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Diogo Pazzini Bomfim,1 Marco Alexandre Dias da Rocha,2 Adriana Sanudo,3 Edileia Bagatin2 1Translational Medicine, Federal University of Sao Paulo (UNIFESP), Sao Paulo, Brazil; 2Department of Dermatology, Federal University of Sao Paulo (UNIFESP), Sao Paulo, Brazil; 3Department of Preventive medicine, Federal University of Sao Paulo (UNIFESP), Sao Paulo, BrazilCorrespondence: Diogo Pazzini Bomfim, Email pazzini.bomfim@unifesp.brIntroduction: In several countries, recent research has shown an increase in the prevalence of adult female acne (AFA), defined as the acne that appears in women aged over 25. This disease brings some particularities and challenges, such as a greater impact on quality of life (QoL) and chronicity. A negative impact on QoL has been observed, as well as anxiety, depression, anger, low self-esteem, and feelings of embarrassment and frustration.Purpose: To quantify AFA’s impact on QoL and the influence of two dermatological treatments.Material and Methods: A prospective study including 40 women, aging from 25 to 44 years old, with mild-to-moderate acne was conducted. Participants underwent clinical, laboratory, and photographic evaluations. They were randomized into two treatment groups: group 1 – azelaic acid (AZA) 15% gel twice daily; group 2 – spironolactone (SPIRO) 100 mg/day and treated for 6 months. At baseline and at the end of treatments, a specific QoL questionnaire for acne, already translated and validated for Brazilian Portuguese (Acne-QoL-BR), was applied. It contains 19 questions allotted in four domains. Each item within a domain is scored from 0 to 6. The total score ranges from 0 to 114 and domains are distributed as follows: 0– 30 (self-perception), 0– 30 (role-emotional), 0– 24 (role-social), 0– 30 (acne-symptoms). Higher scores reflect better QoL.Results: The mean age was 32.7 (SD: 5.42); 85% presented persistent acne. After treatment regardless of group, there was a significant improvement in total score and all domains’ scores of acne QoL-BR (p < 0.001), with no difference between groups, despite one treatment being topical and the other systemic (p=0.918).Conclusion: Acne-QoL-BR is a useful tool for quantifying the impact of acne and should be used as an efficacy parameter in clinical trials.Keywords: adult female acne, quality of life, azelaic acid, spironolactone

Marco A Rocha, Ediléia Bagatin Paulista Medical School, Universidade Federal de São Paulo (Federal University of São Paulo), São Paulo, SP, Brazil Abstract: Acne is a multifactorial and inflammatory disease of pilosebaceous follicles, which affects most adolescents. Recent epidemiological data revealed a difference in adults affected by this disease. Women have a high prevalence and incidence when compared with men, especially after 25 years of age. In contrast to what was initially thought, most of these patients do not present endocrinopathy capable of leading to the development of the lesions. When present, polycystic ovarian syndrome is the main cause. However, in these cases, acne is rarely the only dermatological manifestation; hirsutism and acanthosis nigricans are often present. The majority of the normoandrogenic acne patients present a history since adolescence, but in many cases the lesion distribution and intensity change with time. There is often a typical localization of the lesions in the lower third of the face and lateral region of the neck. Another interesting feature is related to the impact on quality of life (QoL), which is always intense. Often there are signs of depression, even when the lesions are mild. As most adult patients are women, in addition to the conventional options, there is also hormone treatment. Combined oral contraceptives and spironolactone are good options. Knowing more about the particularities in etiopathogenesis, impact on QoL, and specific treatment options is important to all dermatologists who face the challenge of treating acne in adults. Keywords: adult, acne, hormonal, female

Marco Alexandre Dias da Rocha,1 Markéta Saint Aroman,2 Valérie Mengeaud,3 Fabienne Carballido,4 Gautier Doat,5 Ana Coutinho,6 Edileia Bagatin1 1Department of Dermatology, Universidade Federal de São Paulo, São Paulo, Brazil; 2Corporate Medical Direction Dermocosmetics Care & Personal Care, Pierre Fabre, Toulouse, France; 3Laboratoires Dermatologiques Ducray, Pierre Fabre Dermo-Cosmétique, Lavaur, France; 4Laboratoires Dermatologiques A-Derma, Pierre Fabre Dermo-Cosmétique, Lavaur, France; 5Laboratoires Dermatologiques Avène, Pierre Fabre Dermo-Cosmétique, Lavaur, France; 6Laboratorios Pierre Fabre do Brasil LTDA, Rio de Janeiro, BrazilCorrespondence: Marco Alexandre Dias da Rocha, Departamento de Dermatologia, Universidade Federal de São Paulo (UNIFESP), R. Botucatu, 821 - Vila Clementino, São Paulo, SP, 04039-001, Brazil, Tel +55-(11)-3129-5007, Email marcoderm@hotmail.comAbstract: Previously considered a skin disease exclusively affecting adolescents, characterized by inflammatory and non-inflammatory skin lesions, acne vulgaris is now increasingly observed in adult life, including post-menopause. Today, adult female acne (AFA) is a common chronic inflammatory disease of the pilosebaceous unit, with polymorphic lesions presenting as open or closed comedones, papules, pustules, and even nodules or cysts, often with the presence of sequelae. AFA may persist from adolescence or manifest de novo in adulthood. Its etiology is multifactorial, involving genetic, hormonal, dietary, and environmental factors, yet still incompletely understood. Increased sebum production, keratinocyte hyper-proliferation, inflammation, and reduced diversity of Cutibacterium acnes strains are the underlying disease mechanisms. During menopausal transition, a relative increase in androgen levels occurs, just as estrogens begin to decline, which can manifest itself as acne. Whereas most AFA exhibit few acne lesions with normo-androgenic serum levels, baseline investigations including androgen testing panel enable associated comorbidities to be eliminated, such as polycystic ovarian syndrome, congenital adrenal hyperplasia, or tumors. Another interesting feature is AFA’s impact on quality of life, which is greater than in adolescents, being similar to other chronic diseases like asthma. The therapeutic approach to AFA depends on its severity and associated features. This review investigates the intricate facets of AFA, with a specific focus on incidence rates, treatment modalities, and the curious impact of menopause. Utilizing insights from contemporary literature and scientific discussions, this article seeks to advance our understanding of AFA, offering new perspectives to shape clinical practices and improve patient outcomes.Keywords: adult female acne, epidemiology, treatment, dermocosmetics, menopause, hormonal dynamics

Alison M Layton,1 Marco Alexandre Dias da Rocha2 1Skin Research Centre, Hull York Medical School, University of Hull, Hull, UK; 2Federal University of São Paulo, São Paulo, BrazilCorrespondence: Marco Alexandre Dias da Rocha, Federal University of São Paulo, Rua Oscar Pinheiro Coelho, 115 casa 04. Caxingui, São Paulo, Brazil, Email marcoderm@hotmail.comAbstract: Acne Vulgaris is a chronic inflammatory skin disease, and one of the most prevalent inflammatory dermatoses among teenagers, affecting more than > 95% of boys and 85% of girls. Adult female acne (AFA) is a subtype of acne, pragmatically defined as affecting women over the age of 25. The clinical presentation of AFA may be distinguished from adolescent acne according to some key clinical and psychosocial characteristics. The etiopathogenic factors and the chronic clinical course that are implicated in AFA make management complex and challenging. A frequent tendency to relapse makes the requirement for maintenance therapy highly likely. Therefore, AFA typically requires a specific, tailored therapeutic approach. This paper presents six challenging case studies that demonstrate the efficacy of azelaic acid gel (AZA) in adult female acne. The six cases use AZA as monotherapy, as part of a combination regimen at treatment initiation, or as maintenance treatment (which is frequently required in this adult population). The positive outcomes achieved in this case series demonstrate that AZA can be efficacious, result in excellent patient satisfaction in mild to moderate adult female acne, and can be effective as a maintenance therapy.Keywords: acne vulgaris, adult female acne, azelaic acid, skin conditions, inflammation