Warfield Weekly Update
Jan. 16, 2009
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Hormonal Contraceptives for Acne Management


By Phoebe Rich, M.D.
Published in Lasers Surg Med 2008, 40;2:11323
Published in Cutis 2008, 81;1s:1318

Introduction

Approximately 42 million people are affected by acne vulgaris of which half are women older than 25 years. Adolescents make up 85% of this group. The treatments for acne includes oral and topical antibiotics, retinoids, and hormonal therapy in the form of oral contraceptives (OCs). The OCs reduce acne lesions by increasing estrogen levels and sex hormone-binding globulins, and by decreasing free testosterone/androgen levels. Studies have shown that drospirenone, a progestin available in certain OCs, minimizes the potential negative effect the progestin has on acne.

Acne has a complex etiology. It is an androgen-mediated disorder that involves abnormal keratinization, bacterial growth, and immune-driven hypersensitivity. The extrinsic factors that can aggravate acne are stress, friction, occlusion by comedogenic products such as pomades, medications such as anabolic steroids, antiepileptic drugs, progestin-only contraceptives, medical conditions such as Cushing disease, and possibly diet.

Among the many treatments for acne, are oral or topical antibiotics, retinoids and hormone therapy. First-line therapy for patients with moderate to severe inflammatory acne are oral antibiotics. For patients with severe nodular acne and cases resistant to other treatments there is oral isotretinoin. The down side of long-term topical or oral antibiotics is the possibility of bacterial resistance.

To summarize, the overall therapeutic effect of OCs on acne is potentially brought about by (1) stimulation of SHBC, which decreases testosterone concentrations; (2) inhibition of 5 alpha-reductase, an enzyme that converts testosterone to dihydrotestosterone (an active androgen in the skin); (3) decreased production of ovarian androgens; and (4) decreased production of adrenal androgens. Collectively, this process results in a decrease of sebum production and hair growth.

The Roles of Estrogen and Progestin

The study authors explained where estrogen is in higher doses than those found in modern OCs, a suppression of sebum is observed; therefore the development of acne lesions. With the metabolization of estrogen in the liver, this hormone also increases SHBG. Because OCs suppress the ovary, testosterone production is reduced. Progentins have androgenic characteristics that may exacerbate acne. Drospirenone, the progestin in certain OCs (ethinyl estradiol (EE) 20 mcg/drospirenone 3mg (Yaz), EE 30 mcg/drospirenone 3 mg (Yasmin) has both antimineralocorticoid and antiandrogenic effects, which minimize the potentially negative effect that progestins can have on acne.

How Effective Are Drospirenone-Containing OCs in Treating Acne?

This part of the study discussed several examples of combination OCs as being particularly effective in treating acne.

Who Qualifies and Does Not Qualify for Acne Treatment With OCs

Containing Drospirenone?

There were several criteria to qualify for acne treatment with OCs. The criteria included the patient seeking contraception. In addition to seeking contraception, patients needed to be healthy, nonsmoking women, with recalcitrant lower face, jawline, and neck acne. The study participants were women with hyperandrogenic conditions, women who have had difficulty adhering to an OC schedule because of untoward side effects from high estrogen levels but who are now willing to take a low-dose OC, women who have acne and pre-menstrual dysphoric disorder, and teenagers with these considerations.

Women with hormonally driven acne who want contraception may be good candidates for an OC. It has been found that women with chronic low-grade acne, usually cystic, affecting the lower face, jawline, and neck, often responded well to hormonal therapy. Another category of women candidates are those who have menstrual flares of acne, who are nonsmokers and frustrated with the chronic nature of their condition. Those who have been on topical retinoids and antibiotics but are not improving with these treatments are also good OC candidates.

Comment

Acne is a disorder of many patients older than 25 years, not just a disorder of adolescents. One cause of acne may be a result of an androgen disorder, which can manifest as acne vulgaris, hirutism, seborrhea, or androgenic alopecia. Studies have shown the effectiveness of OCs in decreasing total acne lesion counts and clinical androgenicity. In part, the OCs can decrease androgen expression, which is an important factor in the making of acne. OCs are not the first-line therapy or monotherapy for acne, but they can serve as a good solution for those women with mild to moderate acne vulgaris.


Reprint requests: Dr. Phoebe Rich, Clinical Associate Professor of Dermatology at Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, Oregon 97239.


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