The Frustrating Complexity of Adult Acne

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Sarah Keller walked down a grass aisle bordered with bright sunflowers when she got married just outside the tiny town of Silverton, Colorado in August of 2009. Steep mountains shouldered with trees, wreathed in a tinge of blue further down the valley, provided the backdrop.

Even in that pristine setting, one small thing ended up being a very big deal for Keller: her halter-necked, low-backed dress revealed a chest and shoulders miraculously zit-free. The maddening, confidence-stealing acne blemishes she had battled for years had inexplicably disappeared a few weeks earlier.

Don’t hold your breath to learn her secret. Keller, a journalist now living in Bozeman, Montana, can’t say for certain whether it was the prescription benzoyl peroxide cream she’d slathered on through her late teens and early twenties (probably not, as she was 25 that summer), the probiotic pills she’d been popping, the three-step morning and evening Mary Kay product regimen recommended by her aesthetician, the admonishments not to pick and poke, or the last-ditch attempt acupuncture sessions.

After too many years suffering from acne, Keller had thrown everything she could think of at the frustrating spots. "I was in grad school for science at the time and I usually like to see evidence that things work," she says. "In this case, I just didn’t care. I was going to do everything, try anything to see what would happen."

One of the biggest lies told to get us through our turbulent teen years is that pimples are a bane of adolescence that vanish once you grow up. Depending on what study you read, nearly half of women and at least a third of men get clinical acne well into adulthood. A 2012 study published in the Journal of Women’s Health recruited nearly 3,000 women ages 10 to 70 and found that 27 percent of adults had clinical acne, while an additional 29 percent had mild acne. A teenage thing it is not.

In any case, some combination of luck and what she calls "woo-woo science" worked for Keller. That is, until the newlyweds set off on a honeymoon camping trip. Two days later, the zits were back.

Now 30, Keller still faces occasional breakouts, though her skin has been better in the past year. "I have an okay relationship with my acne now," she says. "I don’t feel like it’s affecting my self esteem, but there have been points where I’ve been more affected or had more of it."

Pimples and inflammation that start in adolescence and linger well into the late twenties is called continuing acne; adult acne that rears its head after years of clear skin is called late-onset.

The acne you see in adulthood is different from the pimples you popped in your teens in that it’s tougher to tackle. Topical ointments often don’t work. Even isotretinoin, the drug first marketed under the name Accutane and considered one of the most potent weapons in a dermatologist’s arsenal, beats back most adult acne for only a short time—stop the treatment and the acne resurfaces. Scientists don’t have a definitive answer why this is so.

In most adult acne cases, zits crop up along the chin and jaw line. The spots tend to get better and then come back a few weeks later with a vengeance. "For many young women, it will be the first sign that their period is coming," says Kanade Shinkai, an associate professor at the University of California, San Francisco and a dermatologist who specializes in acne.

Breakouts that coincide with the menstrual cycle are a sign of adult hormonal acne for women. The phrase is a little confusing—nearly all acne has hormones at its roots—but since treatments that get hormones under control help, it fits.

Some researchers think that adult hormonal acne is on the rise, buoyed perhaps by the stress of modern life or dietary or other environmental factors such as pollution. However, evidence is scant: Though dairy products are commonly rumored to associate with acne breakouts in teens and adults, there aren't any convincing studies that show this is so. Other researchers admit that we simply don’t know enough about hormonal acne patterns and that the increase in adults visiting clinics and dermatology offices for acne-related concerns may just signal that more people are realizing they can seek treatment.

Before diving into the complexity of why adult acne is so hard to treat, let’s cover the basics of acne itself. Surging hormones during puberty stimulate glands in the skin to pump out more oil, or sebum. When dirt, skin flakes, or cosmetics clog skin pores, the extra sebum gets locked in the hair follicle. Sebum in a closed clogged pore stays light—a whitehead. If the top remains open, the sebum turns dark when it hits the air and we call the result a blackhead.

The next step happens when bacteria called Propionibacterium acnes that lives on the skin’s surface move in and chow down on the sebum sitting around. Infection follows, the skin gets red and painful, and a full-blown pimple mars the face.

"It's not essential to treat from a skin health perspective," says Shinkai. But studies that measure the quality of life—how happy a person is and whether they can accomplish day-to-day tasks—show that having acne can profoundly affect mental and emotional health.

Shinkai points to a 2014 study which found that people who thought their acne was bad (a matter of perception, not a clinician’s assessment) took a blow to their well-being that was just as profound as that delivered by living with a chronic disease. "This is important to recognize as not just being skin deep," she says.

Drier, less resilient skin is one reason acne in adult women is trickier to treat. To make matters worse, acne in teens is widespread and viewed as a stumbling block of puberty, while adult acne can be seen as a sign the sufferer isn’t practicing proper hygiene or just doesn’t care. As any woman plagued by pimples can attest, this is far from the truth.

"People who do not have acne don’t understand how socially and emotionally devastating it is," says Poppy Gard, a practice administrator at Pure Dermatology, who has more than 15 years experience advising adult acne patients.

Gard, now 44, recalls being "totally in love" with a guy in grad school. "But I was so preoccupied," she says. Her acne kept her running to the bathroom to see if her makeup had stayed in place any time they kissed. "I became a master camouflager," she says. "I was always self-conscious about my skin."

Her frustration over acne in her mid-20s drove Gard to research possible causes and eventually to choose the career she enjoys today. When she was working as an aesthetician in her late 30s, her camouflage game only got stronger. "People would tell me, ‘Your skin looks so great!’" she says. "But it was because I had spent four hours on it."

Gard used mineral-based powders and a whole platoon of high-quality makeup brushes—"tiny little brushes like watercolor brushes"—plus careful feathering to blend in yellows and greens that obscured the red of her pimples. Finally, though, her acne cleared up. "My skin did shift when I was 41 or 42," she says. "It was hormonal."

Fortunately, experts have cooked up some solutions for hormonal acne that don’t involve just waiting until it gets better.

"I work in the public eye, in customer service," says 23-year-old Becca Rose, who asked not to go by her full name. She works part-time as a children’s librarian in Northern California and gets cystic acne so painful that a stray lock of hair brushing against her cheek can cause her to stop talking and grit her teeth. "It's a real confidence breaker."

Becca Rose also has polycystic ovary syndrome (PCOS), a hormonal disorder that often comes with irregular menstrual cycles, obesity, enlarged ovaries, excess hair growth, and yes, acne. "All these factors you are fighting to control can make acne seem like the least of your worries," she says.

Since women with the disorder have high levels of the same hormones responsible for adult acne, learning how the condition responds to treatment can offer some insight into helping adults with acne who don't have PCOS. One of the main medications physicians prescribe for adult hormonal acne was actually first used in women with polycystic ovary syndrome—but it wasn’t originally intended for them

Spironolactone was first developed in 1957 and used to treat hypertension and patients with heart failure. It's a diuretic that causes people to urinate more and get rid of excess liquid without draining them of salts the body needs to function.

Physicians soon noticed the drug actually wasn’t a great diuretic, but it did lessen some of the symptoms of PCOS. Spironolactone has many different effects on the body, including alterations in the way some hormones are made and processed, explains Arash Mostaghimi, a physician specializing in dermatology and internal medicine at Brigham and Women’s Hospital in Boston, Massachusetts. The drug specifically affects testosterone and other hormones typically associated with men, but also produced by women, called androgens.

Androgens in men and women are one of the main classes of hormones that tell skin glands to produce more sebum and contribute to acne. Spironolactone blocks the receptors for these androgens and also aids the body in mopping up excess testosterone. As a result, spironolactone can bring down androgen levels in women with PCOS.

It also seems to help women with adult hormonal acne, even if they don’t have excess androgens. In these women, it may be that they are particularly sensitive to androgens and even "normal" levels can be enough to trigger acne, posits Mostaghimi.

This uncertainty is surprisingly typical of our understanding of the biology of acne. Despite the skin condition's prevalence, there has been relatively little research on it, and what we do know is complex. "Every time we learn something new, there is always the suggestion that it is a little bit more complicated than we thought," Mostaghimi adds. "It’s like peeling layers of an onion."

Fortunately, Mostaghimi has answered at least one question about acne treatment. Spironolactone has been used to address acne since the early 1980s, but the FDA has never officially approved this use; dermatologists and physicians instead prescribe it off-label.

The original heart failure patients on spironolactone were at risk of retaining too much potassium when on the drug, a condition called hyperkalemia that can lead to heart arrhythmia and death. To prevent this, doctors regularly monitored patients' potassium blood levels. When young healthy women took spironolactone, it was considered safer to also monitor their potassium levels every few months.

However, no one knew if those women should even be worried about hyperkalemia, so Mostaghimi led a study, recently published in JAMA Dermatology, that combed through the records of 1,000 women who had taken spironolactone some time over the course of a 15-year span; not one had developed hyperkalemia.

"It doesn’t mean the possibility is zero," he says. "But it does mean it is exceedingly rare." Bolstered by decades of physicians and dermatologists utilizing spironolactone to treat acne, Mostaghimi says the routine screening isn’t necessary. This means that prescribing the medicine now doesn’t need to come with the added burden of extra trips to a clinic, or the cost of running the tests.

Combining spironolactone with the other mainstay for hormonal acne treatment, birth control pills, will give about 60 percent of adult women notable improvement, says Shinkai. The drug combats the effects of androgens and the birth control offers a boost to the body’s supply of estrogen. Another plus is that concerns about birth control pills increasing the risk of blood clots in otherwise healthy young women have lessened with the most recent generation of birth control pills.

Reassurances about these two medications are also helping physicians move away from another acne treatment that is effective, but comes with a different set of worries. Antibiotics can keep P. acnes, the bacterial culprit behind acne, at bay. However, rampant over-use of antibiotics has created microbes that resist even our most powerful drugs against them. While antibiotics may clear the skin temporarily, dermatologists no longer prescribe them for long-term use to avoid contributing to this problem.

These advances are offering more relief than ever before, but treatment remains incredibly personal. People have told Becca Rose to simply wash her face, as if that was the obvious solution. Instead, she opts for an organic bar soap followed by witch hazel as a toner. Sometimes she’ll rub argan oil on the non-acne affected parts of her face and tea tree oil on her blemishes. She doesn’t usually use concealer, but she will choose a bold lip color or eyeliner. "If there is one part of my face that I feel confident about, I want to show it off," she says.

"I am someone who would rather judge someone based on who they are instead of what is on their face," Becca Rose continues. "But the world is not always like that."

Editor: Julia Rubin