Lifetime Course of Acne: A Retrospective Questionnaire Study in School Teachers

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1 Original Study Lifetime Course of Acne: A Retrospective Questionnaire Study in School Teachers Yi-Sheng Yu Yu-Wen Cheng WenChieh Chen Acne is primarily a disorder of adolescence, but its occurrence in adult women is not unusual. There have been few studies addressing the longitudinal lifetime course of acne in general population, especially in men. A total of 250 school teachers aged over 40 years were recruited in this self-administered questionnaire study, in which 159 subjects (105 female and 54 male) completed the questionnaire (response rate 63.6%). The lifetime prevalence of acne was recorded in 83% of men and 87% of women. Adult acne as defined by acne occurrence after 25 years of age was found in 38% women, of them 87% had acne onset from adolescence and persisting into adulthood, while the rest 13% had their first episodes after 25 years old. In male population, 46% still had acne after age 25, with age onset all dating back from adolescence and none after 25 years. 13% (4/31) of the menopausal women had acne in their perimenopausal period. The acne distribution was noticed mainly over cheeks and forehead in both genders before age 25. In women with adult acne, the distribution of acne seems to move downward to perioral area. Association of acne with menstrual cycle was reported in 69% of women, with pre-menstrual exacerbation in 71% of them. Our study showed a similar lifetime course of acne in men and women. Persistence of adolescent acne into adulthood is not unusual in both genders. Acne of late onset is more commonly observed in women. (Dermatol Sinica 26: 10-15, 2008) Key words: Adult acne, Prevalence INTRODUCTION Acne vulgaris is a common skin disorder involving the sebaceous follicles primarily seen in adolescents. In some studies, facial acne was still found in above 40% of adult women older than 25 years. 1, 2 Many epidemiologic statistics derived from cross-sectional, time-point studies without addressing the lifetime prevalence or long-term course of acne. This kind of information may be helpful in our better understanding of the disease nature and course as well as the treatment impact. Since a prospective lifelong followup study of acne is practically nearly infeasible, the aim of the current study was designed to retrospectively investigate the lifetime development of acne in people aged 40 and above. From the Department of Dermatology, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Taiwan Accepted for publication: September 20, 2007 Reprint requests: Yu-Wen Cheng, M.D., Department of Dermatology, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Ta-Pei Road 123, Niao-Sung Hsiang, Kaohsiung, Taiwan TEL: ext FAX: ywcheng@seed.net.tw 10

2 Lifetime course of acne MATERIAL AND METHOD This is a retrospective self-administered questionnaire study carried out in April, 2005 using a purposive sampling method to survey school teachers aged 40 and above. A total of 250 teachers from four different schools in Kaohsiung county were recruited. The main interest concerned the age onset of acne, distribution of acne lesions, the age of highest activity, the presence or absence of adult acne and the latest age of acne formation in adulthood. Adult acne or post-adolescent acne was defined as having acne after the age of Persistent acne was defined as acne beginning from adolescence and carrying on after 25 years old. 3 Acne of late onset was defined as first appearance of acne after age In women, the regularity of menstrual cycle and the influence of menstruation on acne formation were also inquired. Statistics was performed by using Pearson chi square to analyze the differences in (1) regularity of menstrual cycle between women with and without adult acne and (2) sites of involvement between different groups (having acne before versus after the age of 25, late-onset acne versus persistent acne). Student t-test was used to analyze the gender difference in acne onset. A P value < 0.05 was considered to be significant. RESULTS One hundred and fifty nine subjects completed the questionnaire (response rate 63.6%), including 54 men (mean 57.5, age range years) and 105 women (mean 56.5, age range years). An identical percentage of women (87%) and men (83%) ever had acne occurrence at certain period of their lifetime (Table 1). Adult acne, including persistent acne and acne of lateonset was found in 38% of women and 46% of men. In women who had first acne appearing from their adolescence, 37% of them still had acne when they were older than 25 years old, and even higher percentage (45%) was found in men. In women with adult acne, 13% had lateonset acne and 87% had persistent acne, while only persistent acne but not late-onset acne was present in men with adult acne. The reported onset age of acne was at 13.7 ± 2.5 years in women and 14.7 ± 2.9 years in men ( p = 0.06). The most severe acne activity was reported to occur in 53% of women and 82% of men in their adolescence (during age years old), while 20% of women and 7% of men experienced the highest acne activity at age 25 and above. Acne development in the perimenopausal period was found in 13 % of postmenopausal women. Regarding the site of facial acne in women below age 25, 67% had involvement of upper face (cheeks or forehead), and 19% had lower face involvement (chin or perioral area). In women with adult acne, the percentage of lower face involvement was significantly higher (44%) (Fig. 1). Women with adult acne tended to develop acne in lower face, in comparison with those who had only adolescent acne ( p = 0.03). The distribution of acne appeared to move from cheeks to perioral area at advancing age. The cheeks/forehead were most commonly involved in persistent acne, while acne formation in the perioral area was more frequently observed in late-onset acne, although the difference was statistically less remarkable ( p = 0.055). In men, involvements of cheeks/forehead were most commonly observed in both adolescent and adult acne, accounting for 95% in adolescent acne and 80% in adult acne. The percentages of lower face involvement in adolescent and adult acne were 27% and 10%, respectively. There was no correlation between the regularity of menstrual cycle and the occurrence of adult acne ( p = 0.26). In women with persistent acne, 37% had regular menstrual cycles, while an irregular menstruation was reported by all the women with late-onset acne. Worsening of acne associated with menstruation was found in 69% (63/91) of women; 71% of them reported premenstrual exacerbation, 27% had aggravation during menstrual period, and 2% experienced postmenstrual worsening (Fig. 2). DISCUSSION Our study has the following strength and weakness: (1) most of the epidemiologic studies on acne prevalence were based on cross-sectional sampling of acne patients at certain time point, Dermatol Sinica, Mar

3 Yi-Sheng Yu, et al Fig. 1 Sites of involvement in women having acne in the age of < 25 years old and > 25 years old. Fig. 2 The relationship between menstruation aggravation and acne. which could not reflect the life-time course and long-term change of the disease in the same individual, as being investigated in our study; (2) the recall bias or reporting bias in this retrospective study is obviously the main factor compromising the validity of our results; (3) the sample size is relatively small and the use of purposive sampling in selection of only school teachers could not represent the whole population; (4) survey of acne types (comedones, papulopustules and nodulocysts) was not included in our study, because the precision of diagnosis in such a self-reported questionnaire study can not be confirmed. Our study showed an identical percentage of women and men (71% vs. 78%) having had acne in their adolescence. The onset age of acne was slightly earlier in girls (13.7 ± 2.5) than in boys (14.7 ± 2.9) in our study, which kept in line with the most reported data. 4 The later acne onset of our series than most Western reports might be explained by the genetic difference and the environmental factors such as diet and life style. 5 The prevalence of acne in the adult population has been documented in several prior studies (Table 2). Goulden et al.found an overall prevalence of acne in 54% women and 40% men from England (age range 25-55, mean 35.5), Plunkett et al. from Australia reported acne in 13.6% women and 11.8% men at age 20 and above, Poli et al. reported acne in 41% women aged , 2, 6 years in the French population. Our study revealed a prevalence rate of adult acne in 38% of women and 46% of men. Unlike the previous studies, a higher prevalence rate of adult acne was observed in men than in women in our study. The prevalence and manifestation of acne in men aged 40 and above is far less defined and characterized. On the other hand, it is not uncommon in our daily practice to see acne in men at age of forties seeking dermatological counseling for other problems (personal observation). Actually, significant reduction of sebum is observed much later in men than in women, usually at age beyond seventies. 7 Several factors should be considered in interpretation of the different results: (1) recall bias may result in overestimation of the prevalence; (2) the mild or physiological acne might be ignored while the moderate to severe acne was being reported; (3) our lifetime or longterm retrospective study can reduce the selection bias which may occur in many cross-sectional time-point epidemiological studies, as physiological acne may spontaneously remit and thus avert the detection at the time of examination. Although our sample size is relatively small, it indicated that adult acne is not uncommon in men and needs more attention. A predominance of persistent acne was observed in our cases with adult acne, especially in men (100%) than in women (87%). Different results were seen in one previous study, in which late-onset acne was documented in only 18.4% of women and 8.3% of men, 3 while an even higher percentage (41%) of late-onset acne was revealed in another study by Poli et al. on 3,394 adult women aged An association between 12 Dermatol Sinica, Mar 2008

4 Lifetime course of acne Table. 1 Comparison Between Male and Female Subjects female male Number Mean age (years) Ever had acne during their life time 87% 83% Adolescent acne( 11~18 years old) 71% 78% Adult acne( >25 years old) 38% 46% Age of first acne attack (years) adult acne and underlying endocrinological problems has been highlighted in many reports. 8, 9 In general, adult acne tends to be more inflammatory, involving more frequently lower part of the face. 2 In our study, we did find a slightly higher rate of perioral involvement in women with late-onset acne as compared to those with persistent acne ( p = 0.055). It is assumed that the lower part of face, the area where beards or moustache grow in men, is an androgen sensitive area susceptible to hormone influence in women with acne. 10 Premenstrual flare of acne was documented in 44-83% of women In our series, 69% of women reported worsening of acne associated with menstruation, and 71% of them had premenstrual exacerbation while 21% had worsening during menstrual days. Little is known about the molecular mechanism underlying the premenstrual acne flares. Burton et al. found a premenstrual decrease in sebum excretion and proposed premenstrual skin edema could impede the free flow of sebum to the skin, causing sebum buildup and subsequent acne formation. 14 Williams et al. found sebaceous duct opening was smallest in days of a 28-day menstrual cycle. 15 Far more enigmatic is the post-menstrual worsening of acne, as seen in 3% of our patients having acne flare-up after menstruation. Similar results were found in another study on 400 women aged 12-52, which revealed 4% of them experienced flare-up of acne after menses. 11 Postmenopausal acne is said to be a lowgrade acne mainly in the form of closed comedones more frequently occurring in women with darker skin within the first two years in the perimenopausal period. 2,16 Our study found four of the 31 women in their menopause (13%) had an acne attack during the perimenopausal period. In summary, our study revealed the development and course of acne on a lifetime scale. Identical to many previous reports, adult acne is common in both women and men in our series. Men have a similar acne prevalence-versusage curve as seen in women, with even a higher prevalence rate at age 25 years and above. Association of acne activity with menstruation is quite common. Further longitudinal prospective studies exploring the lifetime development of acne may help us better understand the nature and longterm course of this common skin disease. REFERENCES 1. Goulden V, Stables GI, Cunliffe WJ: Prevalence of facial acne in adults. J Am Acad Dermatol 41: , Poli F, Dreno B, Verschoore M: An epidemiological study of acne in female adults: results of a survey conducted in France. J Eur Acad Dermatol Venereol 15: , Goulden V, Clark SM, Cunliffe WJ: Post-adolescent acne: a review of clinical features. Br J Dermatol 136: 66-70, Dreno B, Poli F. Epidemiology of acne. Dermatology 206: 7-10, Cordain L, Lindeberg S, Hurtado M, et al.: Acne vulgaris: a disease of Western civilization. Arch Dermatol 138: , Plunkett A, Merlin K, Gill D, et al.: The frequency of common nonmalignant skin condi- Dermatol Sinica, Mar

5 Yi-Sheng Yu, et al Table. 2 Comparison of Adult Acne in Our Study and The Literature Plunkett A Australia 1999 V. Goulden United Kindom 1999 F. Poli France 2001 Our study Taiwan 2005 Subjective > 20 years adults > 25 years employee aged women >40 years school teachers Study type Cross-section Cross-section Cross-section Retrospective Number Prevalence F: 13.6% M: 11.8% Type Menstrual cycle aggravation F: 54% M: 40% Female Persistent: 82% Late-onset: 18% Male Persistent: 92% Late-onset: 8% F: 41% F: 38% M:46% Female Persistent: 59% Late-onset:41% 78% 69% Female Persistent: 87% Late-onset:13% Male Persistent: 100% Reference tions in adults in central Victoria, Australia. Int J Dermatol 38: , Plewig G, Kligman AM: Proliferative activity of the sebaceous glands of the aged. J Invest Dermatol 70: , Vexiau P, Husson C, Chivot M, et al.: Androgen excess in women with acne alone compared with women with acne and/or hirsutism. J Invest Dermatol 94: , Vexiau P, Chaspoux C, Boudou P, et al.: Role of androgens in female-pattern androgenetic alopecia, either alone or associated with other symptoms of hyperandrogenism. Arch Dermatol Res 292: , Shaw JC: Acne: Effect of hormones on pathogenesis and management. Am J Clin Dermatol 3: , Stoll S, Shalita AR, Webster GF, et al.: The effect of the menstrual cycle on acne. J Am Acad Dermatol 45: , Shaw JC, White LE: Persistent acne in adult women. Arch Dermatol 137: , Lucky AW: Quantitative documentation of a premenstrual flare of facial acne in adult women. Arch Dermatol 140: , Burton JL, Cartlidge M, Shuster S: Variations in sebum excretion during the menstrual cycle. Acta Derm Venereol 53: 81-84, Williams M, Cunliffe WJ: Explanation for premenstrual acne. Lancet 2: , Kligman AM: Postmenopausal acne: Cutis 47: , Dermatol Sinica, Mar 2008

6 Lifetime course of acne 痤瘡之終身進程 : 一以中小學老師為對象之回溯性問卷式研究 游懿聖鄭裕文陳文杰 高雄長庚紀念醫院皮膚科 長庚大學醫學院 痤瘡是一主要發生在青少年上的疾病, 但成年女性有痤瘡者並不少見 文獻上少有針對一般人, 特別是男性, 痤瘡之終身進程長軸式的分析, 因此我們針對 250 名年齡超過四十歲的學校老師做一自填問卷式研究, 共有 159 名受訪者 (54 男性及 105 女性 ) 完成問卷 ( 完成比例為 63.6%) 83% 的男性及 87% 的女性回顧過去的歷史中曾經有過痤瘡 38% 的女性有成年期痤瘡 ( 定義為 25 歲後仍有痤瘡 ), 其中 87% 的痤瘡是由青春期開始持續至成年期, 而其餘的 13% 則是第一次痤瘡在 25 歲以後才發生 46% 的男性有成年期痤瘡, 所有成年期痤瘡的男性第一次發生痤瘡都是在 25 歲以前 13%(4/31) 已停經的女性受訪者在停經前後發生痤瘡 在 25 歲以前發的痤瘡, 不論男性女性都是以兩頰及前額為最好發部位, 在女性成人期痤瘡, 其好發部位則有往下延伸到嘴巴周圍的現象 69% 的女性認為痤瘡的發生與月經週期有關, 其中 71% 為經期前惡化 本研究發現男性與女性的痤瘡終身進程相似 ; 不論男性女性, 自青春期延續到成人期的痤瘡並不少見 ; 晚發性痤瘡則在女性較為常見 ( 中華皮誌 26: 10-15, 2008) Dermatol Sinica, Mar