Understanding and Treating Acne in Adult Women: Insights from Dr. Allison Arthur’s Expert Presentation

Understanding and Treating Acne in Adult Women: Insights from Dr. Allison Arthur’s Expert Presentation

Allison Arthur, MD, FAAD, delivered an illuminating presentation on the diagnosis and treatment of acne in adult women, indicating acne can persist for women into their 40s.  Women with adult acne tend to have a strong premenstrual flare.  Unfortunately, persistent adult acne is also associated with anxiety, depression and reduced quality of life. When evaluating adult women with acne, the differential should include rosacea, perioral dermatitis, acne cosmetica and acne medicamentosa.  Causes of acne medicamentosa include testosterone, dehydroepiandrosterone (DHEA), progestin, epidermal growth factor receptor (EGFR) inhibitor medications and lithium.

Coverage: SDPA 21st Annual Fall Dermatology Conference, Oct. 25-29, 2023 in Nashville, Tennessee

Medical evaluation of the adult female patient with acne includes evaluating the patient’s previous and current treatment regimens, their medical history, their medication list and a detailed menstrual history.  Patients who have oligomenorrhea or amenorrhea should be considered for polycystic ovary syndrome (PCOS), particularly if they present with additional symptoms of hirsutism, androgenetic alopecia and change in voice. The diagnostic criteria for PCOS were reviewed. In addition to acne, patients with PCOS may present with acanthosis nigricans and seborrhea. Laboratory values Dr. Arthur orders for patients she suspects may have PCOS include free testosterone, DHEA-sulfate and luteinizing hormone (LH): follicle-stimulating hormone (FSH).  These patients need to be off of spironolactone and/or oral contraceptives (OCs) for four weeks prior to having their labs drawn.

Next, Dr. Arthur discussed the hormonal treatment of acne. Female patients who present with hyperandrogenism and/or significant acne along the jawline or “beard” line tend to respond well to hormonal treatment. As estrogen is the highest benefit to the patient with acne, giving patients a “low” dose version of combined OCs is not helpful to these patients. There are now 4 FDA approved OCs for the treatment of acne—all of which contain ethinyl estradiol with varying derivatives of progestin.  It is no longer required by the WHO for women to have a Pap smear prior to initiation of OCs. The initiation of OCs can occur at any time in a patient’s menstrual cycle if the provider and patient are reasonably certain the patient is not pregnant. If OCs are started more than 5 days after their menstrual period, these patients need to use back up contraception for 7 days.  Dr. Arthur went on to discuss how she screens and talks with patients regarding the risk of thromboembolic events with the use of OCs.  She also reviewed the data on hormonal intrauterine device (IUD) influence on acne development.

Spironolactone is one of Dr. Arthur’s “favorite” options for patients with hormonal acne. The newest data reveal potassium screening is not needed of patients who take spironolactone unless they have a history of cardiac disease, renal disease, take spironolactone + drospirenone, take lisinopril or other angiotensin-converting enzyme (ACE) inhibitor or in older patients.  Once patients achieve stable acne control for 6 months, lowering the dose of spironolactone may be considered. Additional options for treatment discussed by Dr. Arthur included integrative treatments, blue light, and lasers. She also addressed the treatment of acne in the pregnant patient.

Byline: Sarah B.W. Patton, MSHS, PA-C

Pictured: Allison Arthur, MD, FAAD