Dermatology World May 2012 Supplement : Page 5
“being regular” is not the same as having a normal cycle. Even if the patient lacks facial hair, he said, ask about it because most women have excess hair removed. Depending on the patient’s age, you may want to ask about pregnancies and their outcomes, Dr. Harper added. Asking about her response to previous acne treatments may also be helpful. “If a person has been on isotretinoin many times and the acne always comes back that might be an indication there’s an underlying problem that needs to be addressed,” she said. For patients suspected of having hormonal abnormalities, dermatologists typically test for levels of total and free testosterone, dehydroepiandrosterone sulfate (DHEAS), and luteinizing hormone/follicle stimulating hormone (LH/FSH). If the lab results come back abnormal, Dr. Harper will test for 17 hydroxyprogesterone. In general, a modestly high DHEAS level may indicate CAH, but higher levels should trigger evaluation for an adrenal tumor. Higher total testosterone levels may be seen in ovarian tumors, but mild increases are indicative of PCOS as are LH/FSH ratios greater than two to three. Levels of 17 hydroxyprogesterone have been used to confirm adult-onset CAH. Even when the lab workup is normal, which is most of the time, these patients can still benefit from hormonal treatment, she noted. in coMbinAtion, Alone Many dermatologists use spironolactone in conjunction with OCs to minimize its side effects, which commonly include menstrual irregularities and breast tenderness, Dr. Shalita explained. A typical treatment dose of spironolactone is 50 to 100 mg daily. At higher doses, the side effects are more prominent. The other advantage to combining these hormonal therapies is that they treat acne using two mechanisms of action, essentially doubling the effect, Dr. Berson said. If the acne is not being adequately controlled with OCs, she may add spironolactone. “Birth control pills can take two to three months to show an effect, but with spironolactone, most patients notice decreased outbreaks and oiliness in a couple of weeks,” Dr. Berson added. Some dermatologists believe that spironolactone shouldn’t be prescribed in the absence of OCs because it is associated with hypospadias and feminization of the male fetus, Dr. Leyden said. But as Dr. Harper points out, spironolactone is one of several medications that patients shouldn’t become pregnant while taking. Although she generally prescribes it in combination with OCs to help minimize side effects, Dr. Harper will prescribe spironolactone alone after thoroughly explaining the potentially serious risks of becoming pregnant. Like her counterparts, she also prescribes spironolactone without OCs for patients in whom the use of estrogen is contraindicated, or in post-menopausal women or those who have had a hysterectomy, or smokers. Moreover, patients are not candidates for combined therapy with OCs if they have risk factors such as obesity, high blood pressure, stroke, deep vein thrombosis (DVT), migraines, or a family history of breast/endometrial cancer, Dr. Krunic noted. topical benzoyl peroxide, and topical or systemic antibiotics. As Dr. Shalita points out, the consensus of the Global Alliance for Improving Outcomes in Acne is that a topical retinoid should be used to treat all but the most severe forms of acne. As the patient responds to treatment, Dr. Berson may stop the oral antibiotics or topical antimicrobials while continuing the hormonal therapy. “But even when the patient is clear, I tend to keep her on retinoids because they treat existing acne and help prevent future breakouts,” she said. Dr. Harper frequently overlaps hormonal and traditional therapies because she gets faster results that way. She may use both for two to three months and then discontinue the traditional therapy. “When hormone therapy is effective, patients are on them for a long time,” she noted. Dr. Krunic has found that most of these patients are just partially responsive to retinoids. In addition, their skin is often more sensitive to the drying effect of topical retinoids or irritation from benzoyl peroxide. As a result, he commonly combines antiandrogen therapy with systemic antibiotics, often in the beta-lactam or cephalosporin group. Topically, he prefers lotions or water-based vehicles like cleansing cloths containing sodium sulfacetamide and sulfur. Dr. Leyden has a slightly different approach. For patients who are unresponsive to several conventional therapies, he will stop all of them and prescribe spironolactone, and assess their progress in six weeks. “Many times, spironolactone is enough,” Dr. Leyden said. But for a teenager with blackheads, non-inflammatory lesions, pustules, and papules, he will use a topical antibiotic and retinoid and add spironolactone. Assuming the patient comes under control fairly quickly, he will slowly stop the antibiotics, but will continue the retinoids because of the blackheads. “Many times, you can get away without oral antibiotics,” he noted. risks, concerns Using OCs is associated with an increased risk of DVT, stroke, and myocardial infarction, among others. But Dr. Berson points out that there is a decreased risk and fewer side effects associated with today’s OCs due to the smaller amounts of estrogen in them. Newer OCs contain 20 to 35 mcg of estrogen compared with 100 mcg in the first-generation OCs. She informs her patients about the signs of DVT, that it can be pains and cramping in both the legs and/or arms, and tells them to contact her if they develop any symptoms. Dr. Berson also recommends that they stay active and drink a lot of water as immobility and dehydration will increase one’s potential to develop DVT. Stroke, myocardial infarction, and DVT are also very strongly linked to other risk factors, such as smoking, Dr. Harper noted. Although a slight increased risk of developing breast cancer has been raised, she questions that. Regarding the FDA’s investigation of DRSP-containing OCs, she said two studies suggest that these birth control pills are associated with twice the risk of developing DVT than those containing levonorgestrel. “When the lay population hears that there is a double risk, it sounds frightening,” she said. “But when you look at the absolute risk, it increases from six out of 10,000 events to 10 out of 10,000 events. It’s really SUPPLEMENT TO DErMaTOLOgy WOrLD // May 2012 used with trAditionAl therApies Hormonal therapies are typically used in combination with traditional acne therapies, including topical or systemic retinoids, 5
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