acne and the term Adult onset acne (AOA)was established.The latter is manifested clinically in the lower third of the face. Primary etiological cause of AOAisahormonal imbalance, mainly hyperandrogenemia. Acase ofa25-year-old woman with adult acne and elevated levels of testosterone and prolactine is presented in this paper.
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J Biomed Clin Res Volume 9 Number 2, 2016
Ivelina A. Yordanova,
Desislava D. Tsvetanova,
Diana D. Strateva ,
Pavlina D. Yordanova-Laleva ,
Dimitar K. Gospodinov
Department of Dermatology,
Venereology and Allergology,
Faculty of Medicine,
Medical University Pleven,
1Department of Obstetrics and
Faculty of Medicine,
Medical University Pleven,
2Medical Diagnostic Clinical
University Hospital Dr. G. Stranski”
Corresponding Author:
Ivelina A. Yordanova
Department of Dermatology, Venereology
and Allergology,
Faculty of Medicine,
Medical University Pleven
1, St. Kliment Ohridski Str.
Pleven, 5800
Received: July 27, 2016
Revision received: October 31, 2016
Accepted: December 20, 2016
Acne vulgaris is among the commonest inflammatory
skin diseases affecting pilosebaceous units. It occurs
mainly in puberty and affects adolescents at the age of 14-
19 years both females and males, in relation to sebum
production of hair follicles under the action of sex
hormones. Clinically the disease is presented with
comedones, papules, pustules, nodules and scars in some
cases. Seborrheic areas face, chest and back are affected.
Recent epidemiologic studies have shown significant
number of female patients aged over 25 years with acne
and the term Adult onset acne (AOA) was established. The
latter is manifested clinically in the lower third of the face.
Primary etiological cause of AOA is a hormonal
imbalance, mainly hyperandrogenemia. A case of a 25-
year-old woman with adult acne and elevated levels of
testosterone and prolactine is presented in this paper.
Key words: acne vulgaris, adult onset acne,
Case Report
Acne vulga ris is among the c ommon est
inflammatory skin diseases affecting pilosebaceous
units. It occurs mainly in puberty and affects
adolescents at the age of 14-19 years both females
and males, in relation to sebum production of hair
follicles under the action of sex hormones. Clinically
the disease is presented with comedones, papules,
pustules, nodules and scars in some cases.
Seborrheic areas, face, chest and back are affected [1,
2]. Pathogenesis of the disease consists of microbial
coloniz ation of pilos eb aceou s u nits wi th
Propionibacterium acnes, hyperkeratinization and
obstruction of sebaceous follicles as a result of
abnormal keratinization of the infundibullar
epi the liu m an d su bse que nt p erifollicul ar
inflammation . One of the most important
pathogenetic factors is the androgenic stimulation of
sebaceous glands [3]. Significant number of female
patients aged over 25 years with acne has shown in
the recent epidemiologic studies [4-6]. The term
Adult onset acne was established by Kaur et al. in
2006 [4].
Yordanova I, et al. A case report of adult acne
Case Presentation
We present a 25-year-old woman who has been
suffering from acne vulgaris since she was
fifteen. She complained from painful acneiform
eruptions, affecting mainly the lower third of her
face. From medical history there were no data
about disturbances in her menstruation, she had
regular cycles. The age of menarche was 11 years
and the patient had no pregnancies. She had
negative family history for acne vulgaris. The
patient reported improvement of the cutaneous
lesions from sun exposure in summer. One year
ago she had visited another dermatologist and
was treated with topical antibiotics and
sunscreens without significant effect. At the time,
a gynecological examination revealed hormonal
abnormalities and a six-month therapy with
Car beg oli ne 0 .5 mg/ dai ly was g ive n.
Nevertheless, the disease was found resistant to
the therapy.
Physical examination did not reveal any
abnormalities. The body mass index (BMI) was
19.1. Dermatological examination showed
pathological skin lesions affecting the lower third
of the face, cheeks and chin, and the back. They
were presented mainly by painful papules, some
pustules and a few comedones (Figures 1, 2).
According to Global Acne Grading System
(GAGS) the global score was 22 which is a
presentation for moderate acne. Laboratory
e x a min a t i ons s how e d r e s u lts f r om
hematological, biochemistry and urine analysis
within normal ranges. Hormonal results were
without deviations except for elevated levels of
total testosterone (0.81 ng/ml) and prolactin
(47.16 ng/ml). Dehydroepiandrosterone Sulfate
( D H E A -S) a n d l u t e i n i z i n g h o r m o n e
(LH)/follicle-stimulating hormone (FSH) ratio
were in normal ranges. Thyroid-stimulating
hormone (TSH), Thyroglobulin antibodies
(TAT), Thyroid microsomal antibodies (MAT),
triiodothyronine (T3) and thyroxine (T4) were in
normal ranges too. There were no abnormalities
in the index of ins ul in res istan ce. A
microbiological examination of pustules showed
a sterile culture. After consultation with a
gynecologist no data of polycystic ovary
syndrome were found. On the basis of the data
from the medical history, clinical and laboratory
examinations, the patient was diagnosed with a
moderate Adult acne. Topical treatment with
Clindamycin phosphate 10 mg/g and Tretinoin
0.25 mg/g gel once a day was administered.
Systemic therapy with Bromokriptin mesylate
2 . 5 m g a n d E t h i n yl estr a d i o l 0 . 0 3
mg/Drosiprenon 3 mg per day was recommended
by the gynecologist.
As a result of the treatment at the end of the
sixth month, slight improvement was observed.
The eruptions on the face and back diminished in
number and Global score was estimated 10
(Figures 3, 4). Despite the systemic treatment,
hormonal results revealed still higher level of
prolactine (199.3 ng/ml) and lower levels of
estradiol (10.0 pg/ml) and progesterone (1.28
ng/ml) at the sixth month. The levels of total
testosterone and DHEA-S were normal. The
patient was directed to conduct magnetic
Figures 1, 2. Comedones and papules on the lower third on the face and back
resonance imaging, to exclude microadenoma of
the pituitary gland.
Adult onset acne (AOA) is defined as a chronic
inflammatory disease of the pilosebaceous units,
occurring at the age over 25 years [ ]. It
commonly affects females between the age of 25
and 50 years and is clinically presented with
comedones, papules, pustules, cysts, and nodules
on the lower part of the face, chin and jaw line [5,
J Biomed Clin Res Volume 9 Number 2, 2016
Figures 3, 4. Patient after six-month treatment
6]. Two different types of AOA are known:
persistent acne and late-onset acne [4]. Persistent
acne affects 82% of patients and is characterized
by continuation of acne from adolescence to adult
life [7]. Persistent acne is presented by painful
inflammatory lesions, mainly papules and
nodules involving lower third of face, jaw line
and neck, as in the case presented. Late-onset
acne appears for the first time after the age of 25
years and affects mainly the chin. Adult onset
acne may be associated with a number of
endocrine and non-end ocrine di se ases:
polycystic ovary syndrome, insulin resistance
and acanthosis nigricans syndrome, Cushing
s y n d r o m e , me t a b o l i c s y n d r o m e ,
hyperandrogenemia, androgen-secreting tumors,
Apert syndrome, pyogen ic arthritis [8].
Commonly AOA is accompanied by hormonal
imbalance. In women, the androgens deriving
from the ovaries include androstenedione and
testosterone. Dehydroepiandrosterone (DHEA),
DHEA-S, androstenedione and testosterone are
produced by the adrenal glands. Peripheral
conversion of androstenedione and DHEA is also
responsible for testosterone production in
women. In female patients with AOA, signs and
symptoms of hyperandrogenism (amenorrhea,
oligomenorrhea, hirsutism, excessive discharge
of sebum etc.) should be considered [9]. Forty-
five percent of adult women with AOA have
hyperprolactinemia, which may be responsible
for their excessive androgen signaling [5]. Skin
androgen receptors are located in the sebaceous
glands and in the outer root sheath of hair
follicles. In the sebaceous glands, androgens
undergo metabolization from DHEA to 5-alpha-
dihydrotestosterone. This process includes many
steps and is concerned with stimulating
proliferation and activity of sebocytes [10].
Sebum regulation is also related to a number of
other hormones like estrogens, growth hormone,
insulin and insulin-like growth factor-1,
glucocorticoids, adrenocorticotropic hormone,
and melanocortins [11]. Prolactin itself increases
the level of 5-alpha-reductase in serum, which
converts testosterone into dihydrotestosterone
(DHT). On the other hand DHT increases
sebocyte proliferation, sebum production and
hyperkeratinisation [12]. Androgen levels often
decrease when treatment for hyperprolactinemia
is started.
Adult onset acne is mainly mild-to-moderate
in severity, according to GAGS. This is a system
introduced by Doshi et al. in 1997, for assessing
the severity of acne, which divides the face, chest
and back into six areas and assigns a factor to
each area on the basis of size (Table 1). Each type
of lesion (comedones, papules, pustules,
nodules) is given a value 0-4 depending on
severity. The score for each area (local score) is
calculated using the formula: Local score =
Factor x Grade (0-4). The global score is the sum
of local scores, and acne severity was graded
using the global score. A score of 1-18 is
considered mild, 19-30 moderate, 31-38
severe and more than 39 very severe acne [13,
When putting the diagnosis AOA, cosmetic
acne, pomade acne, medication-induced acne,
rosacea, perioral dermatitis and seborrheic
dermatitis as differential diagnosis have to be in
mind [15-17].
Most of the cases of AOA are resistant to the
therapy, as in the case here presented [12].
Because hyperandrogenemia was evident in a
majority of studies, these data suggest that
androgen suppression may be useful in treating
Table 1. Global Acne Grading System – division of the face, chest and back into six areas
Area Factor
Forehead 2
Right cheek 2
Left cheek 2
Nose 1
Chin 1
Chest and upper back 3
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(cyproteron eacetate, spironolactone, oral
contraceptives, finasteride) are administered as a
concomitant treatment for adult acne in woman.
Patient selection and evaluation before treatment
is administered as crucial [19]. Reducing sebum
production is a major goal of hormonal
treatment. Oral contraceptives may act through
several mechanisms to reduce acne [20]. They
stimulate synthesis of sex-hormone-binding
globulin in the liver. This globulin binds
circulating androgens, thus decreasing free
testosterone and DHEA-S and probably
contributes to lower sebum production. Oral
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demonstrated by results from a number of studies
[4, 19]. Drospirenone (DRSP) has anti-
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is particularly well tolerated, because it has no
effect on fluid retention, compared to other oral
contraceptives. Additionally, the relative safety
effect of progestins has been demonstrated in
large epidemiological studies [20].
We present a case-report of a 25-year-old female
pa tient with moderate pe rs istent AOA
accompanied by hyperandrogenemia and
hyperprolactinemia. After six-month systemic
therapy with Bromokriptin mesylate, Ethinyl
estradiol and Drosiprenon combined with
retinoid and antibiotic topical therapy, a
satisfactory result was reported. Regardless of
the systemic therapy with antiandrogens, at the
sixth month even higher level of prolactin has
been found. Therefore the patient was directed to
conduct magnetic resonance imaging, in order to
exclude microadenoma of the pituitary gland.
This case report describes results from scientific
research project № 8/2016, funded by Medical
University Pleven Substantiation the
relationship between acne vurgaris, polycystic
ovary syndrome and disturbances in the function
of the thyroid gland”.
J Biomed Clin Res Volume 9 Number 2, 2016
therapy. Am J Clin Dermatol. 2006;7(5):281-90.
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combined ethinyl estradiol/drospirenone oral
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... We recorded a case of Acne Vulgaris in 23 years old female patient. Yordanova et al. [7] presented a case-report of a 25-year-old female patient with moderate persistent AOA accompanied by hyperandrogenemia and hyperprolactinemia. After sixmonth systemic therapy with Bromokriptin mesylate, Ethinyl estradiol and Drosiprenon combined with retinoid and antibiotic topical therapy, a satisfactory result was reported. ...
Full-text available
Acne is a common disorder affecting the majority of adolescents and often extends into adulthood. The central pathophysiological feature of acne is increased androgenic stimulation and/or end-organ sensitivity of pilosebaceous units leading to sebum hypersecretion and infundibular hyperkeratinization. These events lead to Propionibacterium acnes proliferation and subsequent inflammation. Hormonal therapy, including combined oral contraceptives (OCs), can attenuate the proximate androgenic trigger of this sequence. For many women, hormonal therapy is a rational option for acne treatment as it may be useful across the spectrum of severity. Drospirenone (DRSP) is a unique progestin structurally related to spironolactone with progestogenic, antimineralocorticoid, and antiandrogenic properties. It is available in 2 combined OC preparations (30 μg EE/3 mg DRSP; Yasmin(®) in a 21/7 regimen; and 20 μg EE/3 mg DRSP; Yaz(®) in a 24/4 regimen). These preparations are bereft of the fluid retentional side effects typical of other progestins and their safety has been demonstrated in large epidemiological studies in which no increased risk of vascular thromboembolic disease or arrhythmias was observed. In acne, the efficacy of DRSP-containing OCs has been shown in placebo-controlled superiority trials and in active-comparator non-inferiority trials.
Full-text available
Background and Design: Acne vulgaris is an inflammatory disease of pilosebaceous unit. It usually starts after puberty but may continue into adulthood. We studied Growth hormone (GH) and insulin-like growth factor (IGF)-1 levels in women patients with acne vulgaris in whom all other hormon levels were normal. We aimed to show any relation of the acne vulgaris lesion type and GH and IGF-1 levels. Material and Method: The study conducted on the postadolesance period woman patients applying to out patient dermatology department with complaint of acne symptoms between Semtember 2005 and July 2006. All other hormonal parameters were normal in patients. 25 healthy similar age women were accepted as control. IGF-I and GH were quantified by solid-phase competitive chemiluminescence assays. Results: There was no difference according to age between the groups (p=0.726). The mean IGF-1 level was 336.5±112.88 ng/ml in patients and 194±31.32 ng/ml in control; the difference was significantly important (p=0.000). The mean GH level was 3.16±4.35 µIU/ml in patients and 1.15±1.21 µIU/ml in control; and the diffrence was not found as important (p=0.03). IGF-1 level was significantly important in patients with noduler involvement (p=0.015), and GH level was also significantly important in patients with cystic involvement (p=0.05). Conclusion: We supported the hypothesis that GH and IGF-1 levels were important in postadolasence period women patients with acne vulgaris. We recommend new studies comparing GH and IGF-1 levels in adolesence and postadolesence period women patients in order to support the role of these hormones in pathogenesis of acne vulgaris.
Acne vulgaris is usually considered as a skin disorder that primarily affects adolescents reaching a peak at the age of 14-17 years in females and 16-19 years in males. However, recent epidemiologic studies have shown that a significant number of female patients aged >25 years experience acne. As it is regarded as a disease of teenagers, adults are more apprehensive and experience social anxiety. Hence, adult onset acne has become a matter of concern. © 2016 Indian Journal of Dermatology | Published by Wolters Kluwer - Medknow.
Introduction: Rosacea is a common and chronic dermatological disorder of the face. Its effect on facial appearance makes it potentially distressing for patients who can suffer psychosocial disturbances. Methods: Selective literature review. Results: Rosacea occurs in adults, peaking between 40 and 50 years of age. Three main stages are identifiable: Rosacea erythematosa-teleangiectatica, rosacea papulopustulosa, and hyperglandular-hypertrophic rosacea. Numerous specialized forms exist, which complicate differential diagnosis and require specific treatment strategies. These include rosacea conglobata, rosacea fulminans, granulomatous rosacea, persisting edema, ocular rosacea, and steroid rosacea. A recent increase has been noted in patients with rosacea induced by inhibitors of epidermal growth factors (cetuximab, geftinib, erlotinib) used for chemotherapy in patients with malignancy. These side effects have been described as acneiform eruptions but at least some of the described patients clearly have a rosacea like appearance. Discussion: A variety of physical and chemical agents can induce rosacea in predisposed individuals and trigger exacerbations of preexisting disease. Treatment of the various forms of rosacea should be adapted to the stage and phase of the disease. Rosacea is not curable but the symptoms can for the most part be effectively controlled thus, preventing permanent damage to the skin, such as scarring and permanent edema.
This review focuses on the subject of acne in women, a disease that is increasingly common and that can also affect men. Adult acne differs from the type of acne that occurs in teenagers, and it may persist beyond adolescence or have its onset at an older age (adult-onset acne or late acne). Acne can have a negative impact on the quality of life of patients at any age, leading to a negative body image and decrease in self-esteem, and in older patients it can result in discrimination in the workplace and in other social environments. Acne in women must be understood as a specific problem, and here we discuss the pathogenesis, clinical presentation, psychology and treatment of this very prevalent problem.This article is protected by copyright. All rights reserved.
To evaluate the association between acne, quantified by the Global Acne Grading System (GAGS), and abnormal clinical and laboratory markers of androgen excess in patients with polycystic ovary syndrome (PCOS). The retrospective study included 133 patients with PCOS. Acne severity was quantified with the GAGS score, alopecia was graded with the Ludwig classification, and hirsutism was quantified with a modified Ferriman-Gallwey (FG) score. The mean GAGS score was significantly greater in younger women, those with a lower BMI, and those with a higher FG score. There was no relation between the mean GAGS score and waist circumference, waist/hip ratio, androgen hormone levels (free testosterone, total testosterone, or dehydroepiandrosterone sulfate), sex-hormone-binding globulin level, or menstrual irregularity. Alopecia was significantly associated with an increased waist/hip ratio; there was no relation between alopecia and age, waist circumference, body mass index, FG score, androgen hormone levels, or menstrual irregularity. A weak positive correlation was observed between the GAGS and FG scores. The GAGS may provide more precise and comprehensive information about acne severity in obese or hirsute patients with PCOS because this grading system includes evaluation of the type (comedones, papules, pustules, nodules) and location (anatomic area) of acne lesions.
Acne is one of the most widespread skin diseases in the general population and among adolescents in particular. However, it is becoming increasingly common in patients over 25 years of age, and particularly in women. We distinguish 2 types of postadolescent acne: persistent acne—the most frequent such acne—is an extension of acne that began in adolescence and continues into adulthood, and late-onset acne, which first appears in those over 25 years.We review the clinical characteristics of these types of acne in women, the causes, the recommended complementary tests, and the particulars of treatment in order to adequately manage this condition.
In the adult female, acne is a chronic condition with a substantial negative psychological, social and emotional impact. Based on time of onset, two subtypes of adult female acne are recognized: 'persistent acne' is a continuation of the disease from adolescence, while 'late-onset acne' first presents in adulthood. The morphological characteristics of adult female acne are often distinct from adolescent acne. In adults, inflammatory lesions (particularly papules, pustules and nodules) are generally more prominent on the lower chin, jawline and neck, and comedones are more often closed comedones (micro cysts). Adult acne is mainly mild-to-moderate in severity and may be refractory to treatment. A holistic approach to acne therapy should be taken in adult females, which combines standard treatments with adjunctive therapy and cosmetic use. A number of factors specific to the adult female influence choice of treatment, including the predisposition of older skin to irritation, a possible slow response to treatment, a high likelihood of good adherence, whether of child-bearing age, and the psychosocial impact of the disease. Adherence to therapy should be encouraged through further patient education and a simplified regimen that is tailored to suit the individual patient's needs and lifestyle. This article reviews the specific characteristics of adult female acne, and provides recommendations for acne therapy in this patient group.
Acne vulgaris is a common reason why adult women present to dermatologists and can be a clinical challenge to treat. It may also be an important sign of an underlying endocrine disease such as Polycystic Ovary Syndrome (PCOS). Although standard acne therapies can be successfully used to treat acne in adult female patients, hormonal treatment is a safe and effective therapeutic option that may provide an opportunity to better target acne in this population, even when other systemic therapies have failed. In this article, a practical approach to the adult female patient with acne will be reviewed to enhance the dermatologist's ability to use hormonal acne therapies and to better identify and evaluate patients with acne in the setting of a possible endocrine disorder.
Over 6% of women become pregnant when taking teratogenic medications, and contraceptive counseling appears to occur at suboptimal rates. Adherence to contraception is an important component in preventing unwanted pregnancy and has not been evaluated in this population. We undertook a pharmacy claims-based analysis to evaluate the degree to which women of childbearing age who receive Category X medications adhere to their oral contraception. We evaluated the prescription medication claims for over 6 million women, age 18-44 years, with prescription benefits administered by a pharmacy benefits manager. Women with 2 or more claims for a Category X medication and 2 or more claims for oral contraception were evaluated in further detail. Adherence to oral contraception was measured by analyzing pharmacy claims. Multivariable logistic regression was performed to identify factors associated with adherence. There were 146,758 women of childbearing age who received Category X medications, of which 26,136 also took oral contraceptive medication. Women who received Category X medications were prescribed oral contraception (18%) at rates similar to others of childbearing age (17%). Women prescribed both Category X and oral contraception demonstrated adherence similar to the overall population. Age, class of Category X medication, number of medications, prescriber's specialty, and ethnicity correlated with lower adherence rates. Despite added risk associated with unintended pregnancy, many women who receive Category X medications have refill patterns suggesting nonadherence to oral contraception. Compared with all women age 18-44 years, women receiving teratogenic medications do not have better adherence to oral contraception.