Acne in adult life: why it appears in your 30s and 40s

"I'm past 30 and I have more spots than I did at 16." This is a common remark in consultations and usually comes with frustration: acne is seen as a teenage problem, and having it in adult life seems unfair and embarrassing. But it is very common, especially in women, and has its own characteristics.

Adult acne tends to be located on the lower part of the face, to be more inflammatory and persistent, to leave more marks and to respond worse to some treatments that worked in adolescence. On the other hand, there are effective treatments today, including hormonal options, and a good diagnosis makes all the difference.

How many adults have acne

In a study of 1,013 adults in the US (Collier et al., 2008), acne across the ages was as follows:

Source: Collier et al., 2008.

From the age of 20, women have acne more often than men at every age.

Two patterns

• Persistent acne: began in adolescence and never completely went away. It is the most common pattern.
• Late-onset acne: appears for the first time after the age of 25, in people who never had acne or had very little.

How it differs from teenage acne

Not all adult women follow this pattern, and many have a mixture of the two.

Why it appears in adult life

Acne results from four processes: increased sebum production, blockage of the pore, proliferation of a skin bacterium (Cutibacterium acnes) and inflammation. In adult life, several factors can trigger or sustain these processes.

Hormones

Androgens stimulate the sebaceous glands. Many women with adult acne have normal hormone levels, but more sensitive glands. Flare-ups before menstruation, acne after stopping the pill, in pregnancy or postpartum, and in perimenopause reflect these variations.

Polycystic ovary syndrome

Persistent or late-onset acne, with irregular cycles, excess hair, hair loss or difficulty conceiving, may indicate polycystic ovary syndrome or another cause of androgen excess. It deserves medical assessment and blood tests.

Stress

Stress raises hormones such as cortisol and adrenal androgens and is associated with acne flare-ups. It also leads to more picking at the skin.

Cosmetics and habits

• Very occlusive or oily creams, foundations and sunscreens.
• Hair products that run down onto the forehead and temples.
• Touching, squeezing, resting your chin on your hand, phone, face masks worn for many hours.

Medicines and supplements

Corticosteroids, some progestogen-only contraceptives, testosterone and anabolic steroids, lithium, some antiepileptics and high-dose vitamin B6 and B12 supplements can cause or worsen acne. Do not stop any medicine without speaking to your doctor.

Diet

The evidence suggests a modest association between high-glycaemic-index foods (sugars, refined flours) and some dairy products, especially skimmed milk, and acne. It is not a single cause and very restrictive diets are not recommended; a balanced diet, with less sugar, may help some people.

Tobacco

Associated with a form of acne with many comedones in adult women, in some studies.

What can look like acne but is not

A correct diagnosis avoids months of inappropriate treatments.

Treatments with evidence

The 2024 American Academy of Dermatology guidelines (Reynolds et al.) summarise the current evidence. Treatment is chosen according to severity, the type of lesions, the skin, any wish to become pregnant and each person's preferences, and is always defined by a doctor.

Strongly recommended

• Topical retinoids (adapalene, tretinoin, trifarotene): they unclog pores, reduce inflammation and help with dark marks. They are the basis of treatment and maintenance. They must not be used in pregnancy.
• Benzoyl peroxide: antibacterial without the risk of resistance; may bleach fabrics.
• Topical antibiotics, always combined with benzoyl peroxide, to avoid resistance.
• Oral doxycycline, for limited periods (generally up to three to four months), combined with topical treatment.
• Oral isotretinoin, for severe acne, with scarring, that causes psychological distress or that does not respond to other treatments. It is very effective, but requires prescription and monitoring: it is seriously harmful to the foetus (it requires a pregnancy prevention programme), can cause intense dryness and changes in blood tests, and any change in mood should be reported to the doctor immediately.

Conditionally recommended

• Azelaic acid: good for acne with marks and for sensitive skin; may be used in pregnancy, on medical advice.
• Topical salicylic acid.
• Topical clascoterone, a local anti-androgen, where available.
• Combined oral contraceptives, in women with no contraindications.
• Spironolactone, an oral anti-androgen widely used for hormonal acne in adult women; in Europe it is used outside the approved indications and requires contraception and monitoring.
• Other oral antibiotics (minocycline, sarecycline).

In-clinic procedures

Chemical peels, extraction of comedones, corticosteroid injections into painful nodules and some lasers and light sources can complement medical treatment. See Chemical peel: what to expect on the day, during the peeling and in the following weeks.

Patience and maintenance

Most treatments take 8 to 12 weeks to show results. Once controlled, adult acne usually needs maintenance treatment, generally with a topical retinoid.

Daily care, dark spots and scars

Simple routine

• Gentle cleansing twice a day, without scrubbing. Washing more does not treat acne and may irritate. See Washing your face two or three times a day? Oily skin and the rebound effect.
• Light, non-comedogenic moisturiser, especially with retinoids or benzoyl peroxide, which dry the skin.
• Daily, fluid, non-comedogenic sunscreen: prevents post-inflammatory dark marks.
• Non-comedogenic make-up, properly removed.
• Do not squeeze. Squeezing increases inflammation, dark marks and the risk of scarring.
• Change the pillowcase regularly and clean your phone screen.

Marks after spots

The brown (post-inflammatory hyperpigmentation) or reddish marks left after spots are not scars and fade with time, especially with sunscreen. Retinoids, azelaic acid, niacinamide and peels speed up recovery. See Sun spot, melasma or acne mark: how to tell them apart.

Scars

True scars change the contour of the skin ("ice-pick", "boxcar" or "rolling" depressions). The best prevention is to treat inflammatory acne early. Once the acne is controlled, treatments such as microneedling, fractional laser, peels and subcision can improve the contour.

The emotional impact

Adult acne affects self-esteem and social and professional life. If worry about your skin is affecting your wellbeing, speak to your doctor. Treating acne also improves quality of life.

When to seek help

At Luxmed, the skin assessment makes it possible to understand the type of acne, the factors that sustain it and the most suitable plan, which may combine home care, medical treatment and in-clinic procedures. When specialist medical treatment is needed, such as isotretinoin or a hormonal assessment, we arrange the appropriate referral.

This article is for information purposes and does not replace a medical consultation. The results of any treatment vary from person to person.

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