Am J Clin Dermatol 2004; 5 (6): 459-462 1175-0561/04/0006-0459/$31.00/0

PRACTICAL DERMATOLOGY

© 2004 Adis Data Information BV. All rights reserved.

Acne and its Management Beyond the Age of 35 Years Ronnie Marks Cardiff University, Cardiff, UK

Abstract

Although acne is not usually considered to be a disorder that affects the elderly, the disorder occurs sufficiently often in mature individuals to be noteworthy. The variety known as ‘persisting acne’ is, as its name suggests, ordinary acne that continues into adult life. ‘Chin acne’ is a curious type that occurs premenstrually in mature women, while ‘sporadic acne’ describes the sudden development of significant acne in later life for no apparent reason. When acne develops in an individual outside the usual susceptible age group precipitating causes such as exposure to comedogenic substances or drugs must be excluded. Similarly, endocrine causes such as androgen-secreting tumors and the administration of anabolic steroids need to be considered. All inflammatory processes are decreased in the elderly and this may be one reason for the persistence and intransigence of acne lesions in older age groups. The principles of treatment of acne in the elderly do not differ from those in other age groups, although the emphasis during counseling needs to focus on explanation and reassurance rather than prognosis. Topical retinoids and benzoyl peroxide easily irritate elderly skin, so azelaic acid and even sulfur preparations are preferable. Low-dose systemic isotretinoin is reported to be helpful to patients in this age group and is certainly worth a trial.

The diagnosis of acne in senior citizens is usually greeted with incredulity on the part of both the patient and the referring physician. Acne is a disease of adolescence when the flood of sex hormones causes hypersecretion of sebum provoking the forma-

The aim of this article is to point out that acne is not confined to adolescence and may be associated with special features in the elderly. 1. Clinical Features

tion of comedones. How can it also affect the elderly? We do not have a complete answer to this apparent paradox except to point out that acne is essentially a type of folliculitis and the follicular apparatus seems to continue its susceptibility to acne into senescence. It is also worth remembering that acne is not only a matter of sebum. After all, inflamed acneiform lesions are sometimes also seen in Comedone naevus in which there are localized structural follicular abnormalities but no sebaceous glands and, therefore, no sebum. A type of acne also develops after exposure to irritant cutting and lubricating oils. Similarly, cosmetic and oil acne has nothing to do with sebum but a lot to do with exposure to the so-called comedogens found in some cosmetics and lubricating oils, which seem to be follicular irritants.

Several distinct clinical varieties of acne in mature adults and the elderly can be distinguished. The first could be called ‘persisting acne’, as it is ordinary acne that carries on from adolescent years into adult life and middle age. The lesions are usually deep set inflammatory papules (figure 1), and cysts may also occur. The jaw line, shoulders, and upper back are the sites most often affected. Comedones are not prominent. A curiously consistent clinical variant is seen in perimenopausal mature women who develop inflamed papules, particularly on the chin (figure 2). These flare premenstrually on a regular basis, causing much discomfort and cosmetic concern. This condition, often known as ‘chin acne’, is curiously resistant to treatment. ‘Sporadic acne’, as its name suggests, develops unpredictably in the middle and older age groups in the form of outbreaks of

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The inflammatory process becomes muted in the elderly.[3] This can be observed in a number of ways including by the assessment of responses to UV radiation and irritants such as sodium lauryl sulfate. The reasons for the depressed responses are not entirely clear, although decreased skin capillary blood flow and decreased cell trafficking are likely to be involved. The reduced degree of inflammation may provide an explanation for the long-term nature of the condition and lack of sudden acute exacerbations in the large majority of patients with acne in this senior age group. 2. Management

Fig. 1. Acne on the back of a 60-year-old man.

papules and pustules on usually one, but sometimes more than one, of the ‘acne sites’. These episodes of acne are sometimes quite sudden in onset and are precipitated by systemic illnesses or surgical operations or can have no apparent cause (figure 3). In a study in Cardiff[1] 15 patients with acne who were over the age of 60 years were identified over a 1-year period. There was nothing special about the acne in this group other than it tended to affect the chest and back rather than the face, and was more recalcitrant and persistent than acne in the usual age group. No particular type of lesion was seen any more often in this elderly group than would be seen in a group of younger patients with acne.

When acne is diagnosed in older individuals it is important to determine whether it has been provoked by an androgen-secreting tumor and it is certainly worthwhile arranging for levels of bound and free blood testosterone to be estimated. Although an androgen-secreting tumor is a rare reason for acne, the taking of anabolic steroids, for one reason or another, is not particularly uncommon. It must be remembered that these agents not only have ‘muscle building’ actions but often actually cause acne. The use of these agents by body builders is often accompanied by the adverse effect of acne. Acne is also caused by hypercortisonism and is seen in both Cushing syndrome, arising spontaneously because of tumor or hyperplasia, and the Cushingoid state from administration of large

1.1 Pathophysiology

Individuals with acne tend to have a higher rate of sebum secretion than those who do not have acne.[2] In addition, the worse the acne the higher the rate of sebum secretion. The elderly patients in the Cardiff study had a higher rate of sebum secretion, measured with a sebumeter, than did a similarly aged group without acne.[1] Measurements of follicular poral orifice diameter were also taken in this study using a videomicroscope. Two interesting findings emerged: (i) follicular poral diameter rises as a function of age; and (ii) that individuals who have acne have larger pores than individuals of the same age who do not have acne, even in the elderly (table I). © 2004 Adis Data Information BV. All rights reserved.

Fig. 2. Acne on the jaw line and cheek of a 37-year-old woman. Am J Clin Dermatol 2004; 5 (6)

Acne Beyond the Age of 35 Years

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2.2 Counseling

Mature acne patients are rarely as depressed by their disorder as teenagers, who tend to be a lot more self-conscious about their condition. Instead, mature patients are often incredulous and skeptical that they have acne ‘at their age’. Patients must be confident that the right diagnosis has been made and should be strongly reassured that they will eventually improve if they are compliant with treatment. Alongside the reassurance and general support it is worth discussing during the initial interview that the first set of medications may not be successful and that patients should not necessarily expect a rapid resolution of their skin problems. 3. Topical Medications

Fig. 3. Sudden onset of acne in a 66-year-old man with no apparent cause.

doses of glucocorticoids over a significant period of time. There should be no difficulty in distinguishing this type of acne as the clinical morphology is somewhat different from that of ordinary acne in that the lesions tend to be relatively small and are all at the same stage of development. Exposure to lubricants and ‘cutting oils’ are other possible reasons for the sudden appearance of acne in the mature patient.

Generally, I advise that both topical and systemic treatments be used in combination. Older skin seems somewhat more resistant to the irritant effects of benzoyl peroxide preparations than more youthful skin but, curiously enough, more sensitive to the topical retinoids. It is unclear why this is the case, but it is certainly true in my experience. Topical gels containing 5% or 10% benzoyl peroxide are useful and are my first choices for topical treatment. Tretinoin and isotretinoin, as well as adapalene and tazarotene preparations, may cause significant irritation. My personal experience suggests that lotion preparations containing 2–6% sulfur are quite helpful in some elderly patients with acne. The only licensed proprietary agent to contain sulfur in the UK is Actinac®. 1 Azelaic acid preparations (Azelex®) are also quite effective agents for the elderly with acne, but topical antibacterials by themselves seem less useful than for the young. 4. Oral Preparations

2.1 General Issues

In principle, the treatment of acne in the elderly is the same as for acne in younger age groups. However, there are some subtle differences that require attention for a successful outcome.

My preferred oral antibacterial agent for elderly patients is doxycycline. It seems better tolerated than minocycline, which has been associated with hypersensitivity/autoimmune disorders and pigmentary problems. My practice is to prescribe doxycycline 50mg twice daily for the first 6 weeks and after that modulate the dosage according to response. Isotretinoin is effective for the elderly with acne but, as with the topical retinoid preparations, this

Table I. The size of poral orifices in acne patients and normal matched control patients (mean ± SD) Age group (years)

Acne patients

Matched control patients

area (μm2)

diameter (μm)

15–30

1498 ± 1809

133.6 ± 7.3

598 ± 1588

86.2 ± 11.4

30–60

1546 ± 927

139.5 ± 3.6

1065 ± 6006

127.2 ± 13.6

60–75

2431 ± 5342

174 ± 19.5

1718 ± 990

148 ± 4.5

1

area (μm2)

diameter (μm)

The use of trade names is for product identification purposes only and does not imply endorsement.

© 2004 Adis Data Information BV. All rights reserved.

Am J Clin Dermatol 2004; 5 (6)

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age group finds it difficult to tolerate the irritating mucocutaneous adverse effect. Seukeran and Cunliffe[4] circumvented this problem by a using low dosage and managed to successfully treat a total of nine patients in their sixth and seventh decades with isotretinoin 0.25 mg/kg/day for 6 months. Grange et al.[5] also praised the efficacy of isotretinoin in a group of patients on dialysis who developed an odd pruriginous form of acne. Premenopausal patients may be tried on an oral contraceptive agent[6] and in Europe the antiandrogen preparations (Dianette®) containing cyproterone acetate (together with ethinylestradiol) are a well tried remedy for acne in women. 5. Conclusion Acne in the elderly is not uncommon, but it is not often a presenting complaint and is frequently recognized by patients and physicians alike. The disorder is similar in appearance to that in younger age groups but tends to be more ‘indolent’. The response to treatment is slow but sure and patients must be encouraged to stick to the chosen treatment regimen.

© 2004 Adis Data Information BV. All rights reserved.

Acknowledgments No sources of funding were used to assist in the preparation of this review. The author has no conflicts of interest that are directly relevant to the content of this review.

References 1. Allam SG. Acne vulgaris in the sixth decade and beyond [MSc thesis]. Cardiff: University of Wales, 1991 2. Cunliffe WJ, Shuster SG. Pathogenesis of acne. Lancet 1969 Apr; 1 (7597): 685-7 3. Kligman AM, Balin AK. Aging of human skin. In: Balin AK, Kligman AM, editors. Aging and the skin. New York: Raven Press, 1988: 1-4 4. Seukeran DC, Cunliffe WJ. Acne vulgaris in the elderly: the response to low dose isotretinoin. Br J Dermatol 1998; 139: 99-101 5. Grange F, Mitschler A, Genestier S, et al. Severe pruriginous acne in dialysed renal failure: diagnostic difficulties and efficacy of isotretinoin [in French]. Am Dermatol Venerol 2001; 128: 1215-9 6. Thiboutot D, Archer DF, Lenacy A, et al. A randomised controlled trial of a low dose contraceptive containing 20 milligram of ethinyl oestradiol and 100 microgram of levonorgestrel for treatment. Fertil Steril 2001; 76: 467-8

Correspondence and offprints: Professor Ronnie Marks, Medical Director, Cutest Systems Ltd, 214 Whitchurch Road, Cardiff, CF14 3ND, UK. E-mail: [email protected]

Am J Clin Dermatol 2004; 5 (6)