A clinicoepidemiological study of adult acne: Is it

different from adolescent acne?

Original
Article

Niti Khunger, Chandan Kumar

Department of Dermatology
and STD, VM Medical College
and Safdarjang Hospital,
NewDelhi, India
Address for correspondence:
Dr. Niti Khunger,
Department of Dermatology
and STD, VM Medical
College and Safdarjang
Hospital, NewDelhi, India.
Email:
nitikhunger@hotmail.com

ABSTRACT
Background: Although acne is usually recognized as an adolescent skin disorder, the
prevalence of adults with acne is increasing. There is surprisingly a paucity of data on the
prevalence and clinical features of postadolescent acne in the adult Indian population.
Aims:The clinical and epidemiological data of adult acne were evaluated with a view to
establishing possible contributing etiological factors and observing whether clinical features
differ from adolescent acne. Methods: Patients over the age of 25years presenting with acne
in a tertiary care hospital were included in the study. Adetailed history and examination was
carried out, with a stress on aggravating factors. Hormonal imbalances were investigated
in females with alopecia, obesity, hirsutism and menstrual irregularity. Severity of acne
and complications like scarring and psychological stress were included. Results: Out of
280patients included in the study 82.1% were women and 17.9% were men. The mean
age of the patients was 30.5years. Persistent acne was observed in 73.2%, while it was
late onset in 26.8%. Majority of the patients had inflammatory papular acne (55%), whereas
comedonal acne was the least common (6%). Most common predominant site of involvement
was cheek (81%), followed by chin (67%), and mandibular area (58.3%). Family history
of acne was present in 38.6%. Premenstrual flare was seen in 11.7% of female patients,
obesity in 6.4%, hirsutism in 5.7% and alopecia in 1.8%, but raised laboratory markers of
hyperandrogenism were observed in only 3.08%. Scarring was observed in a majority of
patients (76.4%) and psychological stress in 52.8% patients. Conclusion: Adult acne is
predominant in women, and as compared to adolescent acne is more inflammatory, with
involvement of the cheeks and lower half of the face, while comedones are rare. Facial
scarring occurs in a majority and stress is common, which emphasizes that adult acne
should not be neglected.
Key words: Acne, adult, inflammatory, women

INTRODUCTION
Acne is one of the most common skin disorders
worldwide and occurs primarily at puberty with
a prevalence of almost 95%.[1] Although acne is
principally a disorder of adolescence, the prevalence
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of adult patients with acne is increasing.[2] Adult

acne has been traditionally defined as presence of
acnebeyond the age of 25years.[2] There are two
types of adult acne; persistent acne and lateonset
acne. Adolescent acne persisting beyond the age
of 25years is called persistent adult acne and
acne developing for the first time after the age of
25years is called as lateonset adult acne. Both the
types are more common in women. In persistent
acne, patients have lesions on most days and may
experience a premenstrual flare. Late onset acne can
be further subdivided into chin acne, which occurs
around the chin and perioral area, is inflammatory
and flares premenstrually and sporadic acne which

How to cite this article: Khunger N, Kumar C. A clinico-epidemiological study of adult acne: Is it different from adolescent acne?. Indian J
Dermatol Venereol Leprol 2012;78:335-41.
Received: May, 2011. Accepted: November, 2011. Source of Support: Nil. Conflict of Interest: None declared.

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335

Khunger and Kumar

Study of adult acne

occurs suddenly in adult life with no distinguishing

features.[3] It has been reported that patients with
adult acne have a 40% prevalence of psychiatric
comorbidity.[4] There is surprisingly, relatively few
data on the prevalence and studies of acne in the
adult population and to our knowledge none in
the Indian population. The objectives of this study
were to observe the prevalence, clinical features,
contributing etiological and aggravating factors of
acne in adults, with a view to establishing possible
etiological factors and highlight possible differences
from adolescent acne.
METHODS
The study was conducted over a period of 18months
from November2008 to April2010. Ethical clearance
was not obtained as it was an observational study.
Patients over the age of 25years presenting with acne
vulgaris in the outpatient department of dermatology
in a tertiary care hospital in north India were included
in the study. A detailed history and examination was
carried out for each patient, including a medical and
family history. Information about the extent and site
of involvement, aggravating factors including drug
intake, sun exposure, seasonal variation, application
of cosmetics, stress, premenstrual flare and influence
of pregnancy on acne was obtained. Gynecological
and obstetrical history of female patients was
noted. Clinical assessment of each patient included
type of acne lesions, distribution, severity and
grading of acne. Acne vulgaris was graded using a
simple systemtaking into account the predominant
lesionspresent; thus classifying acne into four
grades.[5]
Grade1: Comedones, occasional papules.
Grade2: Papules, comedones, few pustules.
Grade3: Predominant pustules, nodules, abscesses.
Grade4: Mainly cysts, abscesses, widespread scarring.
Acne scars were graded into mild, moderate and severe
according to the qualitative grading system.[6]
Rosacea was excluded on the basis of clinical
examination. Associated findings such as obesity,
hirsutism and alopecia indicating hormonal
imbalance were also noted and investigations for
polycystic ovarian disease and insulin resistance
were done when indicated. Hormonal evaluation
in terms of serum level of total testosterone, serum
dehydroepiandrosterone
(DHEAS),
luteinising
336

hormone (LH), follicular stimulating hormone (FSH)

and prolactin (PRL) were done. Stress was evaluated
through a questionnaire answered by the patient.
A subjective assessment of its association with
aggravation of the acne was made by the patient.
Results were derived by simple statistical means of
percentage and proportions.
RESULTS
The study included 280patients, 230(82.1%)
women and 50(17.9%) men, with a M:F=1:4.6. The
prevalence of adult acne presenting for treatment
in our study was found to be 0.38% (280patients
out of 72710patients attending the OPD during the
study duration). The mean age of the patients was
30.5years with a range of 2650years. The proportion
of population of different age groups is detailed in
Table1.
The duration of acne varied from minimum of 2weeks
to as long as 30years. Proportion of patients having
persistent acne was 73.2% (205patients comprising
of 160females and 45males) while those havinglate
onset acne was 26.8% (75patients comprising of
73females and 2males). There was no difference
in clinical features between persistent acne and late
onset acne. Majority of the patients were having acne
gradeII (55%) followed by gradeIII (28%), gradeIV
(12%) and gradeI (6%) [Figure1]. Facial involvement
was seen in all, except six patients in whom only
truncal involvement was present. On the face, cheek
was the most common site involved (81%) followed
by chin (67%), mandibular area (58.3%), forehead
(51.7%) and nose (18.3%) [Figure2].
Onset of acne due to drug use was found in only three
cases (Two due to antitubercular therapy and one due
to antipsychotic medications). Topical steroid usewas
found to be an important factor responsible for
aggravation of acne in our study population (11.8%).
Table 1: Prevalence of adult acne according to age
Age group
(years)

Number of
patients
N=280(%)

Males
N=50(%)

Females
N=230(%)

26-30

141 (50.35)

29 (20.6)

112 (79.4)

31-35

85 (30.35)

12 (14.1)

73 (85.9)

36-40

37 (13.2)

4 (10.8)

33 (89.2)

41-45

11 (3.9)

3 (27.3)

8 (72.7)

46-50

6 (2.1)

2 (33.3)

4 (66.7)

>50

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Khunger and Kumar

Study of adult acne

Figure1: Severity according to grade of acne

Figure2: Genderwise distribution of acne over face

Family history of acne with first degree relative

involved was found in 108(38.6%) patients. Seasonal
aggravation in acne was noted, summer being the most
common (36.4%) followed by rainy season (5.0%) and
winter season (1.4%) season. Exposure to sunlight
was also responsible for aggravation in 93(33.2%)
patients. Regular use of cosmetics was present in
178(63.5%) patients with aggravation of acne due
to cosmetics in 40(14.3%) patients. Aggravation
due to stress was seen in 72(25.7%) of our patients.
Premenstrual flare was seen in 27(11.7%) of female
patients. Associated conditions such as obesity were
observed in 6.4%, hirsutism in 5.7% and alopecia in
1.8%. Laboratory evidence of hyperandrogenism in
the form of raised testosterone levels was seen in only
7 out of 230female patients (3.04%). Serum DHEAS
and PRL were not deranged in any patient. Serum LH
was found to be raised in 3patients. Serum FSH was
decreased in one patient, the ratio of LH:FSH was >2:1
in 2patients, favouring polycystic ovarian syndrome.
Ultrasonography report of two patients favoured a
diagnosis of polycystic ovarian disease (PCOD). Only
two patients had raised level of insulin, indicating
insulin resistance. Pregnancy was associated with
worsening of acne in 11(5.6%) female patients
while improvement was observed in 14(7.1%) out of
197females who underwent a pregnancy, while the
rest (87.3%) reported no significant change in acne
during pregnancy.

scars (44.3%) followed by icepick (28.6%), rolling

atrophic (27.1%) and keloidal (1%) types [Figure3].
Psychological stress due to acne was reported in
148(52.8%) patients.

Complications of acne studied included facial

scarring and psychosocial stress. Acne scarring was
observed in a majority of patients (76.4%). It was
mild in 149(69.6%) patients followed by moderate in
60(28.1%) and severe in 5(2.3%) patients. Majority
of the scars were persistent pigmented macular

DISCUSSION
Acne is traditionally considered as a disease of
adolescent age and there are very few reports on
postadolescent or adult acne. In a hospitalbased
Indian study, 9.4% patients (29 out of 309) were more
than 25years.[7] Although acne usually declines after
the age of 40years, in our study, it was still present
in 2.1% of patients beyond 45years. In comparison,
Goulden etal.,[2] reported acne in 12.5% beyond
45years. Adult acne is more common in women.[2,3,8,9]
Similarly, in our study women were predominantly
affected (82.1%) as compared to men (17.9%). This
may represent an increased awareness in women
seeking treatment as compared to men. However, a
communitybased survey of more than 700adults
older than 25years also reported clinical facial acne
in 12% of women and 3% of men.[2] Hormonal factors,
increased use of cosmetics and exposure to hot and
humid conditions while cooking may play a role in
increased prevalence of adult acne in women.
Adult acne can either persist from adolescence or be late
onset beginning in adulthood. In our study acne was
persistent from adolescence in a majority of patients
(73.2%) which is in concordance with the study of
Goulden etal.,[2] where 82% of the population had
persistent acne. Thus in a majority, acne develops in
adolescence and persists into adulthood. Genderwise
late onset adult acne is predominant in women
(97.3%) as compared to men (2.7%). Morphologically,

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Khunger and Kumar

Study of adult acne

the classical presentation of adult acne has been

described as inflammatory papulopustular lesions
in the mandibular and chin area.[2,9,10] Capitanio
etal.,[11] described another variant called comedonal

Figure3: Scarring in acne

postadolescent acne, in which inflammatory lesions

were sparse but large prominent cystlike comedones
were homogeneously distributed on the whole face
with a relative absence on the lower third of the face
and the jawline. This variant was common in smokers.
Smoking as an etiological factor was not studied in our
patients. Our study revealed that clinically, adult acne
in Indian patients usually presents as inflammatory
papules and pustules (83%) and is mild to moderate
in severity (gradeII in 55% of patients and gradeIII in
28% of patients) [Figure4]. Comedonal acne is rare as
compared to adolescent acne. However, cystic acne is
not uncommon and was still present in 12% of adult
patients [Figure5]. Similar results were observed
by Goulden etal.,[2] where postadolescent acne was
predominantly inflammatory.
Postadolescent acne is predominantly facial and in
our study only six patients (2.1%) had only truncal
involvement without facial involvement. This may

Figure4: Inflammatory papulopustular acne on the cheeks in a 34yearold woman

Figure5: Nodulocystic acne in the chin and mandibular area in a 28yearold woman
338

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Khunger and Kumar

also be due to the fact that pure truncal involvement

is not cosmetically distressing, hence fewer patients
present for treatment. In our study a surprising finding
was that involvement of the cheek was the most
common site on face in comparison to involvement of
mandibular area. This is in contrast to studies from
western countries that have reported involvement of
lower face and mandibular area more commonly in
adult acne cases.[2,10,11]
The causes of postadolescent acne remain to be fully
elucidated and hormones, colonization by resistant
bacteria, the use of cosmetics, drugs and chronic
stress have been put forward as possible etiological
factors. Since adult acne is more common in women,
there has always been an emphasis on underlying
hormonal imbalance. The role of circulating androgen
levels in adult acne still remains controversial. In our
study, features suggestive of hyperandrogenism such
as hirsutism was observed in 6.95% and alopecia in
2.17%. However, although clinical features suggestive
of hyperandrogenism such as premenstrual flare
(11.7%), hirsutism (5.7%) and alopecia (1.8%) were
present, only 7(3.04%) women had raised laboratory
markers of hyperandrogenism. In the study by
Goulden etal.,[2] 37% of women had at least one
feature of possible hyperandrogenism as characterized
by hirsutism (24.2%), alopecia (7.2%) or menstrual
disturbance (17.7%). In our study, premenstrual flare
was observed in 11.7%, whereas Goulden etal.,[2]
observed premenstrual increase in 84.8%. Polycystic
ovaries have been reported in 5282% of patients with
adult acne, but hormonal profiles were not in keeping
with the classical polycystic ovary syndrome.[12]
Another study showed that 11.8% of patients with post
adolescent acne had reduced activity of the enzyme
21hydroxylase, suggesting lateonset congenital
adrenal hyperplasia.[13] In another study of 13patients
with late onset adult acne, underlying abnormalities
in levels of androgens were not observed, but onset
was related to stress.[14] These patients failed to
respond to antibiotics and to isotretinoin, but five of
the patients had clearance of acne after fluoxetine
was prescribed for depression. Kligman[15] proposed
that perhaps the major etiological factor in adult acne
was increased levels of stress, leading to increase in
adrenal androgens. Another study reported finding
significantly higher levels of adrenal testosterone
and DHT in adult women with acne compared with
controls.[16] In a contrasting study, adrenal androgens
in 9women with postadolescent idiopathic acne

Study of adult acne

were not significantly raised as compared to age and

sexmatched normal controls.[17] Studies concluded
that adrenal androgen secretion is only mildly
elevated in patients with post adolescent acne but
patients without acne may have similar hormone
levels.[17,18] These contrasting findings suggest that
endorgan hypersensitivity and not androgen levels
may be the central factor in development of adult acne
in women.[19] Increased sensitivity of the sebaceous
gland to androgens or increased local metabolism of
androgen hormones in the skin to potent androgen
metabolites may offer alternative mechanisms for
the pathogenesis of this disorder.[17] More so, studies
are there to support the concept that target tissue
androgens might play a major role in pathogenesis
of female acne.[20] It is possible that a certain number
of follicles are acneprone and these follicles have
different levels of susceptibility to the circulating
hormones.
It has been suggested that chronic stress might be a
possible cause of increased androgen secretion in
some of the women, resulting in the pathogenesis of
acne in such patients.[15] Several such reports have
been published regarding the association of increased
level of cortisol and emotional stress.[21] In our study,
25.7% patients reported on stress as an aggravating
factor, in contrast to Goulden etal.,[2] who reported
that in 71% of their patients acne flared with stress.
In our study, pregnancy was associated with worsening
of acne in 5.6%, while improvement was seen in 7.1%,
and a majority observed no change. This is in contrast
to the study by Goulden etal.,[2] where pregnancy
resulted in a flare in 18%, improvement in 43%, and
had no effect in 39%.
Steroids have been implicated in causation of acne by
inducing hypercornification of the upper portion of
pilosebaceous unit. There was no significant relation
with drug usage in our patients, except the use of
topical steroids which caused aggravation in all the
patients applying it (11.8%). In three of our patients it
was evident that the acne was precipitated due to drug
use (2 due to antitubercular therapy and 1 due to anti
psychotic medications). Similar results were reported
by Goulden etal.,[2] where prednisolone, lithium,
anabolic steroids and phenytoin were causative factors
in five patients.
Cosmetic induced acne has been originally discussed

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Khunger and Kumar

Study of adult acne

as an important cause of mild to moderate acne in

female subpopulation.[22] In our study only 40patients
(22%) out of 176 using some form of cosmetics,
reported aggravation due to cosmetic use. Similarly,
other studies do not reveal cosmetic as an etiological
factor in adult acne.
It has been traditionally believed that acne improves
in summer and aggravates in winter. However, in our
study, sun exposure and summer season were found
as aggravating factors in 32% and 36.7% of our cases
respectively. Similarly, an Indian study observed that
in a majority (80.62%) of patients a summer aggravation
of acne was seen.[23] It is possible that UV radiation,
which may cause inflammation and generate squalene
peroxides which are highly comedogenic, may play a
role in the persistence of acne in tropical countries,
in addition to sweating and increased humidity.[24,25]
No differences in bacterial flora have been observed
between adolescent and adults with acne, hence
antibiotic resistant bacteria and high antibody levels
to P. acnes seem unlikely to be involved in the
pathogenesis of postadolescent acne.[26]
It has been suggested that acne might be familial
according to the results of a large study of identical
twins showing 97.9% of affection.[27] In our study
population, 38.8% patients had at least one first degree
relative affected with clinical acne, while Goulden
etal.,[2] observed a higher incidence of 50%. Hence it
seems to be true that genetic factors might play role in
acne development and persistence.
Scarring in adult acne is more common as compared
to adolescent acne. This is probably because acne in
adults is predominantly inflammatory, may be resistant
to treatment and treatment is often delayed, which
leads to greater scarring. Scarring was very common
in our patients (76.4%), with predominantly persistent
pigmented lesions followed by icepick and rolling
atrophic scars. One Indian study for acne of all groups
documented scarring and hyperpigmentation in 39.5%
and 24.6% of patients respectively.[7] Goulden etal.,[2]
observed scarring in 77.2% men and 58.5% women
and icepick scars were the commonest type. Thus
there are no predominant etiopathogenetic factors in
adult acne. The differences between adolescent acne
and adult acne are highlighted in Table2.
Patients with adult acne are now being recognized as an
increasingly important population requiring treatment.
340

Table 2: Comparison between adolescent and adult acne

Adolescent acne

Adult acne

Age

Puberty and
adolescence

>25 years

Sex

More common in
males

Predominantly women

Severity

Varying from mild

Commonly low grade
comedonal to severe inflammatory, papular
nodulocystic

Sites

Facial-cheek
Truncal-common

Facial-cheek, chin,
mandibular Truncal- rare

Predominant type Comedones

of lesions

Inflammatory
papulopustules

Comedones

Common

Comedones rare except

in smokers

Inflammatory
papules

Common

Very common

Cysts

Can occur

Rare

Scarring

Depends on severity Common

Sebum production Increased

Normal or increased

Microbial flora

P acne

Similar to adolescent acne

Hormonal
influences

May occur

More common

Response to
treatment

Expected outcomes

Often refractory with

relapses

Though inflammatory lesions are more refractory to

treatment, in most cases, prescribed therapies are very
similar to those used for adolescent acne. Hormonal
therapy should not be the first line for acne treatment,
but is appropriate for women with raised androgen
levels or signs of hyperandrogenism, refractory acne
and those who also require contraception.[19] The chief
limitation of our study is that response to treatment
was not included in the observations.
CONCLUSIONS
Acne as a disease is lasts longer, persists into adulthood
and requires treatment well into the forties. Patient
with post adolescent acne remains a challenge to
treat. There are hardly any welldocumented studies
that define why acne persists or begins in adulthood,
why adult women continue to be affected with acne
significantly more than adult men and what is the role
of etiological and aggravating factors in the presence
of acne well beyond adolescence. To the best of our
knowledge this is the first Indian study on adult
acne. Unlike teenage acne, where males tend to be
affected more commonly and show the most severe
forms of the disease, postadolescent acne mainly
affects females and is more inflammatory in nature. It
is predominantly facial and unlike previous studies,
in Indian patients, cheeks are still the commonest

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Khunger and Kumar

predominant site of involvement. Facial scarring

occurs in a majority of patients and emphasizes the
fact that adult acne should be adequately treated.
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