On the spot treatment

Jeremy Laurance on causes and cures for the misery of adult acne

You Have the job, you have the hair-do, but do you have the skin to succeed? The zits that plague the lives of so many teenagers are now causing misery among adults, too.

Acne in the boardroom is growing, especially among women. Dermatologists are seeing increasing numbers of patients in their twenties, thirties and forties desperate about the state of their complexion. Although chiefly a problem of adolescence, affecting up to 60 per cent of 14-20 year olds, acne also afflicts one per cent of men and five per cent of women over 40 - that's hundreds of thousands of people.

Many people sail through puberty and adolescence with no problems at all, only to develop acne in their mid to late twenties or thirties. No one knows what triggers it, although one suspect is stress. With more women juggling office deadlines and children's bedtimes, "late onset" acne may be the result.

The cause of acne in adults is the same as in teenagers - an abnormal response of the skin to the male hormone testosterone. Sufferers do not have excess hormones, their skin and the oil glands in the skin react abnormally to normal levels of it. (Testosterone is present in both men and women, but in women its effects are countered by the female hormone oestrogen.)

What triggers the abnormal response is unknown but it seems to work like a switch. When it is switched on, perhaps by the hormonal changes that accompany puberty, acne develops, and it is normally switched off by the time the sufferer hits the late teens or early twenties. However, the switching on may occur very late and the switching off may take several decades. For some patients, acne remains a problem throughout their lives, with the spots that first erupted at the age of 15 still bothering them into their late sixties.

Alison Dudley, co-ordinator of the Acne Support Group, says, "Many women spend a fortune on facials or never get further than over-the-counter remedies. Late onset acne is harder to treat." For some, the stigma and suffering can curtail their social lives and drive them into hiding.

Adults tend to suffer worse than teenagers. Professor Bill Cunliffe, head of the dermatology department at St James Hospital in Leeds and the UK's leading expert on acne, has collected records of 16 people who have committed suicide over the past 20 years because of their acne. Dr Victoria Goulden, an acne specialist in the department, says, "For adults the damage to self-esteem and self-confidence caused by acne is even greater than for teenagers. Women especially suffer psychologically and socially. If all your friends have got acne it is easier to bear - and it is seen as a disease of the teens. But as an adult, with one in ten or fewer affected, you tend to feel isolated."

One of the major difficulties, for adults and teenagers, is that most treatments take weeks or months to work. That can mean weeks and months of waiting to discover that a treatment doesn't work. Much advertising of spot creams and lotions implies a response overnight which compounds the disappointment when it doesn't happen.

An estimated pounds 94,000 a day is spent on over-the-counter acne remedies and 1.7 million people are known to consult their GPs about the problem. At least 60,000 are judged severe enough to be referred to dermatologists. Yet research by the Acne Support Group suggests on average people suffer for over four years before seeking help from the family doctor. The stigma is so great that even admitting to the problem involves crossing a psychological barrier.

The usual treatment, where over-the-counter remedies have failed, is antibiotics. However, a survey of 200 adult patients by Dr Goulden and her colleagues found they were more resistant to antibiotics than teenagers and did less well.

Use of isotretinoin, the synthetic version of vitamin A which has revolutionised the treatment of acne in the past few years, is effective even in the antibiotic-resistant cases. Latest figures suggest that 88 per cent of patients improve markedly on the drug and more than 60 per cent are acne- free for ten years after a course of treatment. Dr Goulden says, "I am always keen to get adults who have gone through all other treatments without success on to it. Here we have got a cure and it is under-prescribed."

Isotretinoin is a powerful drug and blood and liver function tests need to be performed before it is started. But a bigger problem for many patients is that it is expensive, costing about pounds 500 for a four- month course, and health authorities tend to be reluctant to pay for it. The advantage of the drug is that a four- month course is all that is needed in most cases. The acne disappears and does not return. Compared to five years on antibiotics, at a cost of pounds 2,100, it is cheap. And sufferers say its value in boosting confidence and self-esteem in those worst affected is priceless.