Inflammatory Papulopustules in a Young Woman


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A 24-year-old Caucasian woman presented with intermittent, inflammatory papulopustules and nodules on the face, neck, chest, and back. The lesions would appear 1 week premenstrually and resolve 1 week postmenstrually with normal menstrual cycles. She has a history of adolescent acne that is only responsive to isotretinoin 6 years ago. Examination revealed scarring and postinflammatory hyperpigmentation diffusely on her face.

Acne vulgaris, known for its high prevalence in adolescents, was reported to occur in more than half of women older than age 25 years.1 Postadolescent acne appears more in adult women than in men.2-8 Due to the time of onset...

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Acne vulgaris, known for its high prevalence in adolescents, was reported to occur in more than half of women older than age 25 years.1 Postadolescent acne appears more in adult women than in men.2-8 Due to the time of onset of adolescent acne, the age of occurrence in adults is not clearly defined.9 There are 3 subtypes of adult female acne. Most commonly, persistent acne begins in adolescence and continues into adulthood. According to most sources, late-onset acne occurs after 18 to 25 years. Least commonly, relapsing acne initially occurs during adolescence, resolves for a few years, then reappears during adulthood.

Acne vulgaris derives from a combination of inflammatory reactions, hyper-seborrhea, differentiation of keratinocytes, hyper-keratinization of the pilosebaceous follicles, and increased anaerobic Gram-positive bacteria, Propionibacterium acnes, which survives on sebum and stimulates inflammation.8,10,11 Androgens are also believed to play a role in the etiology of postadolescent female acne and can increase the size of sebaceous glands to stimulate sebum production.12 Additionally, most female adults with acne complain of premenstrual flares, coupled with menstrual cycles, typically described as being the most aggravating factor. The exact mechanism responsible for premenstrual flares is unknown, though it has been proposed that reduced openings of the pilosebaceous follicle produce excessive sebum in the sebaceous glands.11,13,14 Stress, diets inclusive of dairy products, exercise, cosmetics, and genetics may all be contributing factors.8,9,15-17 

Female adult acne most commonly presents as mild to moderate, and severe acne, indicating a high number of lesions, is rare in adult women.8 Acne in postadolescent women mainly appears on the face, but the chest, neck, and back can be affected.8 Similar to adolescent acne, female adult acne can present as inflammatory lesions, such as papules, pustules, and nodules, as well as noninflammatory lesions, such as open and closed comedones, and cysts.18 There are two clinical presentations of female adult acne, retentional and inflammatory. The retentional form consists of numerous comedones with a few inflammatory lesions that appear on multiple zones of the face. The inflammatory form is comprised of papulopustules and nodules appearing mainly on the lower face, chin, and mandibular region. An explanation regarding the presentation of inflammatory acne is unknown.8,19 Lesions localized to the mandible are the stereotypical presentation of female adult acne.9 While some studies support this appearance, others have found that mandibular localized acne is only a small subtype of female adult acne and the majority of cases involve multiple facial areas.8,9,20 More than half of the participants with perimenstrual acne in one study complained of worsening acne 1 week before menstruation, though there were also complaints of worsening symptoms during menses, postmenstruation, or continuously throughout their entire cycle.11

Female adult acne is a clinical diagnosis. Laboratory evaluation may be indicated to rule out an underlining endocrine disorder if the patient presents with symptoms of hyperandrogenism, signs of virilization, or subcutaneous signs such as abrupt onset of severe acne, hirsutism, acanthosis nigricans, and alopecia.15,20 The most common cause of hyperandrogenism is polycystic ovary syndrome.20 Another common differential diagnosis for acne vulgaris is rosacea. Rosacea is an inflammatory disorder that presents with inflammatory papulopustules, telangiectasia, or erythema in the centrofacial location.21 Some patients have rosacea and acne simultaneously.22 Several signs can differentiate rosacea from acne, such as the hallmark rosacea characteristic of facial flushing, worsened by heat, alcohol, or spicy food. Additionally, rosacea occurs in older patients, with the typical age of onset between 30 and 60 years.22,23 More than half of rosacea patients also have ocular manifestations.24 Unlike acne, rosacea does not appear with comedones, nodules, cysts, and scarring, and rarely has lesions on the trunk.21, 22 

Typical treatment regimens such as antibiotics and topical or systemic retinoids can be used in postadolescent female acne. Topical retinoids include tretinoin, adapalene, tazarotene, and isotretinoin (not available in the US). Topical antimicrobials include benzoyl peroxide, clindamycin, erythromycin, and dapsone. Topical combination products include ­benzoyl peroxide/clindamycin, benzoyl peroxide/erythromycin, clindamycin/tretinoin, and benzoyl peroxide/adapalene. Azelaic acid and salicylic acid are also options. Oral antibiotics include tetracycline, doxycycline, minocycline, erythromycin, trimethoprim-sulfamethoxazole, and azithromycin. Hormonal agents include combination oral contraceptives (estrogen/progestin) and spironolactone. Furthermore, the oral retinoid to treat acne is oral isotretinoin.25

Hormonal therapy can improve acne in patients with and without hyperandrogenism. In patients with androgen levels in the normal range, hormonal therapy is usually indicated for postmenarchal women with moderate to severe acne who are not planning to become pregnant, and those unresponsive to topical treatment. Hormonal therapy for pregnancy prevention has an additional benefit of improving mild acne, but topical regimens will also treat mild acne.25 

Major systemic treatment options for women include oral antibiotics, hormonal therapy, and oral isotretinoin. There are not enough studies to compare the effectiveness of oral antibiotics and hormonal therapy, but they are both considered first line for moderate to severe acne in women. It is suggested that women with normal serum androgen levels who present with acne involving the lower face and premenstrual acne flares may be more likely to respond to hormonal agents than oral antibiotics. Hormonal therapy is usually adjuvant, given in conjunction with topical or oral antibiotics, as well as topical retinoids. However, hormonal therapy does not deliver immediate results. Improvement requires at least 3 to 6 months of treatment.25 

The prevalence of acne decreases with age, which suggests spontaneous resolution.26 Women, however, may experience acne for many years. In one study, the average duration for adult female acne was 20.4 years.16 Also, acne can cause scarring and postinflammatory hyperpigmentation, and there is a high correlation of depression, anxiety, lack of confidence, self-consciousness, and an inability or lack of focus in women with acne.9,27 

Although our patient continued hormonal therapy, topical tretinoin was discontinued due to intolerable skin irritation. Patient education included topical tretinoin compliance, strategies to decrease inflammation, length of therapy (6 to 12 weeks) before improvement, stress management, and follow-up in 12 weeks. 

Hillary Hendley is a student at Augusta University, and Alicia Elam, PharmD, is associate admissions director, Physician Assistant Department, Augusta University, in Georgia.


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