Adult acne: the impact of stress

Adult acne is a very common form of acne that develops primarily in women between the ages of 20 to around 40. The majority of women with adult acne did not have the condition during adolescence. Adult acne is found on the face and rarely on the trunk (shoulders and decolletage) and causes comedones (blackheads/whiteheads) and subcutaneous microcysts. However many women also develop painful furuncles, as with teenage acne, before or during their period.

Causes

Genetic predisposition is the main reason why the skin produces acne as a response to psychophysical stress. In a way, adult acne is a somatization of the skin and is not impacted by hormonal alterations.

The common mistake with acne and polycystic ovaries

Many women with adult acne assume it’s down to hormones and make an appointment with a gynecologist. Many gynecologists may also believe that a hormone disorder is at play and will perform an ovarian ultrasound, before concluding that the acne is the result of polycystic ovaries. Due to a simple confusion of terminology, this means the patient has been misdiagnosed and will receive the wrong treatment for their skin condition.

Polycystic ovary syndrome (PCOS)

Polycystic ovary syndrome (PCOS) is a serious hormonal disorder in women. While the exact cause is not clear, it is likely to be genetic. Symptoms of PCOS include:

• Irregular cycle or amenorrhea (absence of menstruation)
• Irregular ovulation or non-ovulation
• Hirsutism (appearance of terminal hair on the face and trunk)
• Thinning hair
• Oily skin
• Obesity
• Short stature

On the biochemical side, PCOS is mainly characterized by:

• elevated free testosterone
• elevated androstenedione
• lowered luteinizing hormone (LH)
• ratio of LD to FSH (follicle stimulating hormone) above three

Diagnosis of PCOS should only be made after other endocrinological diseases have been ruled out.
Hirsutism, oily skin and hair thinning are mainly caused by the increase in androgen hormones, while obesity is largely related to the insulin resistance that accompanies this metabolic condition.

Polycystic ovaries: a confusing term

The name ‘polycystic ovary syndrome’ causes some confusion. This is mainly due to the fact that, while half of people with PCOS have clinical signs of the condition, they have no traces of polycystic ovaries on an ultrasound.
From as early as the end of the last century, discussions had begun to change the name of the syndrome to avoid any further confusion. However, due to lack of international agreement among PCOS referents, this imprecise and confusing name is still in use today.

So, do polycystic ovaries exist?

Polycystic ovaries exist only because of an incorrect ultrasound diction. In around half of all women of childbearing age, ovarian cyst-like forms can be spotted during ultrasounds, however these are actually the follicles of maturing eggs. Instead of PCOS, a more accurate, straightforward yet little used term is ‘micro-poly follicular ovary’. Micro-poly follicular ovaries’ or ‘polycystic ovaries’ is a normal condition and there are no hormonal changes that distinguish the syndrome (PCOS). Some studies simply refer to the condition as PCO, removing the ‘syndrome’ (S) to reflect a diagnosis based on an ultrasound that does not show hormonal alterations.

What is the correlation between acne and PCOS?

There is no correlation between adult acne and PCOS. In a recent endocrinology study of patients with PCOS, it was found that acne was present in about 12% of cases. This percentage is roughly the same number of people without PCOS who have adult acne, which means acne can be excluded as a PCOS symptom.

What is the correlation between adult acne and PCO?

There is no correlation between adult acne and PCO. This is because polycystic ovaries, or micro poly follicular ovaries, are not associated with any hormonal imbalances.

Is the pill an effective way to treat adult acne?

No, the contraceptive pill is not an effective way to treat adult acne. While roughly one third of people using the pill to treat adult acne will benefit from it, two thirds will find their symptoms stay the same or worsen. Even if a patient sees some improvements, the birth control pill comes with some ‘burdens’, including both short- and long-term side effects, and it is worth considering other treatment options that are more effective and less invasive.

The androgen saga

The hypothesis that androgen hormones could cause various forms of acne had been a well-established concept in dermatology. However, due to a lack of scientific evidence of a clear link between an excess of androgen and acne appearing, the cause/effect hypothesis was completely undermined. This is specific to adult acne, but a generation of women have been nonetheless using birth control pills containing anti-androgens (not progesterone) that do not provide any benefit to the issues they were meant to solve. Thanks to the study led by Professor Christos Zouboulis, it has been discovered in the last decade that the skin itself can produce sex hormones – including estrogen and androgen – completely independently of the ovaries. This research changed the pathogenesis of adult acne.

Adult acne and the paracrine theory

Today, many think that stress triggers androgen secretion through nerve pathways to the face of the skin. Therefore, the mechanism of acne genesis occurs directly where acne appears. With this theory, the concept of ovarian “pathology” in women with acne lapses, as does the use of the birth control pill as a remedy.

Adult acne and cosmetics

Women who develop adult acne usually try to hide it by using opaque make-up such as foundation. However, in doing so, they worsen the acne because the make-up is absorbed into the skin follicles which irritates the skin and causes blackheads, microcysts,and even furuncles to appear. The worse the acne gets, the more make-up is used to cover it up and thus a vicious cycle begins, where the acne and distress of the sufferer both get gradually worse.

Treating adult acne

As for other forms of acne, adult acne can be treated with simple or combination micropeeling. Micropeeling ensures most cases of adult acne regress, as long as it is applied correctly and the use of other creams or foundations is avoided.
In cases of adult acne where there is a lot of inflammation and, therefore, a greater risk of scarring, photodynamic therapy can also be used as a treatment.

Micropeeling in practice

Apply Glicosal Lotion in the evening to areas affected by acne. To ensure effective make-up removal and cleansing before application, use the non-foaming Eudermic Base Wash, which helps maintain skin softness and prepare it for micropeeling.
Apply seven to ten drops of Glicosal Lotion onto a moistened cotton pad. Gently massage in circular motions over the entire face until the lotion has been absorbed and the pad is dry. Avoid vigorously rubbing the pad against the skin, as the friction can cause skin redness. Do not wash the face or use any other products after applying Glicosal Lotion. The morning after, only wash the face with tap water and apply no other products, including moisturizers.
For make-up, use only mineral-based products, such as Sun Clay or Argillina Skin Color which are both non-comedogenic and remain only on the skin’s surface. Foundation and other colored creams must not be applied as they can penetrate follicles, causing comedones and folliculitis.

When micropeeling isn’t enough: combined micropeeling

Side effects of micropeeling

In more severe cases of acne or where the skin is very seborrheic, micropeeling alone will likely not be enough to control acne. In such situations, combined micropeeling treatment can be adopted, which includes the addition of tretinoin lotion, a retinoic acid. The choice between following a simple or combined micropeeling treatment plan is up to the dermatologist who will base their decision on the type of acne, skin type and seasonality. Tretinoin lotion is not available ready-made and must be prepared by a pharmacist. To request the lotion, the following prescription, preferably signed by a doctor, can be presented to the pharmacy.

Prescription for tretinoin

Place and date: ___________________________ Name and surname: _________________________

R/

Tretinoin 0.05 %

Propylene Glycol 40 %

Ethyl Alcohol (96%) 59,9 %

Alpha-Tocopherol 0.05%

To be prepared in a dark, 50ml bottle with a dropper cap.

S/ Apply once in the evening, rubbing well into the skin. The amount of product to use and the frequency with which to apply will be recommended by the dermatologist.

Friction with Tretinoin Lotion is performed in the same way as with Glicosal Lotion but, to avoid retinoid dermatitis, it is used one evening a week or at most two non-consecutive evenings a week. The choice between Simple and Combination Micropeeling treatment is up to the dermatologist who assesses the type of acne, skin type and seasonality.

Some possible side effects of micropeeling can be skin dryness and an initial worsening of the skin condition.
Dryness is caused by the peeling agents and the fact that moisturizers cannot be used following application. While dryness can be irritating, it will improve as the treatment progresses.
Similarly, the results from micropeeling are not immediate, with improvements appearing after the second or third month of treatment. It is important to be aware of this, so as not to feel discouraged or tempted to stop the treatment before it has had a chance to work.
Moreover, cases of acne may actually worsen during the first two months of treatment. While it doesn’t always happen, this phenomenon is due to the treatment bringing cysts and comedones up to the surface and, although it may appear the acne is getting worse, it is in fact a sign that micropeeling is working well.

Micropeeling rules

The technique of Simple or Combined Micropeeling is very practical, but certain rules must be observed to ensure that the treatment is as effective as possible.
These rules are:
During the treatment remember to:
Do not use soaps or cleansing milk but wash/make-up with a non-foaming cleanser (such as Eudermic Cleansing Base)
Do not use coloured make-up creams
For make-up it is advisable to use mineral Make-up such as Sun Clay which does not penetrate the skin.
Those who wish to mask skin imperfections during the Micropeeling treatment can apply Argillina Skin Color. This concealer does not cause folliculitis or comedones.

• Do not use moisturizing or emollient creams during the day
• Do not have facials or other types of intense facial cleansing.
• Do not squeeze pimples or blackheads.
• Do not expose yourself to UV lamps or sunlight.
• Do not use other medications or vitamins.
• Do not follow specific diets.
• Do not use sunscreens, as they are loaded with chemical compounds. To protect the skin from UV rays, apply the mineral, light reflectant Sun Clay.

During the treatment, the skin becomes dry and flaky to allow the acne to be eliminated. If burning or redness appears, the Micropeeling is suspended for a few days, the skin returns to normal and then the treatment can be resumed using fewer drops or carrying out Micropeeling on alternate evenings.
In the summer months, when sun creams cannot be used, the Sun Clay mineral photoreflectant is used.
When the skin is too dry and tight and cannot use moisturising/emollient creams, a layer of Extreme Emollient Ointment can be applied in the morning , which does not penetrate the skin and is therefore non-comedogenic. The same Ointment can be used as an under make-up for mineral make-up. If Argillina Skin Color is used, which also has a moisturising effect, it is not necessary to use Emollient Ointment Extreme.

From micropeeling to photodynamic therapy

Simple or combination micropeeling treatment is a very effective treatment for most forms of acne. However, another equally effective treatment, photodynamic therapy (PDT), is also now available.
Photodynamic therapy involves applying an aminolevulinic acid (ALA)-based cream to the area of acne, which then penetrates inside the inflamed acne follicles. Following exposure to a particular intensity and wavelength of LED light, the cream will have transformed into the protoporfirina IX compound after just two hours.
This light activation causes the immediate release of oxygen radicals which sterilize the follicle and, in the days after treatment, make inflammation disappear.
Photodynamic therapy is efficient in eliminating inflammation and, because it does not involve pharmaceuticals, it is harmless and can be performed time and time again. However, it requires much more time and money than micropeeling, with each session lasting for around three hours at varyingly high costs.

Why photodynamic therapy doesn’t replace micropeeling

Ideally, micropeeling remains the treatment of choice, with photodynamic therapy only introduced in combination with micropeeling in cases of inflammatory acne. Photodynamic therapy could also be considered when the patient wants to accelerate treatment of a sudden worsening of acne, which can often be brought on by stress. From micropeeling to PDT: a comprehensive treatment plan without drugs.
The introduction of first micropeeling and, later, photodynamic therapy radically changed the way in which both teenage and adult acne could be treated. With these methods, clear results are achieved without resorting to the use of any drugs, which is a considerable advantage when acne is a condition often affecting teenagers or women of childbearing age. Treating acne without the use of additional drugs is a notable achievement, but it does require consistency on behalf of the patient and trust in the dermatologist. This is particularly important, as acne is not an acute disease but a chronic one with moments of improvement and worsening that follow each other, often without apparent cause.

Photodynamic therapy in acne treatment

• To accelerate healing, eliminate inflammation, reduce scarring and to counteract periods of worsening acne, photodynamic therapy (PDT) is a modern solution.
• PDT does not require drugs and instead uses photodynamic agents and red light treatment to flare the acne follicle (furuncle).
• An ointment containing a substance called 5-aminolevulinic acid (5-ALA) is applied to the area to be treated. This substance is picked up by the inflamed acne follicles and transformed into a photoactive product, that is, one capable of reacting with light (protoporphyrin IX).
• After applying the ointment containing 5-ALA, the area to be treated is covered with special bandages.
• After about two hours, the area is exposed to visible red light of wavelength around 630 nm for 10 to 20 minutes.
• During light treatment, a sensation similar to sunburn may be felt. This feeling will be stronger the more intense the acne is. Although uncomfortable, these sensations of perceived heat are usually well tolerated, and in cases of intolerance, water spray can be applied.
• After treatment, the skin appears red and should be dressed with a special healing ointment without bandaging.
• Over the next week, the acne furuncles in the treated area will dry out and flake off. During this period, apply PEG Ointment twice a day without bandaging, wash with an appropriate washing base, and do not expose the area to strong sunlight or UV lamps.
• After one week has passed, micropeeling treatment can be resumed as prescribed by a dermatologist.
• As long as there is no damage to the structures of the skin, there is no limit to the number of photodynamic treatment sessions a patient can undertake.

One week after PDT: within the enlarged images, the dramatic decrease in comedones is clear.

PDT: alongside a reduction in comedones, inflammation has also considerably reduced.

In this patient, PDT was first used to reduce inflammation. Micropeeling was then used to ensure acne remission.

Adult acne: in this case, inflammation was reduced with PDT, before simple micropeeling performed to achieve remission.