High school is a memory. You have a career, you’re going to college, or you’re raising a family. You’ve settled down. Acne, you assume, is a thing of the past. But just when you think that you’re out of the woods, acne hits you right in the face.

Dermatologists regularly hear the lament “Acne, at my age?!” expressed by women who suddenly develop acne after the ages of 20 or 30. “It’s not fair; it’s supposed to be only for teenagers!” is usually the next statement out of their mouths.

It may not be fair, but it’s a fact. Many people — mostly women — get acne for the first time as adults or develop acne after years of being relatively pimple free. And sometimes teenage acne can continue unabated from teen years into adulthood.

In here, I prepare you for some surprising occasions when acne can rear its ugly head — adulthood, pregnancy, and menopause. Adult-onset acne is overwhelmingly a condition seen in women.

Therefore, I spend the bulk of this article discussing adult-onset acne as it relates to women. And as always, I show you that there is hope to help your acne symptoms clear up. But if you’re one of the relatively few guys facing acne as an adult, don’t worry; I help you get a handle on your condition at the end.

Identifying Adult-Onset Acne

Adult-onset acne is a type of acne that turns up after the age of 18 — somewhat later than the typical teenage variety of acne. It can crop up during a woman’s 20s, 30s, or even later in life. Adult-onset acne, sometimes referred to as female adult acne or post-adolescent acne, is overwhelmingly a condition of females.

The fluctuating nature of adult-onset acne tends to make the influence of hormones more obvious than with the typical case of teenage acne vulgaris; however, teenage girls often begin to note those premenstrual pimply “ups” and “downs” as they approach adulthood.

As many woman are aware, the lesions have a propensity to come and go more readily than they do with teenage acne, and their appearance and disappearance is often linked to their menstrual cycle.

Describing acne symptoms

The appearance of post-adolescent acne differs from that of teenage acne:

• Blackheads and whiteheads (comedones) are less commonly seen.

• Breakouts are usually mild to moderate.

• Significant scarring is unusual (but the term “significant” is a relative and in the in eyes of the person who has acne, it can be very significant).

• Lesions more often appear on the lower cheek, the chin, and along and below the jaw line. Although some women may have breakouts on the chest and back, most have blemishes exclusively on the face.

Breakouts are usually limited to inflammatory papules (pimples, bumps, zits), pustules, and small inflammatory nodules. The papules and pustules can be superficial or deep. Many women describe certain papules as “deep ones,” the ones that feel like they come from under the skin. (If you get ’em, you know what I mean.)

The deep ones are often more palpable (you’re able to feel, or palpate them) than visible. They represent papules and pustules that haven’t reached, and may never reach, the surface of the skin. When these deep lesions grow even larger, they’re called nodules (or cysts).

Nodules are tender, firm lumps that may hang around for weeks or months. They may grow to an inch or more in diameter and can leave scars after they heal. Fortunately, nodules and subsequent scarring are infrequently seen in women who have adult-onset acne.

The diagnosis of adult-onset acne isn’t always clear-cut. Your healthcare provider may easily confuse adult-onset acne with other acne-like disorders:

• Rosacea: Symptoms of rosacea include facial lesions that consist of acnelike red papules and pustules. Moreover, both rosacea and acne can appear together.

• Pseudofolliculitis barbae and keratosis pilaris: These conditions involve hair follicles, and can sometimes be acne look-alikes.

• Endocrinopathy: Sometimes what appears to be a simple case of acne vulgaris or adult-onset acne can be due to an underlying hormonal abnormality, called endocrinopathy (pronounced en-de-krin-op-ath-ee). At times like this, acne may be difficult to get under control, and other measures such as blood tests to look for higher or lower than normal hormone levels should be evaluated by your doctor.

Taking an emotional toll

Having acne can be just as trying for adults as it is for teens. Job hunting, social events, and dating can be negatively impacted by a few pimples. Even mild acne that might seem insignificant to an outsider can force some people to miss out on opportunities and relationships that otherwise they might have explored.

Whether you have rather mild or severe acne, effective treatments are available, and your condition can improve. Look at the sidebars in this chapter for stories about patients with varying degrees of acne. The patients discussed may have the same type of acne you have.

Emerging At Any Age

When acne begins in the teenage years, the increase in your androgens — male hormones that are present in both men and women — play a major role in its development. In a nutshell, these hormones stimulate the sebaceous glands, enlarging them, and they respond by producing excessive oil that helps to promote the lesions of acne.

Although the entire story isn’t well understood, the vast majority of women who have adult-onset acne don’t have elevated androgen levels; rather, they appear to have an increased response to normal levels of androgen, and to a much lesser degree, to their female hormone, progesterone, that also has androgenic effects. The other major female hormone, estrogen, has an opposite (estrogenic) effect and tends to curb acne.

In addition to a woman’s own hormones, adult-onset acne may be related to, and heightened by, the ingestion of external hormones and drugs that have androgenic effects such as those contained in certain oral contraceptive medications, food products, and performance enhancing drugs. In the sections that follow, I outline common points in your life at which acne can be an issue and delve into why this may occur.

Acne and your menstrual cycle

If you’re reading this, I probably don’t have to tell you about those little red bumps that appear on a monthly basis. You’re probably well aware of those unwelcome visitors that appear, disappear, and reappear like clockwork during your menstrual cycle. They usually last for several days, but sometimes they can persist for a month or longer. No fun!

Most often, pimples tend to pop up right before your period. This is the time — usually two to seven days before your period — when estrogen levels fall and progesterone levels rise and stimulate the sebaceous glands to produce extra oil; with this extra oil comes acne.

Much less commonly, you may see no apparent connection between the appearance of pimples and your menstrual cycle. In such instances, they will erupt with a mind of their own only right before you have that important date, interview, cocktail party, public speaking engagement, or wedding! Great!!

Acne and pregnancy

During pregnancy, acne is unpredictable. For some lucky women, the result is a welcome surprise — clear skin, the “glow of pregnancy” that you were told about. If this is your case, enjoy it! But don’t get overconfident. When existing acne virtually disappears during pregnancy, it often recurs afterward — sorry!

However, existing acne can also get worse. Pregnancy is a time of tremendous hormonal upheaval. Your levels of estrogen and progesterone are rising, and your skin becomes more sensitive to the changes in the circulating hormones in your body.

In fact, some women may experience acne for the first time when they become pregnant, even if they never had acne during their teens. Acne is a perfectly normal occurrence during pregnancy (more common than most women realize), whether you have previously had acne or not.

There’s no way to prevent it from developing during pregnancy, but be patient and, with time, your skin will probably clear up and return to its natural, pre-pregnancy state. Lesions during pregnancy are generally inflammatory in their appearance and typically take the form of papules, pustules, and sometimes nodules.

Acne tends to be worse during the first trimester (the first three months) of pregnancy when the levels of these hormones are increasing. Your progesterone is more androgenic (male hormonelike) than estrogen and causes the secretions of your skin glands to increase, which can lead to more acne.

There are also times when your sebaceous glands go into high gear during the first, second, and third trimesters, causing even more frequent and serious breakouts. When breastfeeding, some of the hormones that trigger your acne during pregnancy may still be at work, and you may wish to continues treating those pesky pimples.

But be aware, as I mention in the sections that follow, that certain medications taken by mouth or applied to your skin may wind up in your breast milk.

Safe acne drugs when you’re pregnant

The best course is to “say no” to any unnecessary drugs if you’re pregnant or breastfeeding. Your baby is your first concern and you want to minimize any potentially harmful agents that might reach her. That said, the best way to treat acne during pregnancy is with a topical acne-fighting preparation.

If you’re planning to get pregnant, discuss your acne treatments with your dermatologist or healthcare provider. Some of the medications that are safely used to treat acne when you aren’t pregnant may be potentially harmful to a developing fetus.

Topical treatments that your doctor may prescribe during pregnancy include:

• Erythromycin: There are many topical prescription products that contain this antibiotic.

• Benzamycin Gel: Benzamycin Gel combines erythromycin and benzoyl peroxide.

• Azelaic acid: This is a natural chemical produced by a yeast. It is the active ingredient in the prescription products Azelex and Finevin.

The U.S. Food and Drug Administration (FDA) classifies Azelaic acid as a pregnancy category B drug. This designation means that animal reproduction studies have failed to demonstrate a risk to the fetus; however, there are no adequate and well-controlled studies in pregnant humans.

Because passage of the drug into maternal milk may occur, this drug should be used during pregnancy or by nursing mothers only if clearly needed. On the whole, I recommend that you avoid all oral medicines to treat acne when you’re pregnant.

However, oral erythromycin — if you’re not allergic to it — may be taken safely if your acne is really bad. If you’re allergic to erythromycin or it’s not working, your dermatologist may prescribe another oral antibiotic that can be used in pregnancy.

Drugs that may be harmful to developing fetuses

The FDA classifies some topical and oral medications as pregnancy category C drugs. This categorization means that it’s not known whether the medication will be harmful to an unborn baby.

But, when it comes to benzoyl peroxide, sulfacetamide, and sulfur drugs, they’ve been around for ages and no evidence has ever shown them to be harmful to a fetus.

With some of the other drugs mentioned below, definitive evidence isn’t available one way or the other, so I recommend that you avoid them unless your healthcare provider or dermatologist says otherwise. The following acne topicals have been used for many years and are probably safe to apply during pregnancy and nursing:

• Benzoyl peroxide: This drug has been around for generations. It’s very effective for treating acne and can be purchased over the counter. There have never been reports of problems that came from using benzoyl peroxide during pregnancy.

However, even though benzoyl peroxide is generally considered to be safe to use during pregnancy, you should be aware that the FDA classifies it in pregnancy category C. It’s also not known whether benzoyl peroxide passes into breast milk.

Because this product has been around for so long, when it was approved, the FDA didn’t require that it be tested to the extent that drugs are nowadays. If you’re pregnant or breastfeeding your baby, you shouldn’t use benzoyl peroxide topical without first talking to your doctor.

You can then decide if the risks are low enough and the benefits are high enough for you to use it. If during pregnancy or breastfeeding, you’re advised to use a benzoyl peroxide combination product, it’s probably wisest to use one that contains erythromycin such as Benzamycin Gel, rather than one that contains clindamycin.

• Sulfacetamide/sulfur combinations: As with benzoyl peroxide products, these pregnancy category C agents have been used safely for many years. Combinations of sulfacetamide and sulfur are contained in such products as Rosula, Rosac, Rosanil, Nicosyn, and Novacet.

These medications should be used only when clearly needed during pregnancy. Discuss the risks and benefits with your doctor. These medications may pass into breast milk, so breastfeeding while using these medications isn’t recommended.

The following FDA pregnancy category C topicals are “newer kids on the block” and aren’t recommended for use during pregnancy:

• Topical retinoids: These consist of tretinoin, Retin-A, Differin, Tazorac, and Avita. Even though there is minimal absorption of topical retinoids that can potentially reach a fetus, and there’s no evidence that these agents can harm an unborn child, you should stop applying them once you think that you’re pregnant.

• Clindamycin: Prescription products that contain this antibiotic include Cleocin-T, as well as several generics. The effects of clindamycin during pregnancy haven’t been adequately studied. Clindamycin combined with benzoyl peroxide is also found in the combination products Benzaclin Gel and Duac Gel.

Because clindamycin may appear in breast milk and could affect a nursing infant, it’s probably not advisable to use products containing it if you are pregnant or plan to become pregnant.

• Aczone Gel: This agent contains dapsone. There is minimal absorption of this drug in the bloodstream when it’s applied topically; however, it’s known that dapsone is excreted in human milk when taken orally.

Clindamycin and benzoyl peroxide are also found in the combination products Benzaclin Gel and Duac Gel.

Many oral drugs can harm your unborn baby. In these cases, clear evidence exists that your child may have serious birth defects if you use them. The following medications must be avoided if you’re pregnant or if you’re contemplating becoming pregnant:

• Tetracycline: Tetracycline and its derivatives, minocycline and doxycycline, may cause some inhibition of bone growth and discoloration of teeth in a fetus.

• Hormones: The anti-androgens such as spironolactone that are sometimes used to treat acne, can, by blocking testosterone, interfere with the normal development of a male fetus and cause feminization.

• Oral isotretinoin (Accutane): Oral isotretinoin (eye-so-tret-ihno- in) available as Accutane, Roaccutane, Amnesteem, Claravis, and Sotret, is a powerful drug that’s used to treat severe nodular acne in carefully selected patients. This drug can cause severe fetal abnormalities.

There are many restrictions currently in place regarding oral isotretinoin, and with understandable cause. Oral isotretinoin can cause serious birth defects to infants born to women exposed to them. They should never — not under any circumstances — be taken during pregnancy!

Even if a woman becomes pregnant within one month after stopping the drug, problems can still occur. There also is an increased risk of miscarriage, premature births, and infant death associated with taking oral isotretinoin during pregnancy.

A recently published Swedish study showed an increased occurrence of certain heart defects in children born to mothers who had taken oral erythromycin in early pregnancy (first trimester).

But it can’t be certain that factors other than erythromycin didn’t contribute to the increase in malformations. In the same study, the risk after treatment with penicillin demonstrated no increase in these malformations.

You’re never too old

Some women pass through menopause without outgrowing their acne. Yes — acne during and after menopause! Just when you felt certain that the years of pimples have faded from your skin and your memory, they’re back! No, you’re not going through a second adolescence, it’s those pesky hormones again!

Although hormonally influenced acne typically begins around age 20 to 25, acne can persist in women over the age of 40 and continue into the perimenopausal and menopausal periods.

Along with all the other changes that you go through during this time, acne just seems to add insult to injury. Post-menopausal acne isn’t a common occurrence, but when estrogen levels begin to taper off and testosterone becomes the dominant hormone, acne — usually mild — can appear.

Facing Acne As an Adult Man

The good news for most adult men is that acne that first appears after age 20 is an unusual occurrence. I suppose the bad news is that if you’re reading this, you’re having just such an “unusual occurrence.” In men with adult acne, lesions are more often seen on the chest and back.

When it arises on the back, it’s sometimes playfully called “backne.” If you’re a guy, and you’re facing acne, odds are that one of several things is occurring:

• The teen version has stuck around: Though most acne vulgaris (teenage acne) clears up by the time you approach the 20 mark, it can stick around.

• You’re an athlete: In recent years, acne is being seen increasingly on the chests and backs of men who participate in vigorous athletic activities. Some observers speculate that sweating and friction causes the acne because the primary sites are most often under clothing.

• You’ve used performance-enhancing drugs: Another, more likely, source of chest and back acne may result from the use of performance-enhancing preparations that contain such ingredients such as creatine, colostrum, and, of course, anabolic steroids such as testosterone and andro.

• You don’t really have acne: If you have any doubt about your diagnosis, see a dermatologist because she may tell you that you don’t have acne at all but may have rosacea, an adult acne look-alike, or folliculitis (an inflammation of hair follicles) due to shaving your face and maybe even from shaving your chest and back.

Significant scarring from acne is more common in men than in women. In men, lesions that leave scars may be the dominant type present, especially in men who had severe acne in their teens.