Adult acne: causes, triggers and treatments

Causes and triggering factors¹ ³

• Genetic predisposition
  A family history strongly increases the risk and severity of acne. People with one or more first‑degree relatives affected are significantly more likely to develop the disease themselves and to present with a more severe form.
• Premenstrual flare‑ups
  In women, acne often worsens before menstruation. This flare‑up, more common in adults than adolescents, is thought to reflect hormonal fluctuations that increase water content in the pilosebaceous unit, leading to pore blockage.
• Hormonal disorders
  Imbalances are frequent causes of adult acne, particularly in women. A sudden onset of severe acne should prompt a search for signs of virilisation or underlying endocrine disease such as polycystic ovary syndrome (PCOS), adrenal hyperplasia or androgen‑secreting tumours.
  
  Red‑flag symptoms include irregular periods, hirsutism (excess hair), scalp alopecia (hair loss), late menarche (first period) or infertility—features suggestive of hyperandrogenism which is an abnormal increase in the concentration of androgens (masculine hormones) in the blood.
• Cosmetics and moisturisers
  Comedogenic products constitute a significant trigger, especially in adult women. Ingredients such as lanolin, isopropyl myristate, cetyl alcohol and stearic acid can block pores and spark break‑outs. Greasy sunscreens and unsuitable make‑up may have the same effect
• Body‑mass index (BMI) and diet
  Links between adult acne and BMI remain controversial. Some studies point to a higher risk with overweight or obesity; others do not. Insulin resistance (cell resistance to insulin), common on a Western‐style diet rich in sugars and fats, appears more clearly implicated.
  
  High‑glycaemic foods, sugary drinks, fatty or sweet snacks and lactose‑rich dairy elevate insulin levels, driving sebaceous‑gland proliferation, increased lipid synthesis and keratinocyte (epidermal cells) hyperplasia, thereby fostering acne.
• Stress
  Emotional stress is a key trigger. It worsens skin inflammation, encourages picking and scratching, which raises the risk of scarring and post‑inflammatory hyperpigmentation, and boosts cortisol production, affecting androgen levels.
• Smoking
  Smoking is linked to adult acne, particularly in women. Cigarette smoke oxidises skin lipids, alters sebum composition and favours non‑inflammatory lesions. While some studies in adolescents suggest the opposite, smoking remains a recognised aggravating factor in adults.
• Medications
  Several drugs can provoke or exacerbate adult acne, notably corticosteroids, oral contraceptives containing androgenic progestins, vitamin B12, isoniazid, testosterone, lithium and specific anticancer agents. These substances alter sebum production or trigger follicular inflammation.
• Seasonal factors
  Seasonal variation affects individuals differently. Some improve in summer, possibly thanks to the transient anti‑inflammatory effects of UVA and visible light, plus the drying action of sunlight. Others worsen, owing to UVB irritation, heavy sweating or occlusive sunscreens. An “autumn rebound” is common, linked to UV‑induced thickening of the stratum corneum and the loss of summer’s temporary benefits.

Differences between acne in men and women⁴ ⁵

Acne differs markedly between men and women in its underlying mechanisms, clinical presentation and management. These distinctions affect how severe the condition becomes, where lesions appear, and how well treatments work.

Pathophysiology and sebum production⁴ ⁵

Male skin usually produces more sebum than female skin because circulating androgens are higher. This excess sebum fosters an environment where Cutibacterium acnes thrives, amplifying inflammation. Men also have a lower skin pH and lose less transepidermal water, factors that may alter their response to topical therapy.

In women, adult acne is often linked to hormonal imbalance, most notably hyperandrogenism in conditions such as polycystic ovary syndrome. 78% report pre-menstrual acne flare-ups.⁴ 

Specific triggering factors⁴ ⁵

Protein-rich supplements such as whey (usually taken by men to increase muscle weight) can trigger acne. Similarly, anabolic steroids used for bodybuilding can cause severe forms such as acne fulminans.

In women, cyclic hormonal fluctuations, whether natural or pill-related, play a significant part, while heavy or comedogenic cosmetics can aggravate lesions. 

Psychological and social impact⁴ ⁵

Adult acne exerts a greater documented psychological burden on women, driven by societal beauty norms. This may lead to high emotional distress, compulsive picking, and a higher risk of scarring and hyperpigmentation. Although the question is less studied, severe lesions can also undermine self-esteem in men. 

Tailored therapeutic approaches⁴ ⁵

For men, treatment often focuses on sebum control with retinoids and anti-inflammatory agents. In women, hormonal strategies, notably suitable oral contraceptives, constitute a management option. 

Treatment options for adult acne¹ ³ ⁶

Adult acne management requires a comprehensive plan that combines pharmacological therapy, lifestyle guidance and appropriate skincare. Decisions must reflect age, sex, patient expectations and individual triggers.

Topical treatments

Topical agents remain first-line for mild-to-moderate disease. But, as adult skin is often more sensitive than adolescent skin, their tolerance to local treatment is lower.

Benzoyl peroxide and retinoids curb inflammation, limit comedone formation, and help prevent new lesions; they should be continued after improvement to forestall relapse.

Because of photosensitivity, topical treatment should be applied in the evening. 

Systemic treatments

For moderate-to-severe acne, systemic therapy may be required.

• Oral antibiotics (cyclines) are widely prescribed for their anti-inflammatory action, but the duration should be limited to curb resistance. 
• Young women who also need contraception can use progestins with low androgen activity.
• Isotretinoin is reserved for severe to very severe, scarring or treatment-resistant forms; strict monitoring is essential, and pregnancy is an absolute contraindication. 

Maintenance therapy

Adult acne is more relapse-prone and treatment-resistant than teenager acne , so prolonged maintenance is vital, typically with topical treatments like retinoids or azelaic acid.

Cosmetic care and skin hygiene in adult acne¹ ³ ⁷

These measures help reduce breakouts, improve skin quality and prevent scarring.

Skin hygiene and care

Daily cleansing: Wash your face morning and evening with a gentle, non-irritating cleanser for acne-prone skin, and cleanse again after heavy sweating.

• Appropriate hydration: Apply a non-comedogenic moisturiser to maintain the skin’s hydrolipid balance and counteract the drying effects of treatment.
• Product choice: Avoid aggressive scrubs like alcohol-based masks and other irritants. Opt for non-comedogenic skincare and cosmetics and remove make-up thoroughly each night.
• Hair hygiene: Regularly shampoo, especially if your hair is oily, to reduce the risk of forehead lesions.

Environmental factors and lifestyle

• Hands off your face: Picking or frequent touching worsens lesions and increases scarring risk.
• Sun protection: UV rays can exacerbate acne and darken scars, particularly when you are on photosensitising treatments (retinoids, benzoyl peroxide, cyclines). Avoid direct sun exposure and use a suitable non-comedogenic SPF.
• Shaving: Choose devices and techniques that minimise irritation, like an electric shaver or clean blades, and avoid alcohol-based aftershaves.
• Balanced diet: Eat fruits, vegetables and low-glycaemic foods; cut back on refined sugars and dairy if they trigger flare-ups.
• Quit smoking: Tobacco degrades skin quality and can worsen acne lesions.
• Stress management: Stress aggravates acne; incorporate relaxation methods such as yoga or meditation, and exercise regularly.