Dr. Ahmed Have you noticed how acne, once considered primarily a teenage concern, now persists into adulthood?
An estimated 25% to 40% of adults experience acne post-teenage years, causing a lasting impact on their skin and confidence.
Over the last decade, dermatologists have observed this significant rise in adult acne cases, which are often more stubborn than those in teenagers.
Adult acne isn’t just a cosmetic annoyance. It affects self-esteem, social confidence, and overall skin health.
Let’s examine the factors driving this trend and what the existing science suggests works.
Why Is Adult Acne Rising? The Underlying Drivers
Hormones: Not Just Teenagers’ Problem
One of the most consistently cited contributors to adult acne, especially in women, is hormonal imbalance, particularly androgen excess or fluctuations.
In adult women, acne is sometimes considered a clinical sign of hyperandrogenism (elevated “male” hormones).
What does that mean? Androgens like testosterone stimulate the sebaceous (oil) glands in skin follicles, making them produce more sebum.
Extra oil may block your pores, adhere to dead skin cells, and nourish acne-causing bacteria.
In addition, variables such as PCOS, endocrine disorders, or infrequent or irregular menstrual cycles might also exacerbate this hormonal exposure
Hormonal acne in adults often appears in particular patterns — along the lower face, jawline, chin, or neck area — places that are more hormonally sensitive.
In assessing adult acne, clinicians may check serum androgen values (total testosterone, free testosterone, DHEA-S) to guide treatment.
Thus, hormonal shifts (naturally with age, or due to underlying endocrine conditions) play a major role in the rising prevalence of acne among adults.
Stress & Cortisol: The Hidden Fuel
Adult lives tend to be more stressful, with career pressure, family responsibilities, and financial strain — and our skin often feels the fallout. Stress impacts acne through the hormone cortisol and downstream inflammation.
When you’re stressed, your body triggers the HPA (hypothalamic-pituitary-adrenal) axis, releasing stress hormones like cortisol. These hormones affect the skin directly by stimulating lipid synthesis, causing more oil production.
In datasets of adult female acne, many patients report flares during stressful periods; elevated adrenal androgens and cortisol correlate with acne severity. [Ref]
Diet & Lifestyle: More Than Folklore
Diet’s role in acne is complex and historically controversial. Newer research strengthens the link — particularly in adults, where metabolic factors may interact more with skin physiology.
High glycemic-load diets induce spikes in insulin and insulin-like growth factor 1 (IGF-1). These can stimulate sebum production and keratinocyte proliferation — essentially feeding the same cascade that leads to clogged pores and inflammation.
A prospective study of adult female acne found that diet and stress were among the triggers, noting high adrenal androgen levels in conjunction with sleep deprivation and diet factors.
Beyond diet, lifestyle factors like poor sleep, smoking, and lack of exercise worsen oxidative stress and inflammatory load, amplifying acne risk in adults.
So, when we see rising adult acne, it’s not simply more people developing the condition, but more people under hormonal flux and dietary strain.
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What Works: Evidence-Based Treatments Beyond Benzoyl Peroxide
If adult acne is driven by multiple internal factors, the treatment approach must also go beyond a single product.
Topical Therapies: Retinoids, Azelaic Acid, and Clascoterone
Topical treatments remain the first line for mild-to-moderate adult acne, sometimes in combination. While benzoyl peroxide is common, several potent alternatives exist:
1. Retinoids
Topical retinoids (e.g., adapalene, tretinoin, tazarotene) help by normalizing desquamation (skin turnover), reducing microcomedo formation, and having anti-inflammatory effects. They also help fade post-acne pigmentation.
In a network meta-analysis of mild-to-moderate acne, combination therapies (retinoid + benzoyl peroxide) ranked among the most effective topical pharmacological strategies. [Ref]
Tazarotene is known to synergize with antibacterial agents, improving efficacy beyond monotherapy.
2. Azelaic Acid
Azelaic acid is a dicarboxylic acid with antibacterial, anti-inflammatory, and comedolytic effects. A 15% gel was shown to be comparably effective to adapalene 0.1% for inflammatory adult acne in women. [Ref]
Azelaic acid is often better tolerated and usable during pregnancy or lactation (under medical supervision).
It also helps with post-inflammatory hyperpigmentation, which is a common issue in adult acne.
3. Clascoterone
A newer topical antiandrogen, clascoterone 1% cream (brand name Winlevi), directly antagonizes androgen receptors in the skin
As a topical with hormonal activity, it offers a middle ground for patients who need some androgen modulation but prefer to avoid systemic therapy.
Hormonal Treatments: When Topicals Are Not Enough
In women whose acne is driven by hormonal imbalance, hormonal therapies yield some of the best results.
Combined Oral Contraceptives (COCs)
Many dermatology guidelines recommend COCs (estroprogestins) as an adjunct or second-line therapy in adult female acne. They reduce androgen production and block androgen effects in the sebaceous glands.
In a study of adult female acne, contraceptive-based treatments (ethinylestradiol + drospirenone) showed effectiveness in hormonal and clinical markers. [Ref]
Spironolactone
Spironolactone is an oral antiandrogen that inhibits androgen receptors and decreases sebum production. It is primarily used in women with hormonal acne when combined oral contraceptives are contraindicated or not effective.
Recently published review on hormonal therapies, benefits of spironolactone, and facilitation of patient-centered dermatologic care
However, spironolactone is not typically prescribed for men due to the risk of hormonal effects; caution is also needed in women who are pregnant or at risk.
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Systemic Therapies: Antibiotics, Isotretinoin & Beyond
For adult acne that’s moderate-to-severe, systemic treatments are often required:
1. Oral Antibiotics
Tetracyclines (doxycycline, minocycline) remain standard. In network meta-analysis, topical + oral antibiotic combinations ranked among effective approaches for moderate-to-severe acne. [Ref]
However, antibiotics come with concerns: resistance, side effects, and their appropriateness for long-term use. Guidelines generally recommend limiting duration and combining with non-antibiotic therapies.
2. Oral Isotretinoin
Isotretinoin is the most potent systemic acne therapy and can induce long-term remission in many users. It works by drastically reducing sebum production, reducing inflammation, and normalizing keratinization
For severe or treatment-resistant acne, isotretinoin is standard. In less severe cases, lower-dose regimens are sometimes considered to reduce side effects.
Because isotretinoin has significant side-effect potential (e.g. teratogenicity, lipid changes), it requires close medical supervision
Adjunctive & Procedural Therapies
1. Chemical Peels & Light Therapies
Chemical peels (e.g., salicylic acid, mandelic acid) and photochemical or photodynamic therapies have shown benefit in mild-to-moderate acne in some trials. In the same network meta-analysis, chemical peels ranked highly. [Ref]
The AAFP review includes light-based therapies (e.g,. pulsed-dye laser, photodynamic therapy) and comedo extraction as possible options, though high-quality evidence is still limited. [Ref]
These procedures are often used as adjuncts to medical therapy, not stand-alone cures.
2. Skincare & Barrier Support
One of the challenges with adult acne is that treatment regimens (retinoids, acids, etc.) can irritate and compromise the skin barrier. A consensus piece on adult acne notes the importance of gentle cleansers, non-comedogenic moisturizers, and barrier repair strategies alongside active treatments.
Maintaining skin barrier function helps reduce rebound inflammation, flares, and sensitivity — making active therapies more tolerable and sustainable.
Putting It All Together: A Balanced, Realistic Strategy
Treating adult acne isn’t about a magic single cure — it’s about matching treatments to underlying drivers and layering wisely.
First, get a proper assessment. If hormonal imbalance is suspected, check androgen levels. Monitor lifestyle factors (stress, diet, sleep) that may be aggravating inflammation.
Second, start with combination therapy. Use a retinoid (or azelaic acid) to normalize turnover; add a gentle antibacterial or anti-inflammatory (non-benzoyl peroxide options where sensitivity is a concern).
In women with hormonal influence, a hormonal treatment (COCs or spironolactone) could be considered in consultation with the dermatologist.
Thirdly, promote compliance and tolerability by protecting the barrier, which can be accomplished with soothing moisturizers and gentle cleansers.
Avoid excessive skin stripping, as this may not only exacerbate the inflammation but also impair compliance with treatment.
Fourth, evaluate results over months, not days. Adult acne is chronic for many, so patience is essential.
If progress is lukewarm, escalate to systemic therapy (oral antibiotics or isotretinoin) under supervision. Consider procedural adjuncts as needed (e.g., peels, light therapy).
Lastly, consider addressing lifestyle as a whole. Reduce stress (through interventions such as meditation, exercise, and sleep hygiene), reduce dietary glycemic load and/or dairy if implicated, and support gut health and systemic inflammation. Every healthy lifestyle choice will improve your skin’s resilience.
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