Dermatology World May 2012 Supplement : Page 6

acne treatment important that dermatologists understand those numbers because we’re the ones our patients will ask.” In addition, an increased risk of hyperkalemia when DRSP-containing OCs are combined with spironolactone was not demonstrated in recent studies, Dr. Krunic noted. Despite the hyperkalemia warning, physicians are using OCs containing DRSP with spironolactone preferentially and they are not following the recommended potassium monitoring requirements, he said. There is, however, some concern regarding the use of OCs hindering bone density in young adolescents. The body relies on estrogen for bone development, much of which occurs within four years after menarche. By the late teens and early 20s, however, peak bone mass is formed. “When you give someone the birth control pill, you’re choosing how much estrogen that person will have because you’re suppressing the amount the body will make,” Dr. Harper said. “The concern is that estrogen levels in the pill are too low to support enough bone formation to prevent osteoporosis and bone fractures later in life. After reviewing the literature, I’m not sure that we know the answer to that.” There is evidence showing that the combination OCs with 30 mcg of ethinyl estradiol are adequate to ensure sufficient bone accrual during adolescence and normal bone health into adulthood. Still, Dr. Harper cautions dermatologists to be aware that lower levels of estrogen may not always be better, especially for young adolescents. Regarding antibiotics decreasing the effectiveness of OCs, Dr. Harper said that there is no evidence to support that with the antibiotics used to treat acne. The hypothesis is that antibiotics decrease the gut flora needed to further degrade inactive metabolites of the OCs to active drug during enterohepatic recirculation. Dr. Berson points out that the failure rate of OCs is 3 percent, which remains the same with antibiotic use. Moreover, it takes one month for birth control pills to take effect, the same amount of time it takes the gut flora to normalize, she said. Women are told to use appropriate precautions to prevent pregnancy during that time. They may not be the first line of therapy, but hormonal therapies are an effective secondary adjunctive treatment that will, no doubt, continue to grow in popularity. “Women are asking for it by name,” Dr. Leyden said. “They want the pill that doesn’t make them break out.” dw hormonal therapies serve as key adjunct Dermatologists Prescribing more ocs, but nuMbers still low Oral contraceptives (OCs) are rarely prescribed for acne despite their efficacy for treating it, according to a study presented by Steven Feldman, MD, PhD, of Wake Forest University, at the AAD’s recent Annual Meeting in San Diego. Overall, physicians prescribed OCs at 2.58 percent of acne visits, with dermatologists prescribing them at 2.03 percent of visits. In recent years, such prescriptions increased by 0.9 percentage points among dermatologists. Dr. Feldman suggested that the low rate of OC prescriptions among dermatologists is likely due to their lack of experience with birth control pills in routine practice. Some dermatologists may be reluctant to prescribe OCs because they tend to think of them as falling under the purview of a gynecologist. Part of that could be that dermatologists have the mistaken impression that patients going on the birth control pill must get a pap smear, Dr. Shalita said. But several years ago, the American Congress of Obstretricians and Gynecologists came out with a report saying that women who are not sexually active don’t need to see a gynecologist for a year after being on the birth control pill, he said. If they are sexually active, they should be getting a routine pap smear anyway. Then there is the awkward conversation that can ensue when discussing OCs for teenagers. “I never use the words ‘birth control pill’ with mothers,” Dr. Leyden said. “I always talk about estrogen therapy, which if you take it every day will help prevent 6 SUPPLEMENT TO DErMaTOLOgy WOrLD // May 2012 you from getting pregnant.” Dr. Berson similarly discusses hormone treatment, especially when speaking with a 16-year-old girl who is there with her mom. “You don’t want to say we’re putting your daughter on the birth control pill because it can open a Pandora’s Box,” she said. Younger dermatologists are probably more comfortable than older ones prescribing OCs, Dr. Harper said. She speculates that this is because they are coming out of residency training learning about them. In addition, FDA approval has had an impact. “Oral contraceptives were being used off-label. But now that the FDA has approved them for the treatment of acne, more dermatologists can feel comfortable with prescribing them,” Dr. Berson said. When she first started prescribing OCs, Dr. Berson always recommended that patients go to the gynecologist, but that is unnecessary unless the patient has an underlying endocrinopathy or is at risk of complication. Nowadays, she gives patients a three-month prescription and recommends that they see a gynecologist annually because the assumption is that a patient on OCs is more likely to be sexually active, which puts them at risk for sexually transmitted diseases. “Oral contraceptives and spironolactone have been very helpful additions to our therapeutic armamentarium for acne,” Dr. Berson said. “Dermatologists are getting more comfortable with giving women this form of treatment as an adjunct to traditional treatments.” www.aad.org

DERMATOLOGISTS PRESCRIBING MORE OCS, BUT NUMBERS STILL LOW

Oral contraceptives (OCs) are rarely prescribed for acne despite their efficacy for treating it, according to a study presented by Steven Feldman, MD, PhD, of Wake Forest University, at the AAD’s recent Annual Meeting in San Diego. Overall, physicians prescribed OCs at 2.58 percent of acne visits, with dermatologists prescribing them at 2.03 percent of visits. In recent years, such prescriptions increased by 0.9 percentage points among dermatologists. Dr. Feldman suggested that the low rate of OC prescriptions among dermatologists is likely due to their lack of experience with birth control pills in routine practice. Some dermatologists may be reluctant to prescribe OCs because they tend to think of them as falling under the purview of a gynecologist. Part of that could be that dermatologists have the mistaken impression that patients going on the birth control pill must get a pap smear, Dr. Shalita said. But several years ago, the American Congress of Obstretricians and Gynecologists came out with a report saying that women who are not sexually active don’t need to see a gynecologist for a year after being on the birth control pill, he said. If they are sexually active, they should be getting a routine pap smear anyway. Then there is the awkward conversation that can ensue when discussing OCs for teenagers. “I never use the words ‘birth control pill’ with mothers,” Dr. Leyden said. “I always talk about estrogen therapy, which if you take it every day will help prevent you from getting pregnant.” Dr. Berson similarly discusses hormone treatment, especially when speaking with a 16-yearold girl who is there with her mom. “You don’t want to say we’re putting your daughter on the birth control pill because it can open a Pandora’s Box,” she said. Younger dermatologists are probably more comfortable than older ones prescribing OCs, Dr. Harper said. She speculates that this is because they are coming out of residency training learning about them. In addition, FDA approval has had an impact. “Oral contraceptives were being used off-label. But now that the FDA has approved them for the treatment of acne, more dermatologists can feel comfortable with prescribing them,” Dr. Berson said. When she first started prescribing OCs, Dr. Berson always recommended that patients go to the gynecologist, but that is unnecessary unless the patient has an underlying endocrinopathy or is at risk of complication. Nowadays, she gives patients a three-month prescription and recommends that they see a gynecologist annually because the assumption is that a patient on OCs is more likely to be sexually active, which puts them at risk for sexually transmitted diseases. “Oral contraceptives and spironolactone have been very helpful additions to our therapeutic armamentarium for acne,” Dr. Berson said. “Dermatologists are getting more comfortable with giving women this form of treatment as an adjunct to traditional treatments.”

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