By Gary M. White, MD
Acne in adult woman 20-40 years of age is very common and is usually not due to any hormone abnormality. In contrast, most men are acne-free by 20 years of age.
The adult woman with acne tends to primarily have inflammatory lesions (few visible comedones). The distribution of these lesions is typically along the jawline and chin (as opposed to the teenage pattern of acne uniformly distributed on the face). Flaring premenstrually is common. Rosacea should be excluded. Inquiry should be made about menstrual disturbances, impaired fertility, and hirsutism (see also polycystic ovary syndrome).
In one study from Brazil of 835 women with acne, workup showed that 54.56% of the patients had hyperandrogenism and the levels of DHEAS were most frequently elevated [Dermatology 2013;226:167–171]. One drawback to this study, however, is that the exact criteria of "altered" or abnormal blood tests were not provided.
Blood work for androgens optimally should be obtained during the follicular phase (from menses to ovulation--classically days 1-14), optimally between the fourth and the seventh day of the cycle (day 1 is the first day of the period, day 14 is ovulation), and oral contraceptives should be discontinued for at least two months prior to this testing. The blood draw should be in the morning (highest level of testosterone), preferably before 8:30 AM and fasting.
Full hormonal workup can include DHEAS, free testosterone, sex-hormone binding globulin, prolactin, 24-hour urine cortisol, 17-OH progesterone, TSH, pregnancy test, FSH and LH, and pelvic ultrasound.
Women with acne often do well using conventional approaches to acne therapy (e.g., topical retinoids, benzoyl peroxide, minocycline, etc.) If these fail, isotretinoin is usually given. In those women who relapse after a course of isotretinoin, hormonal workup and therapy is most helpful.
Drospirenone-containing birth control pills are effective for both acne and hirsutism. Drospirenone is a derivative of spironolactone and at usual doses, is equivalent to 25 mg of spironolactone. Because drospirenone can cause hyperkalemia, caution should be taken when patients are on other medications that may increase the potassium.
The absolute risk of venous thromboembolism in events/100,000 woman-years is [JAAD 2014;71:864 and Ann Intern Med. 2005;143:697-706]:
See also acne treatment.
Spironolactone is relatively safe and may be given to the woman already on a drospirenone-containing (or traditional) birth control pill. One study of 200 person-years of exposure to spironolactone and 506 person-years of followup over 8 years found no serious illnesses thought to be attributed to spironolactone [J Cutan Med Surg 2002;6:541-5]. With respect to breast, uterus, ovarian, and cervical cancer, there does not seem to be evidence of increased risk with spironolactone [Cancer Epidemiol 2013;37:870-5]. One study found the combination of spironolactone 100 mg/day and drospirenone/EE 30 ug efficacious, safe, and well-tolerated [JAAD 2008;58:60-2]. Do not, however, give spironolactone along with trimethoprim-sulfamethoxazole. That combination in one study was more than 12 times likelier than spironolactone/amoxicillin to cause hyperkalemia. In the elderly, giving trimethoprim-sulfamethoxazole to a patient on spironolactone puts them at risk for sudden death [CMAJ].
Prior to starting spironolactone, the potassium, pregnancy test, DHEAS, and free testosterone may be checked. Note that even though these women are thought to have a hormonal connection to their acne, the hormone levels are usually normal. Spironolactone (e.g., 50-100 mg/day) may be started. Side effects the patient should be made aware of include headache, lethargy, menstrual irregularities (usually not a problem if the patient is on a birth control pill), hyperkalemia, breast tenderness, and decreased sex drive. These side effects are less common at 100 mg/day or less. Women who wish to become pregnant, who are on antihypertensives, cardiac drugs, or diuretics should not take spironolactone. The patient needs to wait at least 3 months to see the full effect. Some women will note decreased facial oiliness. Women with baseline low blood pressure may have trouble with lightheadedness and even syncope. The blood pressure should be monitored at followup visits.
A national acne expert recommends spironolactone for all females with acne (as young as 11 years of age) who fail to respond to 3 months of a topical benzoyl peroxide and a retinoid. He many give it alone or in combination with BCPs. If this is not sufficient to control the acne after 3 months, he moves on to isotretinoin.
Not that this totally eliminates the use of antibiotics for acne.
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