Acne Treatment with Birth Control Pills and Antiandrogens



Antiandrogen treatment of acne

Antiandrogen treatment may be considered for adult women. Those who fail systemic antibiotics, relapse after a course of isotretinoin or for women who have symptoms of hyperandrogenism are likely to benefit. Symptoms of hyperandrogenism include irregular menses, infrequent or light menses, mild hirsutism, oily skin and androgenetic alopecia. Women with premenstrual flares, adult onset acne, acne worsening as an adult and acne on the mandibular line and neck may also benefit. Women with ovarian cysts and hirsutism may also benefit.

Patient selection

Failure of oral antibiotic

Recurrences after isotretinoin

Irregular menses

Light menses

Mild hirsutism

Increased oiliness

Androgenetic alopecia

Treatment

There are two approaches.

Combination oral contraceptives ( COC) reduce circulating androgens. Spironolactone is an peripheral androgen receptor blockers. The two drugs are frequently combined to achieve optimal results.

Oral contraceptives

All COCs can be effective for mild to moderate acne. They are often ineffective for more severe cases. COC suppress pituitary gonadotropins. This results in ovarian hormone suppression. They also raise circulating sex hormone binding globulin which decreases circulating free testosterone.

All of today’s low-dose COC s are estrogen dominant and are beneficial in women with acne regardless of which formula is used. Use COC containing the lowest dose of each hormone that limits the early-cycle side effects of nausea/vomiting, breast tenderness, weight gain and headache. Several months of treatment are required.

Concomitant intake of a COC and an antibiotic prescribed for acne does not impair the efficacy of the COC.

Products

Ortho-TriCyclin

Estro-Step

Alesse

Yasmin

Ortho-TriCyclin and Estro-Step are approved for treating acne. Estrostep is formulated so that the ethinyl estradiol dose rises as pills are used during a cycle. It may be better tolerated than higher dose estrogen formulations. Alesse is the lowest dose estrogen formulation. It may be better tolerated in women with bloating or nausea on higher dose formulations.

Yasmin is an oral contraceptive (OC) with a new progestin called drospirenone. Drospirenone has an antimineralocorticoid and antiandrogenic effect similar to that of spironolactone and can cause potassium retention. Whether this antimineralocorticoid effect leads to less weight gain than with other OCs is still unclear. The effect of Yasmin on acne appears to be similar

to that of other OCs. Information to date does not support any increase in the risk of venous thromboembolism with use of the drospirenone-containing OC as compared with any other combination OC.

Spironolactone

Spironolactone is the androgen receptor blocker used in the United States. Active metabolites have a half-life of 14 to 16 hours. Improvement in acne is variable.

Spironolactone

Start 50 mg qAM ?2 to 4 weeks

50 mg bid

Maximum dose 200 mg/d

Monitor blood pressure

Monitoring K not necessary

Spironolactone 50 mg once each day is prescribed for 2 to 4 weeks and increased to 100 mg/d as tolerated. Doses as high as 200 mg/d are sometimes necessary. The medication may be given as a single morning dose. Higher doses are divided and given twice each day. Lower the dose after several months of treatment if the patient is clear. Spironolactone is safe to use for months or years. The simultaneous use of oral contraceptives may be helpful. Spironolactone is often beneficial when used as monotherapy without oral antibiotics. Check blood pressure at each visit. Monitoring potassium levels in healthy young women is not necessary.

Side effects

Menstrual irregularities

Breast tenderness

Fatigue

Headache

Side effects increase with higher doses but the drug is generally well tolerated. Side effects are menstrual irregularities, breast tenderness, fatigue, and headache.

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