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acne
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1
ACNE IN THE ADULT FEMALE PATIENT :A PRACTICAL APPROACH
Armando VSLM
41090026
2
BACKGROUND
Acne vulgaris is a common skin condition with
85% lifetime prevalence.
Adult acne is a common reason for patients to
present for dermatological evaluation, and adults
in fact make up a large portion of the patient
population seen by dermatologists for acne.
Various studies have reported acne prevalence in
the range of 41–54% in women and 34–40% in
men
3
BACKGROUND
Several studies suggest that women are
more likely to report acne than men.
Acne in adult women has also been shown to
have a late onset and become persistent.
4
PATOGENESIS
Pathogenesis of acne in adult women is
complex, involving androgens in addition to
other important factors well accepted for
their role in the pathogenesis of acne:
Sebum Production; follicular plugging; genetics;
Propionibacterium Acnes; diet; medications;
innate immunity; and alterations In follicular
keratinization and differentiation.
5
PATOGENESIS
The role of androgens in adult women with acne
has been well supported in the literature, and four
clinical observations highlight this important role.1. Androgen-insensitive individuals do not produce
sebum and do not develop acne.2. Conditions of hyperandrogenism, such as polycystic
ovary syndrome (PCOS), are associated with acne that is highly responsive to hormonal therapies.
3. Hormonal-based therapies such as oral contraceptives and anti-androgen medications are effective treatments for acne.
4. Rising levels of dehydroepiandrosterone sulfate (DHEA-S) are associated with the onset of acne in pre-menarchal girls, and higher levels in pre-menarche may predict the development of more clinically severe acne in puberty.
6
CLINICAL FEATURES
Especially at the jaw line and chin, with a broad clinical spectrum of : Comedones Papules Pustules Cysts, and/or nodules
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DIFFERENTIAL DIAGNOSIS
The common differential diagnosis of adult
female acne includes:
1. Rosacea
2. Seborrheic dermatitis
3. Acne Cosmetic
4. Pomade acne
5. Medication included acne (Danazol,
Testosterone, progestins, glucocorticoids,ect.)
8
POLYCISTIC OVARY SYNDROME
The most recent consensus criteria defines a
diagnosis of PCOS as two of the following
three criteria:
1. amenorrhea or oligomenorrhea
2. biochemical or clinical hyperandrogenism
3. ultra-sonographic documentation of increased
follicle count (>12) or follicular volume (>10
cm3) per ovary.
9
PCOS
Acne is an important
and common cutaneous
sign of PCOS. Other
dermatological signs
associated with PCOS
include hirsutism,
androgenic alopecia,
seborrhea, and
acanthosis nigricans.
10
PCOS
11
PCOS
12
TREATMENT
13
OCP
OCPs work by several mechanisms to reduce acne.
OCPs stimulate hepatic synthesis of sex hormone-
binding globulin, which bind circulating androgens,
decrease free testosterone and DHEA-S, and likely
reduce sebum production. OCPs also inhibit 5-a-
reductase, decreasing peripheral conversion of
testosterone, as well as decreasing production of
ovarian and adrenal androgens. OCPs are effective
in the treatment of acne, with studies
demonstrating 40–70% reduction in lesion counts.
14
15
SPIRONOLACTONE
Spironolactone is a highly effective treatment
for acne in adult women and may surpass
the efficacy of OCPs.
Spironolactone is a safe and well-tolerated
medication, yet patients should be counseled
on potential side effects.
16
OTHER HORMONAL TREATMENT FOR ACNE
Flutamide
Cyproterone acetate (CPA)
17
ALGORITHM FOR THE HORMONAL TREATMENT OF ACNE
Combination treatment of spironolactone and
OCPs is likely the safest approach, reducing
adverse effects, and is supported by
evidence that it is the most effective
treatment for acne.
18
THERAPEUTIC ALLIANCE AND SPECIAL CONSIDERATIONS
It is imperative to build a strong therapeutic
alliance with the patient and set realistic
goals of treatment.
Patient concerns regarding treatment and
cosmetic practices should also be addressed.
19
TREAATMENT OF ACNE DURING PREGNANCY
If possible, treatment during the first
trimester should be avoided. Recommended topical agents include azelaic
acid, metronidazole, erythromycin, clindamycin, and glycolic acid.
Systemic therapies with adequate safety data in pregnancy include penicillins, cephalosporins, erythromycin.
20
CONCLUSION
Acne is common in adults and especially in women.
It may also be a sign of an underlying systemic disorder such as PCOS.
Hormonal therapies such as OCPs and
spironolactone are effective even when other
standard therapies for acne have failed,
including antibiotics and isotretinoin.
21
TERIMA KASIH