| DERMATOLOGY | PEER-REVIEW


see in daily practice an impairment of wound healing in smokers, mainly by vasoconstriction73


. Smoking has a lot


of adverse effects on the skin, owing to the effect on skin microcirculation, as well as keratinocytes, collagen, and elastin synthesis. Smoking is strongly linked to acne, with the severity of


acne following a linear correlation with the number of cigarettes smoked. The prevalence of acne in smokers is higher compared with non-smokers74


. Smoking is


associated with development of wrinkles, atrophy, grey appearance or red complexion, and is commonly defined as ‘smoker’s face’75


.


Smoking is a major factor in non-inflammatory type post-adolescent female acne76, 77


, probably owing to an


increase of sebum production induced by the nicotine and the reduced level of vitamin E in the sebum. Additionally, some compounds found in cigarette smoke, including nicotine, have a hyperkeratinising effect76–78


.


Differences between acne in adults and adolescents We have two major subtypes of adult female acne, one is ‘persistent acne’ (which is a continuation or a relapse from adolescence) and the other is ‘late-onset acne’ (presents for the first time after 25 years)8, 79


. Adult female acne may be very refractory to treatment


and older skin may be more predisposed to irritation with certain topical treatments80


. Women over the age of


25 years have higher rates of treatment failure; Goulden et al found that 82% fail multiple courses of systemic antibiotics, and 32% relapse after isotretinoin81


.


Severity The severity of acne depends on lesion size, density, type, and distribution, and acne can be evaluated not only from objective disease activity (based on measurement of visible signs) but also from impact on QOL. Prognostic factors of disease severity include acne


family history, early onset of comedonal acne, persistent or late-onset disease, hyperseborrhoea and androgenic triggers and psychological sequelae82–85


.


Treatment and management The main principles in managing adult female acne are enhancing the care of patients (including psychological care), lessening of serious conditions and scarring, raising of adherence, and prevention of antibiotic resistance. The choice of treatment is connected with the


resistance of female adult acne to various therapies and the specific characteristic of the skin, which can be more predisposed to irritation86


. Severity and duration of the


acne, previous treatments, the predisposition to scarring and hyperpigmentation, and the areas affected by acne are all factors which have specific effects on the choice of therapy87, 88


.


The rates of adherence to treatments are higher in adult females, compared with males and teenagers89


.


However, the response to the treatment may be very slow and practitioners must explain the importance of


time to reach any significant clinical results88, 90 . Practitioners must have a holistic approach,


respectively integrate the diet, sun exposure, use of specific cosmetics with local and general treatment. Laser surgery can also be beneficial for both active acne and sequelae post inflammation. Regarding sun exposure, some patients may


experience a worsening of acne after exposure to sunlight92


. In these cases, it is very important for the


management of photosensitivity caused by some medical treatments of acne, such as tetracycline93–95 isotretinoin96, 97


and . Cycline or retinoid drugs (commonly


used to treat acne) are associated with photosensitivity reactions, so patients with acne must adopt active photoprotective behaviour (avoiding exposure to sun during the hottest parts of the day, correct and consistent use of sunscreen creams, using certified protective sunglasses, and appropriate clothing to reduce skin surface exposed to the sun).


Many patients with acne have a strong (and false) belief about cleanliness98–100


and this


results in not only the misguided use of a lot of washing products but also a delay before seeking a medical consultation99


. However, the


, and can increase skin irritation adverse effects of topical therapy, and isotretinoin treatment102–104


truth is very different, face-washing exacerbates acne101


.


Advice on the use of cosmetics, moisturisers, sunscreens, and hair gels may be appropriate67


, and


should be a part of acne management in adult acne. Studies have demonstrated that acne improves when


patients with polycystic ovary syndrome (PCOS) are treated with medications that improve insulin metabolism such as metformin, tolbutamide, pioglitazone, and acarbose105, 106


. Polycystic ovarian syndrome is a condition


with a lot of features, including insulin resistance, hyperinsulinaemia, hyperandrogenism, and acne107


. These patients


typically maintain elevated serum concentrations of androgens, IGF-1, and lower concentrations of SHBG108–111


. Falsetti et al agree with the fact that acne is an


important feature in PCOS patients, who are also frequently obese, hyperinsulinaemic, insulin resistant, and hyperandrogenic108


. Insulin resistance


generally precedes and gives rise to endocrine characteristics of PCOS (elevated androgen and IGF-I concentrations and low SHBG)112


. It was in 1956 when one of the first Advice on the use of


observations about the fact that treatments for PCOS with oral hypoglycaemic agents, not only improve insulin sensitivity and restore fertility but improve acne as well113


. prime-journal.com | July/August 2014


cosmetics, moisturisers, sunscreens, and hair gels may be appropriate, and should be a part of acne management in adult acne.


 . A


simple and specific way to improve adherence is to use fixed-dose combinations91


43


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