Acne treatment in women requires detailed history, systematic approach

Key Points

Treating adult female patients with acne begins with taking a thorough patient history regarding the condition's age of onset, says Diane S. Berson, M.D., assistant professor of dermatology, Weill Medical College of Cornell University. "Always ask if the patient has premenstrual flares. Get a very thorough menstrual history, certainly if her cycle is regular and she uses oral contraceptives." Women who present with new acne frequently do so because they have stopped taking oral contraceptives, she explains.

"Also ask about pregnancy status. This will be relevant not only in terms of how you treat her, but also if she's had issues with infertility," she says.

Most adult female patients with acne have normal serum levels of androgens, Dr. Berson says.

"Most of what we call hormonal acne is actually due to an increased local sensitivity of hormones, and there usually aren't hormonal abnormalities," she says. Hence there's usually no need for a routine hormonal workup.

However, she suggests considering an endocrine function assessment (for adrenal, ovarian and pituitary abnormalities) if a patient has irregular menstrual cycles or amenorrhea, significant hirsutism or alopecia, a sudden onset of severe inflammatory acne or therapy-resistant acne, or obesity or infertility. A pattern of classic hair thinning on top of the scalp - with the frontal hairline maintained - also can signal an androgen abnormality, Dr. Berson says.

As dermatologists, she says, "What's very important for us is that if we uncover a potential endocrinopathy, we can potentially save a woman from other potential medical issues and refer her for treatment."

About half of the women with polycystic ovary syndrome (PCOS) will develop metabolic syndrome, Dr. Berson says. "They can potentially develop obesity - usually a central adiposity around the abdomen - as well as insulin resistance, hyperandrogenism, hyperlipidemia and hypertension." Metabolic syndrome also increases women's risk of myocardial infarction and infertility, she adds.

The workup that dermatologists usually do includes measuring free testosterone and total testosterone, along with DHEAS and the luteinizing hormone/follicle-stimulating hormone (LH/FSH) ratio, Dr. Berson says.

"If anything is abnormal, you can refer these patients to an endocrinologist or gynecologist. They may also benefit from a fasting glucose, insulin, and oral glucose tolerance test and a lipid measurement," she explains.

In managing PCOS, "What has become interesting for us in the field of acne is the role of carbohydrates and carbohydrate metabolism. When women with PCOS go on a low-glycemic diet and lose weight, their insulin and androgen levels decrease, and their acne improves."

Accordingly, she says weight loss and use of oral contraceptives are helpful for managing PCOS. Among metabolic treatments, "The purpose of Glucophage (metformin hydrochloride, Bristol-Myers Squibb) is to increase glucose utilization or decrease insulin resistance. And when women are put on this medication, not only does their fertility improve, but their acne also improves."

Hormonal treatments decrease sebum production, she says. "The only other treatment which decreases sebum production is isotretinoin."