226 JOURNAL OF COSMETIC SCIENCE POST ADOLESCENT ANCE: COSMETIC RELEVANCE Helen Knaggs 1, Ph.D., Ying Ye 1, Ph.D. and Ronald L. Rizer 2, Ph.D. •Unilever Research, Edgewater, New Jersey 2Stephens and Associates, Colorado Springs, CO Acne has traditionally been viewed as predominantly affecting adolescents but in fact the age range goes up to and sometimes beyond 45 years, particularly in women. This presentation summarises recent literature challenging the belief that ache is primarily an adolescent problem, and discusses the importance of cosmetics in either exacerbating or improving ache. There is much information describing the clinical picture and incidence of teenage acne, but relatively few reports on post adolescent ache. This might be because concern over adult ache has only grown in recent years. Nevertheless a 1945 study of 500 adult women aged 17-40 showed that 69% had ache ranging from slight to clinical •. In 121 men with clinical ache 25% were over 25 years and 9% were over 30 years. Epstein in 19682 examined the faces of 778 new patients over 1 year and reported that both males and females over 25 presented with clinical ache with the females showing the higher incidence. O'Loughlin 3 proposed that 2 subgroups existed based on his examination of clinical ache in 53 females aged 24 years and over. There now seems to be general agreement that there are individuals with ache continuing from their teenage years ('persistent ache'), whilst for other the phenomenon is new ('late onset ache') first occurring after age 25 years. Premenstrual ache flares seem to occur in either group. More recent studies provide insights into the occurrence of adult acne: two were large scale community- based studies n'5 and the third study describes findings from an ache clinic 6. Both community-based studies emphasize the fact that ache continues well into adulthood for both males and females. In one study, a total of 749 subjects over 25 years were examined for facial ache. The prevalence of ache remained constant between 24 and 44 years in both males and females, and did not decrease significantly until after the age of 44 years. Facial ache was reported in 231 (54%) women and 130 (40%) men. The ache observed was mainly very mild which the authors refer to as physiological ache. Higher grade clinical facial ache was recorded in 3% of subjects and was worse in females. Persistent ache was the most common (82% of patients) compared with late onset ache. In the second community based study 5 ache was present in all age groups investigated up to 87 years and was detectable in 13% of people above 59 years. In the 20-29 year group, 64% have ache and 43% still had ache between the ages of 30-39 years. In an ache clinic the mean age of patients attending increased from 20.5 years in 1984 to 26.5 years in 1994. 6 The trunk area was most affected in males whilst the face was mainly affected in women. This may explain why more females are seen in clinic compared to males, despite the fact that women had a lower mean grade. Most of these patients had ache that had persisted from the teenage years. Ache appearing for the first time after age 25 years was reported by 18.4% of women and 8.4% of men. The causes of adult ache are not clear. Persistent ache could be explained as a continuation of teenage ache and could therefore share similar pathogenic features: increased sebum production, ducta! hypercornification, inflammation and increased bacterial activity. There is a significantly higher sebum excretion rate among adult women with persistent ache, compared to non-ache female adults, suggesting that at least in persistent ache there may be an underlying increase in sebogenesis. 7 It is more difficult to explain late onset ache which starts well after the hormonal changes accompanying puberty. Factors put forward to explain adult ache include the use of cosmetics, stress, resistant bacteria, smoking, oral contraceptive usage and underlying hormone levels. One study investigating the causes of adult ache found that 37% of the women had additional clinical features of hyperandrogenicity 82% had failed to respond to multiple courses of antibiotics, and 32% had relapsed after treatment with one or more courses of isotretinoin. 6 In this study, cosmetic use and occupation did not seem to be significant contributing factors. Clinical signs of ache occur at puberty concomitant with an increase in circulating adrenal and gonadal androgens. Androgens play a role in stimulating the sebaceous glands to enlarge and produce sebum but the role of hormones in adult ache is debated. In addition, the increased use of oral contraceptives, particularly those containing androgenic progesterone may play a role in the persistence of ache in women.

2002 ANNUAL SCIENTIFIC MEETING 227 Whether cosmetics are wholely or partially causative of adult acne is unclear. At one time it was believed that cosmetic use could explain 95% of the cases of adult women presenting with a mild acneiform condition for which Kligman coined the term "acne cosmetica". 8 One study reported an increase in acneiform eruptions after a beauty treatment consisting of a facial massage of cream, steaming, application of a face pack. In this case, the most common ache lesions were nodules with infrequent occurrence of closed comedories. 9 Certain cosmetic ingredients are comedogenic in both human and animal and such substances include lanolins and certain vegetable oils. However, Curtlille reported finding no correlation between the amount of time over which cosmetics were used and the severity of the ache. Iø Stopping the use of the suspected cosmetic did not produce an improvement. Nowadays, many cosmetics are thoroughly assessed for comedogenicity and acnegenicity, perhaps some cosmetics may not be the cause of adult ache, but may exacerbate or aggravate ache prone follicles or low grade ache. Ii One line of investigation which has not been thoroughly explored, is whether the use of cosmetics can actually help to reduce ache. One could speculate that daily cleansing and moisturization maybe beneficial in ache and may underlie the placebo response observed in many ache studies. One study I: examined the effects of a regime consisting of 6 formulations of low predicted acnegenic potential in 10 young women. No increase in ache was noted, on the contrary there was an improvement (i.e. decrease) in the total number of comedones and papules. In our group, we have assessed different moisturizers and cleansers to evaluate whether they were beneficial for adult ache. A mild bar cleanser was tested on 32 female subjects between the ages of 18-45 with mild - moderate ache. A twice daily wash of 45 seconds was followed for 12 weeks. A small, but significant decrease in non-inflamed lesions (27.7%) and inflamed lesions (15.5%) was observed by week 12 compared to baseline and in addition this effect was perceived by subjects. In a comedolytic study on the back, a cleanser formulation was shown to reduce the number of follicular impactions following 8 weeks of twice daily washing. A moisturizer was tested and compared with 2% salicylic acid for antiache efficacy. After 4 weeks, both treatments produced a significant decrease from baseline in total non- inflamed lesions. By week 12, moisturizer produced a 28% decrease in non-inflamed lesions and 2% salicylic acid produced a 33% decrease: these changes were not significantly different from each other. For inflamed lesions, both treatments produced a significant decrease from baseline by week 2 reaching a maximum decrease of about 36% by week 4-8. At week 12, though, total inflamed lesions returned to baseline for moisturizer treatment. At all time points, neither product was significantly different from each other. Treatments for female adult acne are similar to those used for adolescent acne. For example, topical treatments for mild cases (benzoyl peroxide, salicylic acid) with antibiotics for inflammatory acne and retinoids for comedonal or more severe forms of the disease. Newly developed cosmetics such as foundations and blushes have included actives designed to ameliorate acne and improve overall skin condition. In conclusion. there is now good evidence that acne can continue well into adulthood and there is some indication that unlike teenage acne were males tend to show the most severe forms of the disease, adult acne mainly affects females. The role of cosmetics is debated in the literature, but new data supports the role of some cosmetics in reducing the appearance of acne. References l. Cohen EL. Br.lDerrnato157, 10-14, (1945). 2. Epstein E. Dertnatology Digest 49-58 (1968). 3. O'Loughlin M. Aust.lDerrnato!7, 218-222 (1964) 4. Goulden V, Clark SM, Cunliffe WJ. Br.lDerrnatol 136:66-70 (1997). 5. Goulden V, Stables GI, Cunliffe WJ..IArn AcadDertnatol, 41:577-580 (1999). 6. Sharer T, Nienhaus A, VielufD et al. Br.lDerrnatol 145:100-104 (2001). 7. McGeown ell, Goulden V, Holland DB et al..I Invest Dertnatol 108:386 (1997) 8. Kligman AM, Mills OH. Arch Dertnatol l I l: 65-68 (1975). 9. KhannaN, Gupta SD. Intl.lournalDerrnato138:196-199 (1999). 10. Cunliffe WJ. In: Ache. (Marks R, ed) London: Martin Dunitz, 1989:59 I I. Kligman AM..ICutan Aging andCostn Dertnatol, 1:109-114 0988). 12. Epinette WW, Greist MC, Ozols II. Curls, 29:500-514 0982).