AFA is frequently referred to as 'hormonal acne', which is a misnomer, because all acne is hormone-mediated. Cyclical or pre-menstrual acne would be a more appropriate term since acne in adult females often fluctuates with their menstrual cycle.³  

AFA, like all acne, is driven by fluctuations in androgen levels that lead to increased oil (sebum) production, clogged pores (follicular hyperkeratinisation), increased Cutibacterium acnes (C acnes) bacteria, and inflammation.⁴ 

Apart from menstrual cycles, various other factors have been implicated in the onset and exacerbation of AFA. Studies indicate that sleep deprivation, which is prevalent in modern women's lifestyles, along with stress, plays a significant role. These factors impact the hypothalamic-pituitary-adrenal axis, leading to increased secretion of stress-related hormones, thereby potentially aggravating acne.⁵  

Furthermore, dietary habits have emerged as critical influencers. Consumption of high glycemic index foods and dairy products has been shown to elevate insulin and insulin-like growth factor 1 levels. These hormones stimulate androgen production and inhibit aromatase activity, which converts testosterone to oestradiol.⁵  

High glycaemic load diets and dairy intake activate the mammalian target of rapamycin complex 1 pathway, leading to increased keratinocyte proliferation, sebaceous gland hyperplasia, and sebaceous lipogenesis. This metabolic shift also contributes to insulin resistance and high body mass index.⁵ 

In addition to dietary factors, the use of dietary supplements aimed at muscle mass gain, particularly those rich in branched-chain amino acids and whey-derived peptides, has been observed to worsen acne.⁵ 

Tobacco use has also been closely linked to acne, particularly in women. Studies show that smoking significantly increases the incidence of non-inflammatory acne, characterised by micro and macro-comedones with few inflammatory lesions, often referred to as 'smoker's face'. Nicotine stimulates acetylcholine receptors in the sebaceous glands, leading to cellular differentiation, hyper-keratinisation, altered sebum production, and increased lipid peroxidation, including squalene.⁵ 

AFA presentation 

Acne primarily presents with open or closed comedones, papules, pustules, or nodules on the face or trunk and may result in pain, erythaema, hyperpigmentation, or scars.¹ 

AFA typically presents as deep, painful cysts along the lower parts of the face, upper chest, and back, but it can involve multiple facial areas and mixed comedones as well.⁴  

Identifying AFA requires a thorough patient history, including menstrual cycle patterns, medications, and social and family history. The key descriptor in the history is persistent, which was noted in 75% to 85% of cases.⁶  

Lastly, it is important to remember that persistent AFA can also indicate a systemic disease, such as polycystic ovary syndrome, which is associated with hormonal and metabolic disorders.⁶ 

Treatment options for AFA 

Treatment options for AFA include topical and oral pharmacotherapy, as well as alternative therapies. Topical therapies, such as retinoids and benzoyl peroxide (BP), work by unclogging pores and reducing inflammation. Oral therapies, such as antibiotics and combined oral contraceptives (COCs), may be necessary for more severe cases. The jury is still out about the efficacy of alternative therapies, such as laser therapy and chemical peels, can be effective in treating AFA and the role of dietary factors in acne onset.^1,7 

However, lifestyle factors such as maintaining a healthy diet, practicing good skincare hygiene, and avoiding triggers such as excessive sun exposure or stress may be beneficial.⁷ 

What do the 2024 AAD guidelines recommend? 

According to the 2024 AAD guidelines, acne treatment for AFA requires a nuanced approach that balances efficacy and safety across a range of therapeutic options. The guidelines recommend:¹ 

Topical therapies are the foundation of acne treatment, offering effective options either as monotherapy or in combination with other agents. Here are key recommendations and considerations for women considering topical treatments:¹ 

• Topical retinoids, such as tretinoin, adapalene, tazarotene, and trifarotene, are highly recommended due to their efficacy in reducing comedones and inflammation. They also improve dyspigmentation but may cause skin irritation including dryness and peeling. Starting with lower concentrations and gradually increasing frequency of use can mitigate these effects. Sunscreen is crucial due to increased photosensitivity. 
• BP, known for its antimicrobial and comedolytic properties, is recommended but should be used cautiously due to potential side effects such as dryness, irritation, and fabric bleaching. Lower concentrations and non-occlusive formulations are preferred to minimise skin irritation, especially in individuals with sensitive skin. 
• Topical antibiotics (eg clindamycin, erythromycin) are recommended, preferably in combination with BP, to reduce the risk of antibiotic resistance. Long-term monotherapy is discouraged due to resistance concerns and potential for skin dryness or allergic reactions. 
• Fixed-dose combinations of BP with either topical retinoids or antibiotics are recommended to enhance treatment efficacy and adherence. These combinations offer convenience but may increase the risk of skin irritation. The importance of following prescribed regimens closely should be stressed. 
• Clascoterone, a topical antiandrogen, is conditionally recommended as an alternative for individuals intolerant to other treatments. Despite its efficacy, high cost may limit accessibility. 

Considerations for pregnant women include avoiding topical retinoids due to potential fetal harm. BP, erythromycin, and clindamycin are generally safe with limited systemic absorption, while salicylic acid can be used cautiously in small areas. Topical dapsone and clascoterone lack sufficient safety data during pregnancy.¹ 

Systemic antibiotics: Including doxycycline, minocycline, and sarecycline are effective for moderate-to-severe acne due to their anti-inflammatory and antimicrobial properties. However, they are contraindicated during pregnancy, lactation, and in children <9-years due to potential risks of teeth discoloration and enamel hypoplasia.¹  

To mitigate antibiotic resistance, their use should be limited to the shortest duration necessary, typically no more than three to four months. Combination therapy with topical treatments such as BP and retinoids is recommended to enhance efficacy and reduce resistance development.¹ 

Hormonal agents: COCs containing oestrogen and progestin are recommended for AFA, particularly in women living with hormonal imbalances. COCs help by decreasing ovarian androgen production and increasing sex hormone-binding globulin, thereby reducing free testosterone levels. COCs like norgestimate/ethinyl oestradiol, drospirenone/ethinyl oestradiol, and others are approved for acne treatment and have shown efficacy in reducing acne lesions. However, they carry risks such as venous thromboembolism, myocardial infarction, stroke, and certain cancers, necessitating careful patient selection and monitoring.¹ 

Isotretinoin: Should be reserved for severe acne or moderate acne that is unresponsive to other therapies. It is highly effective but teratogenic, requiring stringent pregnancy prevention measures. Long-acting reversible contraceptives like intrauterine devices or implants are preferred due to their high effectiveness and reduced reliance on patient adherence. Regular monitoring of liver function, lipids, and pregnancy tests is essential during treatment. Isotretinoin is associated with mucocutaneous, musculoskeletal, and ophthalmic adverse effects, which generally resolve upon discontinuation.¹ 

Physical modalities: Various modalities are available including acne lesion extraction, chemical peels, laser/light therapies, microneedle radiofrequency devices, and photodynamic therapy have been explored. However, evidence supporting their efficacy remains inconclusive, with specific techniques like pneumatic broadband light combined with adapalene showing no significant reduction in acne lesions and posing risks of hyperpigmentation and purpura.¹ 

Complementary/alternative therapies: Include for example botanical agents such as tea tree oil, and green tea, supplements such as zinc, niacinamide, and dietary modifications have been popular but lack sufficient evidence to support their efficacy in acne management. Clinical studies have not consistently shown benefits from these approaches compared to conventional treatments.¹ 

Dietary interventions: Dietary modifications, particularly low-glycaemic-load diets, have shown conflicting evidence regarding their impact on acne severity. Some studies suggest benefits, while others do not find significant differences compared to high-glycaemic-load diets. The role of other dietary factors such as dairy consumption, omega-3 fatty acids, and chocolate remains unclear due to insufficient evidence.¹ 

Conclusion 

Addressing AFA requires understanding its hormonal basis and a comprehensive approach to treatment. The AAD guidelines recommend a range of topical and systemic therapies, emphasising the importance of individualised treatment plans to balance efficacy and safety. Proper management of AFA not only improves skin health but also enhances overall quality of life for affected women. 

References 

1. Reynolds RV, Yeung H, Cheng CE, et al. Guidelines of care for the management of acne vulgaris. JAAD, 2024. 
2. Collier CN, Harper JC, Cafardi JA, et al. The prevalence of acne in adults 20 years and older. J Am Acad Dermatol, 2008. 
3. Dréno B, Thiboutot D, Layton AM, et al. Global Alliance to Improve Outcomes in Acne. Large-scale international study enhances understanding of an emerging acne population: adult females. J Eur Acad Dermatol Venereol, 2015. 
4. Zeichner JA, Baldwin HE, Cook-Bolden FE, et al. Emerging issues in adult female acne. J Clin Aesthet Dermatol, 2017.  
5. Bagatin E, Freitas THP, Rivitti-Machado MC, et al. Adult female acne: a guide to clinical practice. An Bras Dermatol, 2019. 
6. Dumont-Wallon G, Dréno B. Specificity of acne in women older than 25 years. Presse Med, 2008. 
7. Durairaj A, Elumalai K, Shanmugan A. Cystic acne treatment: A comprehensive review. Medicine Advances, 2023.