Adult Acne: What It Is and How It Differs from Rosacea and Perioral Dermatitis

What is Adult Acne?

Acne can carry on past the age of 25, or appear for the first time in adulthood in someone who had none at school. Acne that continues into, or begins during, adult life is called adult acne (post-adolescent acne). Literature on adult women divides it into a persistent form carried over from puberty and a late-onset form that appears for the first time in adulthood; in the same paper the late-onset form was reported at 18.4%. The rest were cases carried over from adolescence.

In a questionnaire given to 1,013 adults aged 20 and over, 73.3% answered that they had had acne, and in every age group beyond the teens women reported it more often than men (in their twenties, 50.9% of women against 42.5% of men; in their thirties, 35.2% against 20.1%; in their forties, 26.3% against 12.0%). These are self-reported answers on a questionnaire rather than prevalence confirmed by examination, and the sample was gathered at a university campus and a medical complex in the United States. Teenage acne is described as more common in males, while post-adolescent acne is described as predominant in females. Prevalence data in a Korean population could not be confirmed.

Adult acne has commonly been said to stay within the chin and mandible — the so-called U-zone — and to involve few comedones. Yet in an international observational study in which 374 adult women aged 25 and over were examined directly in dermatology clinics, 89.8% had lesions spanning the cheeks, forehead, mandible and temples, with a severity spectrum similar to that of teenage acne, and only 11.2% were confined to the mandible. In the same study, 93.7% had comedones on the face. That this was a clinic sample of women who had come to a dermatologist for acne has to be taken into account, but it means that whether breakouts cluster on the chin is not enough on its own to identify adult acne.

Inflammatory acne is commonly attributed to stress, and premenstrual flares are also reported as common. In a study in which 22 university students were assessed repeatedly during examination and non-examination periods, an increase in acne severity was associated with an increase in stress (r=0.61). In the same study, change in diet quality showed an association as well. Beyond that, hormonal factors such as pregnancy, polycystic ovary disease, and medications or supplements with androgenic activity can matter, and oily face creams and smoking have been associated with comedonal acne.

In people with acne, impaired skin barrier function — assessed through measures such as increased transepidermal water loss (TEWL) — has been reported. Literature on adult women notes that skin at this stage can be more sensitive to irritation than in adolescence and less tolerant of topical medication. How long the red marks or pigmentation left once a lesion settles will last varies a great deal from person to person, so it is judged by looking at the skin during a consultation.

How is it treated?

Adult acne is approached by separating lesions that recur in the same place from the overall sebum state of the face, while taking into account a skin barrier that has become sensitive to irritation.

For suppurative lesions that recur chronically in a particular area, insulated microneedle radiofrequency (such as Agnes) is used. A specialized needle insulated to protect the epidermis delivers radiofrequency energy at the depth of the sebaceous gland, aiming at the glandular area that acts as the origin of repeated inflammation.

For lesions distributed widely across the face, photothermal therapy (PTT) may be used alongside. Specialized particles are delivered into the follicle and a laser of a particular wavelength is then applied to target the sebaceous glands. That said, the 2024 American Academy of Dermatology acne guideline stated that, for procedural categories such as chemical peels, laser and light-based devices and microneedling, the evidence is insufficient to develop a recommendation — so whether and how far they are applied is decided in the consulting room while watching the lesions and the response.

Since literature on adult women describes skin at this stage as sensitive to irritation and potentially less tolerant of topical medication, soothing anti-inflammatory care and moisturizing barrier care are kept within the same plan. The intensity of the procedures and the interval between them are adjusted against that response as well.

Aftercare

While the skin is settling after a procedure, it is better to avoid activities that raise heat in the skin, such as saunas, steam rooms and vigorous exercise. How long that period lasts depends on the depth of the lesions and the extent treated, so follow the guidance given in the consultation.

Fine crusting or redness can appear temporarily where insulated microneedle radiofrequency or PTT was performed; take care not to pull the crusts off with your fingers.

Squeezing forcefully at home with your fingernails can lead to secondary infection or a pitted scar. For lesions where the inflammation sits deep, or that keep recurring in the same place, whether to extract at all is judged in the consulting room after looking at the skin.

Cleanse with a low-irritation cleanser, and use a non-comedogenic moisturizer rather than heavy, oily cosmetics. If you are also using a topical retinoid, its labelling states that exposure to sunlight and sunlamps should be minimized and that it should not be used where sunburn is present until recovery, so take particular care with sun protection. The same labelling states that abrasive soaps and cleansers, soaps and cosmetics with a strong drying effect, and products high in alcohol and astringents should be used with caution, and notes that weather extremes such as wind or cold can also be irritating. The same caution applies if you are taking an oral tetracycline-class antibiotic alongside — photosensitivity, manifested as an exaggerated sunburn reaction, has been observed in some people taking them.

Other conditions that look similar

Not everything that makes an adult face red and spotty is acne. Rosacea, centered on flushing and telangiectasia over the central face, and perioral dermatitis, in which tiny papules come up around the mouth, are separated by the absence of comedones, and they are approached differently.

If acne was assumed and antibiotic treatment was given but there was no response, or things got worse, fungal (Malassezia) folliculitis is considered as well. This form is described as spreading in a cape-like distribution over the shoulders, back and neck. This is not, however, a criterion you can sort out on your own — it is settled in the consulting room.

Where signs of androgen excess such as hirsutism, seborrhea, hair loss or menstrual irregularity are present together, or where premenstrual flares are marked, hormonal testing is recommended. A cross-sectional study (single center in Poland, n=354) also found that a group of adult women with acne had endocrine disorders more often than a group without (P=0.002).

Frequently asked questions

This page is general information about a treatment and is not a diagnosis or a recommendation. The right choice differs by skin condition, so treatment is decided after an in-person examination. Individual results vary.

References

1. Guidelines of care for the management of acne vulgaris J Am Acad Dermatol 2024;90(5):1006.e1-1006.e30 (Reynolds RV et al.)
2. Adult female acne: a guide to clinical practice An Bras Dermatol 2019;94(1):62-75 (Bagatin E et al.)
3. The prevalence of acne in adults 20 years and older J Am Acad Dermatol 2008;58(1):56-9 (Collier CN et al.)
4. Adult female acne: a new paradigm J Eur Acad Dermatol Venereol 2013;27(9):1063-70 (Dréno B et al.)
5. Large-scale international study enhances understanding of an emerging acne population: adult females J Eur Acad Dermatol Venereol 2015;29(6):1096-106 (Dréno B et al.)
6. Diet and acne: A systematic review JAAD Int 2022;7:95-112 (Meixiong J et al.)
7. Large prospective study on adult acne in Latin America and the Iberian Peninsula: risk factors, demographics, and clinical characteristics Int J Dermatol 2019;58(11):1277-82 (Kaminsky A et al.)
8. The Skin as a Mirror of Internal Disease: Comorbidities and Epidemiology of Acne Vulgaris and Adult Female Acne - A Cross-sectional Study and Current State of Knowledge Acta Dermatovenerol Croat 2020;28(3):133-140 (Kaleta KP et al.)
9. The response of skin disease to stress: changes in the severity of acne vulgaris as affected by examination stress Arch Dermatol 2003;139(7):897-900 (Chiu A, Chon SY, Kimball AB)