Gaining control: Birth control pills, spironolactone first-line treatments for hormonal acne

Key Points

"All acne vulgaris is hormonal," says James C. Shaw, M.D., F.R.C.P.C., associate professor, division of dermatology, University of Toronto, Canada.

"In women, there is the opportunity to give hormonal treatment. The same opportunity does not exist for men," he says.

Patients have to be extremely careful that no pregnancy occurs if they are taking isotretinoin, Dr. Shaw says.

Hormonal acne that occurs in adult women is distinct in its presentation from acne that occurs in adolescence, with the latter usually presenting with comedones on the nose and forehead.

There may be a hormonal disturbance that triggers adult acne, Dr. Shaw says.

Common scenario

"The common scenario is that these women have not had any acne in their teenage years," Dr. Shaw says. "They then break out with it in their 20s and 30s. They usually experience worsening before each period, and they may even have irregular periods."

In addition, they may have oiliness on the skin, and the distribution of acne is on the lower face, on the jaw line, chin and even behind the ears. In some cases, they may also experience unwanted hirsutism.

A hormonal work-up of patients with adult-onset acne usually proves the patients to be within the normal range, Dr. Shaw says, but sensitive hormonal testing may demonstrate differences between women who have adult onset of acne and those who do not.

Some patients may have irregular ovarian function that can elevate hormones and bring on adult acne, he says.

Oral contraceptives

Women who have been taking oral contraceptives and did not experience bad acne as a teenager may find that they have an eruption of acne when they stop oral contraceptives, according to Dr. Shaw.

"I think it's all right to consider hormonal treatments earlier on in the treatment process," Dr. Shaw says.

"If there is a female patient who has adult acne and is in need of birth control, then it's best to try that as a treatment.

"Often times, dermatologists try to use antibiotics first or topical therapies like vitamin A acid derivatives, topical antibiotics and topical antiseptics, but they commonly fail," he says.

It is reasonable to move to hormonal therapies and prescribe those, says Dr. Shaw, who usually starts with an oral contraceptive.

Oral contraceptives cause a steady state instead of monthly fluctuations of hormones, and the estrogen component of the oral contraceptives trigger an elevation in sex hormone-binding globulin, which binds to circulating androgens to decrease their impact.

The role of low-dose progestin in oral contraceptives probably does not contribute in large part to controlling acne, though some products make that claim.

"Most any second- or third-generation birth control pill is effective, but some have been designed specifically for the purpose of treating adult acne," Dr. Shaw says.