On-line version ISSN 1806-4841
An. Bras. Dermatol. vol.84 no.4 Rio de Janeiro July/Aug. 2009
CLINICAL, EPIDEMIOLOGICAL, LABORATORY AND THERAPEUTIC INVESTIGATION
Juliano Vilaverde SchmittI; Paula Yoshiko MasudaII; Hélio Amante MiotIII
of Fundação Pró-Hansen - Curitiba (PR), Brazil
IIMedical intern of Fundação Pró-Hansen - Curitiba (PR), Brazil
IIIAssistant Professor PhD of the Department of Dermatology and Radiation therapy of Faculdade de Medicina de Botucatu da Universidade Estadual Paulista (Unesp) Botucatu (SP), Brazil
Acne is a frequent skin disease that occurs in both sexes and all age-groups.
Women present several clinical disease patterns; moreover, persistence after
adolescence is common.
OBJECTIVE: To analyze clinical and epidemiological characteristics associated with different age-groups affected by acne in women.
METHODS: Cross-sectional study involving female patients diagnosed with acne, at a general dermatology outpatient clinic. Variables related to disease and patients were assessed through a standardized questionnaire.
RESULTS: One hundred and three women were assessed. The average age of patients at the time of the consultation was 21.7 ± 7.3 years. Two groups were defined (cut-off age of 21 years), with means of 15.8 ± 2.3 and 28.0 ± 5.1 years. There was correlation between disease duration and current age (R=0.7). There were group differences among frequencies of covariables: combined oral contraceptive (OR=48.1), lesions located on upper chest (OR=11.6), lesions on upper dorsum (OR=0.2), predominance on upper half of face (OR=0.1) and age at disease onset (OR=1.8). Among adult women, 80% reported acne onset before 20 years of age.
CONCLUSION: Chronologic and topographic patterns of female acne in different age-groups were defined, reinforcing the importance of an individualized diagnostic and therapeutic approach.
Keywords: Acne Vulgaris; Cross-Sectional Studies; Dermatology; Hyperandrogenism
Acne, a frequent dermatosis totaling roughly 14% of dermatological appointments in Brazil, affects both genders, different ethnicities and all age groups, with predominance of the first 3 decades of life. It has diversified morphological characteristics according to the etiology and age of onset. Nevertheless, there is significant overlap between clinical manifestations and age groups involved.1,2
The hormonal changes of puberty are almost always related to the beginning of typical acne vulgaris, and male adolescents are the most frequently and intensely affected. Adrenal maturation and gonad development lead to the production of androgens and subsequent increase in sebaceous glands, with the eventual eruption of acne at this age group.3-5
The intensity of acne is suggested to relate more to the pubertal phase than to chronological age. Still, acne is expected to recede in most male patients between 20 and 25 years. In contrast, women may continue with the problem during adult life, even after age 40.6
Assessment of observational studies have shown that Collier et al. identified prevalence of acne complaints in 51% of women between 20 and 29 years;7 Goulden et al. revised records of 200 patients between 25 and 55 years with acne, and observed that 76% were women, and in 82% of cases, adolescent acne persisted, although, Poli et al. observed only 59% with this profile, and verified that the prevalence only fell significantly after 45 years.8,9
Post-adolescence female acne may be divided into persistent, that represents a continuity of the picture related to puberty, and late onset acne that begins after 25 years of age. Acne of the chin is an intriguing form that occurs in the pre-menstrual period in mature women, while sporadic acne describes the sudden development of lesions in adult life, without an apparent reason. Clinically, these variants of acne may differ from that of adolescents in that they tend to be more inflammatory, with fewer blackheads. Moreover, lesions are more commonly located around the mouth, chin and line of the mandible.10
The utilization of cosmetics, hormonal and nutritional changes, coexistence of hirsutism, seborrheic dermatitis, alopecia, irregularity or psycho-developmental aspects are elements assumed in the explanation of the different clinical patterns and of the natural history of acne in different population groups. 8,11-20
There is a lack of epidemiological studies comparing clinical aspects associated with female juvenile and adult acne. The present study aimed to analyze the clinical and epidemiological characteristics associated with the different age groups affected by acne in this population.
The cross-sectional study included all female patients seen at the general dermatology outpatient clinic of Fundação Pró-Hansen, located in Curitiba-PR, between January and December 2008, with a diagnosis of acne, contacted by telephone and interviewed by the author (PYM), with a standardized questionnaire.
Medical records were revised in order to exclude patients with an explicit diagnosis of secondary acne to medication or cosmetics.
The dependent variable analyzed was patients' age group at the time of the appointment. Co-variables explored were: family history of acne, use of face cosmetics for more than three days a week, use of oral contraceptive, abnormal menstrual pattern, oily skin, seborrheic dermatitis of scalp, topographical predominance (above or below half of face, collum, dorsum, shoulder) and morphological pattern (papules or blackheads).
Several categories were represented as percentages in each group (adult and juvenile), and ratios compared by the Fisher and Chi-square tests. Continuous variables were represented by the mean and standard-deviation, compared by the Mann-Whitney test and linear correlation measured by the Spearman coefficient. Mode and median were used to describe samples that were not shown to be parametric. Normality of distributions was estimated by the Lilliefors test.21
Variables were tested by a conditional multiple logistic regression model and reduced as of an algorithm (stepwise backward), with a maintenance criterion of p< 0.3 at each step.
The association between variables was estimated using Odds Ratio (OR) and 95% confidence interval.
The age of the cohort for classification as adult or juvenile acne was estimated by the mean of ages of best discrimination between co-variables, using the ROC curve.
Data tabulation and analysis was performed using MS Excel 2003 software and SPSS17 software. A bicaudal p< 0.05value was considered as significant.22
During the period described, 138 women with a diagnosis of acne were seen. Excluding cases with secondary acne and loss of sample due to impossibility of a phone contact, 103 (74.6%) patients were included in the study.
Mean age (±standard-deviation) of patients at the time of appointment was 21.7±7.3 years, although the age histogram (Graph 1)) identifies two modal peaks (15 and 27 years). In order to enable the application of tests to compare proportions, discriminatory analysis by the ROC curve defined two groups as of the cut-off age of 21 years, generating two samples with the means of 15.8±2. 3 and 28.0±5.1 years comprised of 53 and 50 individuals.
The mean age of initial symptoms was 14.3±4.1 years (Graph 2), and the median duration of the picture was five years (Graph 3). A strong positive correlation was observed between the duration of the picture and age of patients at appointment (RSpearman = 0.74; p< 0.01), which did not happen with the age of initial symptoms or with menarche.
The bivariate comparison between age groups regarding independent variables is described in Table 1. Differences in the frequencies of use of combined oral contraceptive, back lesions, predominance of upper and lower topographies (according to the group), and age of initial lesions stand out.
The multivariate analysis showed a significant association of age groups with age of initial onset, use of combined oral contraceptive, predominance in upper face, presence of back lesions and presence of lesions on collum (Table 2).
Data presented allow to identify two different populations of female patients with acne when assessed from the age perspective, which strengthens the clinical observation of entities with a certain clinical, and probably pathophysiological independence, already described as adolescent acne (vulgaris), and adult women's acne.4,10
Results suggest that the age separating the groups would be around 21 years, corroborating some publications, but under 25 years, the most frequently used limit in previous studies. This small discrepancy may highlight the cultural and geographical aspects of the population studied or even methodological aspects used to define the present cohort.7,10,11,15
Some variables classically associated with adult women with acne, such as the use of cosmetics, menstrual irregularity and obesity, were not corroborated by the present study, showing that the topographic features of acne should exert a better classification capacity, when the age group involved is weighted. Similarly, family history did not show itself as a prominent significant element between the groups, which does not rule out that both variants have the same intensity of family ascendance, although memory bias can not be forgotten in this case.
The predominance of inflammatory papules and lesions in adult women was not more frequent, unlike some previous observations as to the clinical profile. The non association with type of lesion, whether retention or inflammatory, may be due to interviewees' difficulty to identify the pertaining morphological characteristics. On the other hand, the interviewer did not find difficulties to conduct the survey. 8,10,11,23
There was a significant difference in the age of initial acne between groups. Still, 80% of women in the adult group reported initial lesions while still during adolescence, corroborating previous observations that most cases of acne in adult women may be persistence of the juvenile picture. The high correlation between duration of picture and age of patient at appointment strengthens the assumption.8,9,24
The clinical characteristics that most seem to determine the age groups of acne in women, in addition to age of initial picture, refer to topography of lesions: predominance of lesions in the upper half of the face, in addition to dorsum of younger patients. In the meantime, adults presented more lesions in the collum, in addition to face.
The use of oral contraceptives was strongly associated with age group, as an increase in frequency of use among adult women is expected, although its interference with acne cannot be minimized. This adds up another reason for building the final multivariate model adjusting results.
The present study did not contemplate the analysis of hyperandrogenism lab parameters, given acne already represents a manifestation of this clinical condition. However, in an observational study in which a great part of women revealed to be contraceptive pill users, the loyalty of estimates of certain plasmatic androgens could be compromised. Another important element lies in the controversy that isolated persistent acne is a manifestation of hyperandrogenism. Cibula and collaborators did not show a correlation between severity of acne and any clinical sign and lab marker of hyperandrogenism. Albeit that, women with more intense pictures were observed to have lower free testosterone levels, less hirsutism and higher levels of SHBG (Sexual hormone-binding globulin).18 External elements such as consumption of milk and byproducts, heat, sun block, in addition to periods of psychological stress are also described as aggravating elements of acne. This does not support hyperandrogenism as the cause of all adult women acne pictures and its interference in treatment.13,14,25
The psychological evolutionist conception of acne could explain the differences acquired in the pattern of development of acne in women and men during the development of the species. According to Bloom, persistent acne in a woman's life would corroborate toward a sign linked to adolescence and delaying early mating, and in the meantime, women would mature, attaining better circumstances for the care and survival of their litter. Despite the difficulty to prove evolution assumptions, no physiological arguments are found to explain persistent acne in adult women, to nearly the end of reproductive life, and sexual selection could be a plausible explanation.19
The results of the present work lead to two distinct considerations: One in which there would be changes in the clinical profile of a same condition due to the physiological changes caused by age. And another in which we believe to be in face of two separate nosological conditions.
New studies should be conducted with samples that include other populations, investigate pathophysiological aspects and become means of comparison to elucidate the bases for the findings of the present study.
Clinical chronological and topographical patterns that favor the characterization of female acne at different age groups (juvenile and adult) were identified, alerting toward the importance of an individual diagnostic and therapeutic approach toward acne in these groups.
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Juliano Vilaverde Schmitt
Rua Fernando Amaro, nº1.116 Cristo Rei
CEP: 80050-020 - Curitiba - PR
Tel./fax: (41) 3024-2757 3263-2757.
Conflict of interest:
Financial funding: None
How to cite this article: Schmitt JV, Masuda PY, Miot HA. Padrões clínicos de acne em mulheres de diferentes faixas etárias. An Bras Dermatol. 2009;84(4):349-54.