Misconceptions, lack of data leave derms coming up short on contraceptive prescriptions for acne treatment

April 1, 2013

Dermatologists’ prescribing of oral contraceptive pills (OCPs) and antibiotics for acne leaves room for improvement, according to an expert.

Miami Beach, Fla. - Dermatologists’ prescribing of oral contraceptive pills (OCPs) and antibiotics for acne leaves room for improvement, according to an expert.

Regarding OCPs for acne, says Kanade Shinkai, M.D., PhD, “Dermatologists generally don’t prescribe them. And sometimes when we do, we’re not doing it very well.” Dr. Shinkai, assistant professor of dermatology, University of California, San Francisco, School of Medicine, spoke at the 71st annual meeting of the American Academy of Dermatology.

“Unfortunately,” she adds, “there’s very little data about prescribing patterns for OCPs in dermatology. But we probably are not prescribing them because we believe that they fall within the realm of gynecology or primary care.”

Other dermatologists are reluctant to perform pelvic exams and Pap smears, Dr. Shinkai says. However, she says very strong consensus statements from groups including the American College of Obstetricians and Gynecologists, the World Health Organization and Planned Parenthood all state that pelvic exams and Pap smears are no longer required before starting OCPs, partly because newer products contain a fraction of the active ingredients their predecessors did, and because of new (less frequent) screening guidelines for cervical cancer.

“This has been game-changing for many of us,” Dr. Shinkai says.

Compliance issues

One study has shown that having a prescription from a dermatologist is actually a risk factor for poor compliance with OCP regimens, although the study didn’t explore why this was the case (Steinkellner A, Chen W, Denison SE. Am J Med. 2010;123(10):929-934).

“Other risk factors noted in that study included young patient age, patients being on multiple category X medications, single marital status and lower educational levels,” Dr. Shinkai says.

A more recent factor behind dermatologists’ reluctance to prescribe OCPs for acne involves concern for clotting events such as venous thromboembolisms (VTEs), a concern partly stoked by the lay media, Dr. Shinkai says. As such, “It behooves us to understand what those risks are and what the data really show, so we can counsel our patients appropriately.”

The baseline risk of a non-pregnant woman between the ages of 15 and 45 years suffering a deep venous thrombosis (DVT) is one in 10,000 woman-years, she notes. By contrast, for a woman taking a combined OCP that contains ethinyl estradiol for one year, the risk rises threefold, she says.

“It’s still very rare, and this risk decreases after the first year. To put this into context, the risk for DVT during pregnancy ranges in different studies between five and 12 in 10,000 woman-years. It’s notable, but still very rare.”

In April 2012, the Food and Drug Administration mandated that OCPs containing drosperinone carry label warnings about associated risks of clotting. In early 2013, French medical regulators announced a ban on cyproterone-containing OCPs from the French market for the same reason.

In about a dozen studies, Dr. Shinkai says, “The venous thromboembolic risk of the newer OCPs may be a little higher than had been previously appreciated, possibly up to sixfold increased over baseline (versus a threefold increase in the older OCP formulations). These include newer OCP preparations that contain desogestrel, gestodene, drosperinone and cyproterone, which is not used in the United States. But this increased risk, if any, is only slight.”

Of four studies that compared drosperinone-containing OCPs versus those without drosperinone, “Three suggested there may be an increased risk of clotting in the drosperinone-containing preparations. But it’s very slight (odds ratio: 1.13),” Dr. Shinkai says.

Additionally, she says that when one closely scours all the recent studies, “The risk is highest in carriers of a genetic hypercoagulability. This is nothing new. It is an important reminder to dermatologists to continue to screen patients appropriately.”

Thorough screening

To do this efficiently, Dr. Shinkai suggests having patients fill out questionnaires. On these forms, “I ask about their acne history and, for females, their menstrual history, as well as current and prior treatments for acne - and which ones helped. The questionnaire also asks about past medical history and medications, and contains targeted questions about family history (including clotting risk).

“The bottom line is, I still believe OCPs are very safe if a patient has no personal or family history of clotting risk. This area requires more study,” she says.

So does topical antibiotic resistance, Dr. Shinkai adds. In this regard, she says, recent studies show that Propionibacterium acnes can develop resistance to tetracycline, doxycycline, minocycline, topical and oral erythromycin and topical clindamycin - sometimes after as little as eight weeks’ use.

Regarding resistance in other pathogenic species, Dr. Shinkai says that for every potentially reassuring study about long-term oral antibiotic use (Fanelli M, Kupperman E, Lautenbach E, et al. Arch Dermatol. 2011;147(8):917-921), there’s a worrisome counterpart (Levy SB, Marshall B. Nat Med. 2004;10(12 Suppl):S122-S129. Review). Accordingly, some dermatologists may be confused - as Dr. Shinkai admits she is - about the plethora of antibiotic options and their efficacy in acne treatment.

As such, “There is a disparity in the data. And the jury is still out in terms of which populations we should be studying, and how much information we can extrapolate from different study populations,” she says.

Overall, “There’s a lack of data telling us what we should be doing - which antibiotics really work in acne, what is the ideal duration, what else we can do for long-term acne management, and are there any adjunctive treatments that might mitigate the risk of resistance? This is an important area for further study.”

Among adjunctive treatments, Dr. Shinkai says that adding benzoyl peroxide to an antibiotic regimen appears helpful - but only in reducing potential resistance of P. acnes, not colonization at non-skin sites by other organisms.

Disclosures: Dr. Shinkai reports no relevant financial interests.