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Hormonal therapies can safely and effectively combat acne in female patients, but physicians should be cautious given the potential risks and side effects, one expert says.
National report - Clinical acne affects approximately 12 percent of females over age 25 - and only 3 percent of similarly aged men. Women, who are more prone to adult acne, can be treated effectively and safely with hormonal therapies, one expert says.
"Acne develops around the time of puberty when androgen hormones are being produced by gonadal and adrenal tissues. Individuals who are androgen-insensitive do not develop acne, yet the opposite is very much the case for patients who are androgen-sensitive," says Julie C. Harper, M.D., a dermatologist in private practice in Birmingham, Ala.
Most individuals have circulating androgens within the normal range. Dr. Harper suggests performing a laboratory evaluation in patients if acne is persistent despite appropriate therapy, if there are signs of virilism (hirsutism, deepening of the voice, alopecia) or if menstrual periods are irregular. In these patients, Dr. Harper tests for DHEA-S, total and free testosterone, as well as LH/FSH ratio levels.
Dr. Harper says four ways to cause an androgen blockade include:
"All oral contraceptives contain ethinyl estradiol, as well as various progestins, and can achieve such an androgen blockade, as they are able to increase sex hormone-binding globulin and therefore decrease free testosterone.
"The ensuing negative feedback to the hypothalamus/pituitary results in decreased GRH, LH and FSH. This results in decreased ovarian production of the hormone. Lack of ovulation hinders ovarian hormone production," Dr. Harper tells Dermatology Times.
All combination oral contraceptives result in an increase in SHBG and a resultant decrease in free testosterone, she says. Therefore, they may all be effective in the treatment of acne, she adds.
The side effects of oral contraceptives include irregular bleeding, nausea, weight gain, mood changes and breast tenderness. Risks include venous thromboembolism, stroke, MI and breast cancer.
"At the same time, oral contraceptives offer women protection against ovarian and endometrial cancer, protection against PID, uterine leiomyomas and ovarian cysts. And they can regulate the menstrual cycle," Dr. Harper says.
Statistics show that women who use oral contraceptives have a 40 percent to 80 percent overall decreased risk of ovarian cancer and up to a 50 percent decreased risk of endometrial cancer.
"Oral contraceptives are used most safely in women under 35 years of age who do not smoke, do not have migraine headaches and who are normotensive," Dr. Harper says.
Spironolactone, which is marketed under the trade names Aldactone, Novo-spiroton, Spiractin, Spirotone or Berlactone, inhibits 5-alpha reductase and is also effective in fighting acne. Effective doses can be 50 mg/day to 100 mg/day and can be co-administered with oral contraceptives if the patient is of child-bearing potential.
Flutamide, marketed as Drogenil, may improve acne and hirsutism in women with acne. Doses can range from 125 mg/day to 500 mg/day, but here, pregnancy must be avoided. According to Dr. Harper, this therapy is expensive, and liver function must be monitored, as fatal hepatitis and nonhepatitis have been reported.
According to Dr. Harper, the first-line treatment of acne in nonpregnant women is still a topical retinoid. Combination therapies that work include topical retinoids, topical antibiotics and systemic antibiotics.