SAN FRANCISCO – Dermatologists are seeing an increasing incidence of adult women with acne in their offices and they are a clear challenge to treat, Dr. Hilary E. Baldwin said.

Compared to teenagers, women in their 30s, 40s and 50s and their acne lesions can be more resistant to treatment, Dr. Baldwin said at a seminar on women’s and pediatric dermatology sponsored by Skin Disease Education Foundation (SDEF).

"One of the problems of treating moderate to severe acne in the adult woman is that topical medications may not work particularly well. It may be that she is a little harder to treat, but also she has acne on the neck and the jaw, which is more sensitive skin, and the topical products tend to be quite irritating," Dr. Baldwin said.

Acne after adolescence also can be more psychosocially devastating. Unlike a teenage girl, an affected woman may have no one else in her social group who has acne. And "because teenagers are supposed to have acne," Dr. Baldwin said, "people will question: What is she doing wrong? Is she not eating right?"

Acne can have a detrimental effect on sexuality, motherhood, and/or returning to the workplace, and can deepen a midlife crisis, said Dr. Baldwin, vice chair of the Department of Dermatology at SUNY-Downstate in Brooklyn, N.Y.

With fewer topical agents in their armamentarium for the adult woman with acne, dermatologists tend to prescribe oral medication, Dr. Baldwin said.

Oral antibiotics are an example, such as anti-inflammatory dose doxycycline (acne is an off-label indication). This agent does not kill Propionibacterium acnes, but can improve acne through an anti-inflammatory effect similar to full-dose doxycycline, Dr. Baldwin said.

One caveat: if you prescribe an oral antibiotic, you may experience pushback from some patients, Dr. Baldwin said. "I have women who say that they get a yeast infection every time they get an antibiotic." Strategies include antibiotic treatment through a yeast infection; a simultaneous prescription to prevent yeast growth; and/or selection of an antibiotic less likely to cause this effect. For example, extended-release minocycline may be less likely to spur yeast growth than traditional minocycline, she said.

Non-antibiotic alternatives for moderate to severe acne are limited, especially in women of child-bearing potential.

Oral hormonal contraceptives also can improve acne in adult women, Dr. Baldwin said. In the United States, ethinyl estradiol/norethindrone acetate (Estrostep, Warner Chilcott); drospirenone/ethinyl estradiol (Yaz, Bayer); and ethinyl estradiol/norgestimate (Ortho Tri-Cyclen, Ortho McNeil Janssen) are FDA-approved for acne treatment "and others with estrogen may be effective."

Because their full acne-fighting effects can take up to 6 months, Dr. Baldwin recommended prescription of oral contraceptives in combination with a quicker onset agent. "For me it’s a medication on top of a medication that is going to give more immediate improvement, one I can take them off when I start to see the oral contraceptive kick in."

"The difference becomes significant with Yaz at about 6 months," Dr. Baldwin said. "But waiting for 6 months for this to happen is not something most of our patients will do."