Hormonal therapies are an effective strategy to improve acne in women. However, some of these treatments, including birth control pills, are not commonly prescribed.
“As a result, I think dermatologists are leaving an opportunity on the table for us to better treat our patients with acne,” Julie Harper, M.D., a clinical associate professor of dermatology at the University of Alabama at Birmingham, tells Dermatology Times.
Although quite efficacious, hormonal therapies in most instances are not used alone, but in combination with both oral and topical medications.
“This is not the fastest approach we have, as these therapies usually take about 3 months to achieve a meaningful onset of action,” says Dr. Harper, in an interview following her presentation on hormonal therapies at the American Academy of Dermatology (AAD) Acne Boot Camp in March. “So when you prescribe them, you have to be patient.”
There are four FDA-approved oral contraceptives to treat acne: Ortho-Tri-Cyclen, Estrostep FE, YAZ and BEYAZ.
“Approved or not, probably all combination birth control pills help acne,” Dr. Harper notes. “Also, when you are thinking about the side effects and the risk of a birth control pill compared to the risk of pregnancy, you always win with a birth control pill.”
But these pills are also prescribed to women who do not need contraception, so the risk of pill versus acne needs to be balanced. “We do know birth control pills have risk,” Dr. Harper says.
To easily remember the risk of oral contraceptives, Dr. Harper uses the numbers 3, 6, 9 and 12.
“A woman’s baseline risk of having a venous thromboembolic event, if she is of childbearing age, but not on a birth control pill, is about 3 events per 10,000 women in a year,” Dr. Harper relates. “However, if you give her a birth control pill, you double her risk to 6 events per 10,000 women in a year.”
Similarly, if the woman is prescribed birth control pills that contain the progestin drospirenone (YAZ and BEYAZ), the risk is tripled to 9. But during pregnancy, that risk quadruples to 12, and during delivery around 30 events per 10,000 women in a year.
“I use those numbers every day in my clinic when I tell patients about the risk of taking a pill,” says Dr. Harper, who is in private practice at The Dermatology and Skin Care Center of Birmingham.
Conversely, there are benefits to oral contraceptives. “They actually protect against ovarian cancer and endometrial cancer, and even protect against colorectal cancer,” Dr. Harper states.
Moreover, oral contraceptives are not limited to women who have evidence of laboratory abnormality of hormones. “In reality, these pills are good for any woman who has acne and does not have a contraindication,” Dr. Harper says.
Furthermore, Pap smears and bimanual pelvic exams are no longer deemed mandatory prior to initiating combination oral contraceptives. “If we are helping, even accidently, to decrease the risk of an unwanted pregnancy, then we are doing our patients more good overall than we are by doing a Pap smear or a pelvic exam,” Dr. Harper says.
Nonetheless, birth control pills should not be dispensed to women who smoke or have a history of migraine headache. Another contraindication is hypertension, “so we should be documenting a baseline blood pressure in our charts when we start people on birth control pills,” Dr. Harper says.
Spironolactone is another treatment option for women with acne.
A 2015 study compared healthy young women ages 18-45 with acne who were on spironolactone to a control group. “The investigators found there was not a greater hyperkalemia risk in the people on spironolactone,” Dr. Harper reports. “Therefore, the conclusion was that we do not routinely need to monitor for potassium in these patients.”
However, because the study was limited to healthy young women, patients outside this age range or who have cardiovascular disease or renal disease, “still need to have their potassium checked,” Dr. Harper says.
In addition, spironolactone is a drug that should not be used during pregnancy, but it can be used safely during breastfeeding.
As with oral contraceptives, spironolactone takes about 3 months to become effective for treating acne. “Like birth control pills, I think of this as being a long-term treatment,” Dr. Harper says. “We also do not have any evidence that the risk is greater by staying on spironolactone or birth control pills for a longer period of time.”
Dr. Harper says that dermatologists should become comfortable prescribing these medications because “this is a great treatment alternative. Right now, we are all trying to find ways to treat acne without using antibiotics.”
Disclosure: Dr. Harper reports no relevant financial disclosures.