Dermatology World May 2012 Supplement : Page 4
acne treatment Some of the newer OCs contain drospirenone (DRSP), which differs from the classic progestins in its derivation from spironolactone, noted Aleksandar L. Krunic, MD, PhD, associate professor of dermatology and director of dermatologic surgery at the University of Illinois College of Medicine, adjunct associate professor of dermatology at Northwestern University’s Feinberg School of Medicine in Chicago, and one of the authors of a study on DRSP and spironolactone ( J Am Acad Dermatol 2008;58:60-2.). These DRSP-containing OCs exhibit partial antiandrogenic activity, but lack androgenic effect, he explained. They regulate the menstrual cycle and result in lighter, less painful periods as well as reduced sebum production and hair growth, and often improve acne by the third cycle. (On April 11, the FDA announced additional warnings for some DRSP-containing OCs because a review indicated they have three times the risk of other OCs of causing blood clots.) The classic example of hormonal acne is a concentration of lesions along the chin, jawline, lower face, and neck, according to Diane Berson, MD, assistant clinical professor on faculty at the Weill Medical College of Cornell University at New York Presbyterian Hospital. These women tend to have premenstrual breakouts with or without menstrual irregularities and hirsutism. Jim Leyden, MD, emeritus professor of dermatology at the University of Pennsylvania’s School of Medicine, prescribes OCs more freely in women with hormone-related acne in their late teens and 20s. But if a younger teenager is not responding to the traditional therapies, he will consider it an option. The same is true of spironolactone. Prescribing the latter is an easy way of offering hormonal treatment without getting into dicey questions about “the pill” with mothers and daughters, he said. Dr. Krunic said he will prescribe hormonal therapy for 12 to 24 menstrual cycles, then slowly start to wean patients off the treatment — unless the patient desires to continue birth control pills for contraception, in which case he refers them to their gynecologist for further prescriptions and follow-up. Women with endocrine disorders, such as polycystic ovarian syndrome (PCOS) and congenital adrenal hyperplasia (CAH), may benefit from hormonal therapies, as well. Patients who frequently skip menstrual cycles, with or without hirsutism, may have an abnormal hormonal status or PCOS, Dr. Leyden said. When taking a history, instead of asking the patient if her menstrual cycle is regular, he said it’s better to ask how often she gets a period, pointing out that hormonal therapies serve as key adjunct subset of pAtients Candidates for hormonal therapy are women beyond menarche with evidence of hormone-related acne, late-onset acne, and/or menstrual flares. Those who are unresponsive to conventional therapies and need oral contraception for gynecologic/birth control reasons also are good candidates. “The use of OCs in acne is a very effective treatment option for women who have either clear signs of hormonal acne or have been on traditional therapies without an improvement,” Dr. Harper said. “But it is very seldom the first line of therapy unless they have signs of androgen-related acne right away and they need contraception.” Passing the test Dermatologists treating patients for acne who suspect hormonal abnormalities should test them to rule out other conditions. Julie Harper, MD, clinical associate professor at the University of Alabama in Birmingham, recommends following the steps below. Test for testosterone, DHEAS, and LH/FSH ABNORMAL testosterone level with increased DHEAS NORMAL proceed with treatment for acne significantly higher levels mildly increased testosterone levels or LH/FSH ratio higher than 2:3 consider CAH, test for 17-hydroxyprogesterone consider ovarian tumor consider PCOS Evaluate the 17-hydroxyprogesterone results to confirm/rule out CAH 4 SUPPLEMENT TO DErMaTOLOgy WOrLD // May 2012 www.aad.org
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