Adult Acne: Understanding and Addressing the Complexities

Acne, commonly associated with the teenage years, has become a widespread skin disorder globally, affecting approximately 85% of teenagers at some point. However, it is crucial to recognize the escalating prevalence of adult acne, particularly among women. Recent studies have indicated a significant 10% increase in women experiencing adult acne worldwide. This chronic inflammatory condition knows no age or gender boundaries.

Amidst the abundance of misinformation surrounding acne, it is essential to acknowledge its multifactorial nature and avoid oversimplification. Successfully managing this condition requires addressing numerous contributing factors, as solely targeting one trigger or symptom may provide only temporary relief or even worsen the situation.

How does adult acne differ from teen acne? 

While both conditions can share common underlying factors, there are notable distinctions between the two, including the primary contributing factors for each age group. Here are a few main differences:

Onset: 

• Teen Acne: typically begins during puberty, triggered by hormonal changes. 
• Adult Acne: can develop in individuals over the age of 25, even if they did not experience significant acne during their teenage years and if they have relatively balanced and normal hormones.

Location: 

• Teen Acne: primarily affects the T-zone (forehead, nose, and chin) and sometimes the cheeks; areas where sebum levels are highest during adolescence. 
• Adult Acne: more commonly appears on the lower face, including the jawline, chin, and neck. This difference in location is attributed to variations in sebaceous gland distribution and hormonal influences though when environmental and topical factors are at play, it can be normal for an adult to develop acne in areas outside of the more typical “adult acne locations.”  Weaker barrier function in these locations and increased susceptibility to inflammation may contribute to this occurrence.

Hormonal Factors:

• Teen Acne: During adolescence, hormonal fluctuations, particularly increased androgen levels, stimulate the sebaceous glands to produce more sebum, leading to oilier skin. Excess sebum, combined with skin cells, can clog pores and contribute to acne formation.

• Adult Acne: In adults, hormonal imbalances, such as fluctuations in estrogen and progesterone levels, can contribute to acne development. Hormonal changes related to menstrual cycles, pregnancy, or conditions like polycystic ovary syndrome (PCOS) can trigger or exacerbate adult acne.

Presentation: 

• Teen Acne: Teenage acne lesions usually involve comedones (blackheads and whiteheads) and may include papules (small red bumps) or pustules (pimples with pus). Overall, teen acne tends to be less severe and less inflammatory compared to adult acne.
• Adult Acne: Adult acne tends to be more inflammatory and severe, often presenting with larger, deeper, more painful lesions, such as nodules or cysts. In some cases, adult acne may result in scarring due to prolonged and intense inflammatory responses.  Adult comedones, which appear non-inflammatory on the surface, can take a significant amount of time to clear compared to the more rapidly healing teenage comedones.

Other Factors:

• Teen Acne: Diet and hygiene tend to be more contributing factors during adolescence.
• Adult Acne: Stress, topical products, lifestyle choices, medication side effects, and underlying medical conditions become primary contributing factor with adult acne. 

Another area that is often overlooked but plays a significant role in the success of acne treatment in adults is the differences in the skin microbiome and barrier function between adults and teenagers. Recent studies have shed light on the importance of the skin's microbiome in the development of inflammatory acne lesions, with a reduced diversity of Cutibacterium acnes subgroups being a key factor in initiating skin inflammation. Notably, certain subgroups, such as subgroup III, have been found to be more prevalent in the microbiomes of adults with acne and associated with more inflammatory acne lesions. In contrast, teenagers with acne tend to have a higher abundance of subgroup I and II, which are considered less inflammatory than subgroup III.

The beneficial bacteria present in the skin microbiome play a crucial role in maintaining a healthy skin barrier. They produce antimicrobial peptides, enzymes, and other compounds that inhibit the growth of pathogens and ensure a balanced microbial environment on the skin surface. However, studies have shown that the skin microbiome of adults, including those with acne, generally exhibits lower microbial diversity compared to teenagers. This reduced diversity can lead to an unstable and imbalanced ecosystem on the skin, compromising its resiliency and overall skin health.

This disparity is a major reason why teenage skin tends to tolerate more aggressive acne treatments better than adult skin. Teenage skin has a higher level of resilience, which allows it to withstand harsh treatments without significant issues. However, the same treatments can cause problems when applied to adult skin. Teenage skin's resilience is not solely due to the treatments used but is largely inherent in its nature.

The skin barrier, closely related to the microbiome, acts as another line of defense for the skin. A diverse and balanced skin microbiome is essential for maintaining a healthy skin barrier. Beneficial bacteria interact with skin cells and influence the production and maintenance of essential components of the barrier, such as ceramides, cholesterol, and free fatty acids. This helps prevent the overgrowth of harmful bacteria and fungi that could disrupt the skin barrier. Imbalances or dysbiosis in the skin microbiome, characterized by a decrease in beneficial bacteria or an overgrowth of harmful species, can compromise the skin barrier function and contribute to various skin conditions, including acne. Additionally, the age-related decrease in vital epidermal lipids can lead to increased transepidermal water loss and inflammation, further affecting the microbiome negatively.

Targeted Treatments

In order to effectively heal acne-prone adult skin in a sustainable manner, it is crucial to shift the narrative away from aggressive approaches that may have been tolerated during the skin's youthful days. Instead, a more supportive and well-rounded course of treatments suitable for maturing skin should be embraced. Although aggressive treatments may provide temporary relief in adult skin, their inflammatory nature often leads to short-lived results and can even contribute to the aging process that this specific group of individuals is striving to address.

Inflammation

While the role of inflammation in the later stages of acne is widely acknowledged due to visibly inflamed lesions, recent studies have provided evidence of inflammation's involvement even in the earliest stage of acne formation, known as a microcomedone. It is important to recognize the significant role of certain cytokines (protein-based cell signaling molecules) in both the immune and inflammatory response within the skin. These secreted proteins, released by cells, have specific effects on cell interactions and communication. The impact of cytokines can be beneficial or problematic, depending on factors such as their location, concentration, and specific characteristics. Research indicates that various factors can influence the release of specific cytokines, which, in turn, contribute to the development of acne. Individuals with acne typically have higher levels of inflammation present in their skin.

One of the challenges with many common acne treatments today is their exclusive focus on providing immediate relief from inflammation and hyperkeratinization, without addressing the issue sustainably or considering its underlying causes. While a substance may offer temporary relief from inflammation, if it contributes to a sequence of events that lead to further inflammation, it perpetuates a cycle of acne. If this sequence of events also impairs the skin's natural barrier defenses, resulting in dehydration, it actually slows down the healing process of future acne lesions. This not only perpetuates the cycle but worsens it.

Anti-inflammatory ingredients in skincare play a crucial role in managing acne. It is essential to ensure a profile of fully anti-inflammatory ingredients, as many claims of anti-inflammatory effects in skincare are often unsubstantiated. There are specific growth factors available in the market that have a highly anti-inflammatory profile, while others may claim the same but contain more inflammatory building blocks due to their source. The same applies to certain hyaluronic acid ingredients, where the use of low molecular weight fractions may be recognized as inflammatory by the skin. It is important to carefully select ingredients with substantiated anti-inflammatory properties. In the treatment room, additional tools to manage inflammation include LED therapy and microcurrent. These techniques not only assist in controlling inflammation but also offer added benefits for mature clients seeking anti-aging treatments.

The Skin’s Main Lines of Defense

The first two lines of our intricate defensive systems, the Microbiome and the Skin Barrier, play vital roles in acne formation. Disruption of either can compromise subsequent lines of defense, leading to dehydration, inflammation, and slow-healing skin.

Maintaining the integrity of the skin barrier may seem unfamiliar to those who rely solely on peels and exfoliation for acne support. However, aggressive treatment approaches aimed at removing "dead skin cells" that cause congestion often increase inflammation, perpetuating a cycle of acne and triggering more hyperkeratinization. It is crucial to understand the structure of the skin barrier, which can be likened to a brick wall, with lipids acting as the mortar and the "dead skin cells" comprising the bricks. To ensure sustainable relief for our clients, it is important to use ingredients rich in linoleic acid and choose product lines that incorporate proper therapeutic usage rates of bio-identical lipids or ingredients that support lipid synthesis.

Hydration is essential for regulating cellular turnover, and while removing the skin barrier temporarily alleviates excessive buildup, it also impairs the skin's ability to retain moisture and increases inflammation. Therefore, it is crucial to prioritize maintaining a healthy skin barrier while addressing acne concerns.

Comedogenic Ingredients

Addressing comedogenicity in acne treatment is often debated. However, it is essential to recognize that the problem lies not in physical pore-clogging but in the potential of certain molecules to induce inflammation and aggressive hyperkeratinization.  A 2018 study observed more pronounced hyperkeratinization in adult women compared to healthy controls, confirming the presence of microcomedones that are crucial in the development of acne lesions among this age group. The topic of comedogenicity was extensively explored in a well-known paper titled "Acne Cosmetica" by Albert Kligman in 1972, although some criticisms have been raised regarding the testing method involving rabbits' ears. Nonetheless, half of the 25 facial creams tested in that study were found to be comedogenic.

Given the multitude of face products used, exposure to comedogenic substances is high. The potential for comedogenicity may decrease in full formulations, but limited testing leads to speculation which is not ideal when seeking to clear skin with a level of confidence. Although there may be some dilution of comedogenic potential in a full formulation, many problematic ingredients are still used in significant concentrations, even in products claiming to aid with acne.  With acne being an inflammatory condition at its foundation, the skin in an active breakout state becomes more susceptible to further agitation and, consequently, more reactive to ingredients that may not have the same impact on calm, non-inflamed skin.

In Conclusion

Acne is a challenging condition that affects individuals of all ages, taking a toll on their physical, emotional, and financial well-being. While many skincare professionals approach acne treatment with good intentions, it can be frustrating for both professionals and clients when there is limited understanding of the underlying causes of acne. What often seems to be missing in modern acne treatment is the human element. Clients require more than just topical products and instructions; they need ongoing support, encouragement, and guidance.

Acne is a dynamic condition that can change its presentation and even migrate as we make changes to improve overall skin health. To achieve better outcomes, it is essential to thoroughly monitor clients and guide them based on these changes, rather than relying on rigid protocols alone. Understanding the individual needs and concerns of each client and tailoring the treatment accordingly can make a significant difference in their journey towards clear and healthy skin. Addressing acne comprehensively goes beyond the application of products. It involves a holistic approach that considers the physical, emotional, and individual aspects of each client. By providing ongoing support and personalized guidance, skincare professionals can empower their clients to navigate the complexities of acne, leading to improved outcomes and a better overall experience.

Read this blog in Dermascope Magazine!