Hormones fill gap in acne treatment

New Orleans - Acne is a multifactorial disease with four main causes, says Julie Harper, M.D. There are plenty of medications aimed at resolving three of those causes. But options for the fourth - excess sebum - are limited to isotretinoin, spironolactone and hormones, specifically oral contraceptives.

"A lot of dermatologists are not comfortable prescribing oral contraceptives," she says. "They tend to refer their female patients to gynecologists or family practice physicians, but this isn't necessary."

Dr. Harper, who is an assistant professor of dermatology at the University of Alabama Medical School in Birmingham, emphasizes that topical retinoids are the first line of defense for all grades of acne. For added effectiveness, they can be combined with topical benzyl peroxide and topical or systemic antibiotics.

Combination treatments that target multiple pathogenetic factors offer the greatest improvement in the shortest amount of time, she says. Once acne is under control, Dr. Harper decreases the antibiotic and continues a retinoid/hormone combination for maintenance.

Risks, benefits Oral contraceptives have several relatively minor side effects: irregular vaginal bleeding, nausea, weight gain, mood changes and breast tenderness.

Interactions with antibiotics are another reason dermatologists hesitate to prescribe them. Dr. Harper points out that 76 percent of all alleged antibiotic-oral contraceptive interactions involve rifampin.

There are more significant risks associated with hormones. Contraceptive users have three times the rate of venous thromboembolism (four to 18 events per 10,000 woman-years) and two-and-a-half times greater risk of ischemic stroke in women age 20 to 24 (risk increases with age). They also have an increased risk of myocardial infarction.

However, most of these risks can be mitigated.

The incidence of embolism and stroke are related to dosages of estrogen. A history of hypertension, cigarette smoking, diabetes or migraine headaches will substantially increase the risk of a stroke. A full 80 percent of myocardial infarction cases occur in smokers.

Dr. Harper insists that oral hormones are a safe and effective treatment for women under the age of 35 who have no other risk factors.

But she says, "I wouldn't prescribe hormones to women who smoke under any circumstances. If there are other risk factors - high blood pressure or diabetes - I'd refer the patient to a gynecologist or family practice physician."

In addition to regulating menstrual periods and improving acne, Dr. Harper notes that oral contraceptives appear to imbue users with a 40 to 80 percent decrease in ovarian cancer and up to a 40 percent decrease in endometrial cancer. Protection begins after one year of use, increases with continued use, and persists for 15 to 20 years after discontinuation of hormones.

Selecting oral hormones A meta analysis of 21 studies evaluating oral contraceptives for the management of acne vulgaris concluded that those containing cyproterone acetate or chlormadinone acetate were most effective. Neither are available in the United States. However, Dr. Harper does not see much difference in the efficacy of oral contraceptives for treatment of acne. She recommends Yasmin (ethinyl estradiol 30 g/drospirenone) because it's the only oral contraceptive with an anti-androgenic progesterone.

Dr. Harper says, "I've used Yasmin a lot, and it does a nice job. Give it a full three months to work."

She says Yasmin has fewer side effects and is also a diuretic, causing women to lose rather than gain weight. If a patient has kidney disease, potassium must be monitored.