Oral contraceptive pills and antiandrogens for the treatment of acne vulgaris
Hormonal treatments for acne
Oral Contraceptive Pills for Acne
In certain cases hormonal therapies may be helpful in the treatment of acne.Oral contraceptive pills (OCP) are a good choice for acne, especially if contraceptive use is also wanted. The use of oral contraceptive pills can lead to an increase in sex hormone binding globulin and a decrease in circulating free testosterone, a decrease in sebum production, and an improvement in acne.
For example, the Orto Tri-Cyclen label indicates that in a double-blind placebo controlled clinical study, use of Ortho Tri-Cyclen resulted in a 56.6% reduction in inflammatory lesion count and a 49.6% reduction in total lesion count versus 36.6% and 30.3% with placebo.
An OCP formulation with a progestin with low androgenic potential is desired, such as norgestimate, desogestrel or drospirenone. Commonly used OCPs for acne are Ortho Tri-cyclen, YAZ and Beyaz. There may be an increased risk of blood clot formation with the use of drospirenone-containing OCPs. See: https://www.fda.gov/Drugs/DrugSafety/ucm273021.htm
OCPs, such as YAZ, have a black box warning that states that cigarette smoking increases the risk of serious cardiovascular side effects from oral contraceptive use. This risk increases with age, with heavy smoking (15 or more cigarettes per day) and in women over 35 years of age. Women who use oral contraceptives should be strongly advised not to smoke.
Clues to hormonal acne include:
- Acne lesions concentrated in the lower one-third of the face, including the jawline and upper neck.
- Increase in painful nodules versus comedones.
- Acne flares in the week or so prior to menstruation.
Patients must be screened and counseled prior to receiving OCPs for the treatment of acne. A medical history should be obtained including presence or history of high blood pressure, smoking, stroke, blood clots, liver tumors, liver disease, breast cancer, abnormal vaginal bleeding, and current pregnancy or nursing. Family history should be reviewed for a history of blood clots or stroke, breast or ovarian cancer, and liver disease.
Spironolactone for Acne
The drug spironolactone can also be useful in the treatment of acne vulgaris, and can be used alone or added to an OCP. Spironolactone both binds androgen receptors and reduces androgen production. However, use of spironolactone may result in a number of adverse side effects, such as dizziness, breast tenderness, and menstrual abnormalities. Potassium levels are sometimes monitored, and blood pressure checked periodically. Spironolactone cannot be used during pregnancy. The OCPs YAZ and Yasmin contain drospirenone, which is a spironolactone derivative.
The use of an OCP or anti-androgen should be evaluated for 3 to 6 months to see efficacy.
