Optimizing Pediatric Acne Care with Hormonal Therapy

Image Credit: © Марина Демешко - stock.adobe.com

At the 2024 Society for Pediatric Dermatology Annual Meeting in Toronto, ON, Andrea Zaenglein, MD, from Penn State/Hershey Medical Center delivered a session on "Hormonal Therapy in Pediatric Acne." Zaenglein's presentation provided a comprehensive overview of hormonal treatments, focusing on their mechanisms, effectiveness, and practical considerations for clinical practice.¹

Understanding the Role of Androgens in Acne

Zaenglein began by emphasizing the pivotal role of androgens in the development of acne. She explained that androgens stimulate the sebaceous glands, leading to increased sebum production and the formation of acne lesions. Without androgens, acne would not occur, making hormonal therapy a crucial component in managing the condition, especially in patients with hormonal imbalances.

Combined Oral Contraceptives (COCs) in Acne Management

One of the primary hormonal therapies discussed was combined oral contraceptives (COCs). COCs decrease free testosterone levels and increase sex hormone-binding globulin, resulting in a reduction of androgenic activity. This process also involves negative feedback on the hypothalamus, decreasing luteinizing hormone levels. Zaenglein highlighted that many dermatologists underutilize COCs, despite their efficacy in treating acne by addressing the underlying hormonal causes.

Spironolactone: A Potent Anti-Androgen

Zaenglein also detailed the use of spironolactone, an androgen receptor blocker that inhibits 5-alpha reductase. She discussed its dosing, typically ranging from 25 to 100 mg daily, with the most effective doses being 100 mg or more.

A study conducted by the Mayo Clinic involving 80 patients with an average acne severity of grade 3 showed significant improvement, with 80% of participants experiencing greater than or equal to complete response.² However, spironolactone appears less effective in younger patients, warranting further investigation into age-related differences in response.

Safety and Pre-Treatment Considerations

Addressing safety concerns, Zaenglein assured attendees that there is no evidence of hormonal disruption in teenagers using spironolactone. Before initiating treatment, she recommended a thorough acne assessment and physical exam, along with a review of the patient's current medications due to potential interactions with COCs. Blood pressure, weight, and consideration of polycystic ovary syndrome (PCOS) are also essential pre-treatment evaluations.

Managing PCOS in Adolescents

Zaenglein provided a detailed PCOS checklist for clinicians, which includes assessing irregular periods, hirsutism, increased BMI, and insulin resistance. For adolescents suspected of having PCOS, she advised waiting 2-3 years post-menarche before testing and conducting early morning tests between days 4 and 10 of the menstrual cycle for accurate LH/FSH levels.

Counseling and Patient Education

Effective patient counseling is vital in hormonal therapy. Zaenglein stressed the importance of addressing common concerns and misconceptions, such as the myth of weight gain associated with COCs. She explained various starting methods for COCs, including the traditional Sunday start after a menstrual period and the quick start method, involving treatment initiation on the day of the visit. Consistency in taking the pill at the same time each day is crucial, and missing more than 2 doses necessitates starting over.

Addressing "Hormone Phobia"

Zaenglein acknowledged the prevalent "hormone phobia" fueled by social media, which can deter patients from using hormonal therapies. She emphasized the need for dermatologists to engage in shared decision-making with patients, providing clear and factual information to alleviate unfounded fears.

Insights on COCs and Emergency Contraception

Highlighting the importance of education, Zaenglein referenced a survey by the Pediatric Dermatology Research Alliance, or PeDRA, where 37% of respondents felt only somewhat confident in their understanding of emergency contraception.

Additionally, Zaenglein referenced a study published in the Journal of Clinical Aesthetic Dermatology that reported as many as 62% of US dermatology residents reported feeling adequately trained on the efficacy of COCs, with 60% reported comfortability in prescribing COCS to healthy adolescents.³

This underscores the need for continued education and training for dermatologists in hormonal therapies and emergency contraception.

References

1. Zaenglein A. Hormonal therapy in pediatric acne. Presented at the 2024 Society for Pediatric Dermatology Annual Meeting, July 11-14; Toronto, ON.
2. Roberts EE, Nowsheen S, Davis DMR, Hand JL, Tollefson MM, Wetter DA. Use of spironolactone to treat acne in adolescent females. Pediatr Dermatol. 2021 Jan;38(1):72-76.
3. Swink SM, Jones-Sheets MA, Sinharoy A, Butt M, Gust A, Zaenglein A. Evaluating dermatology residents combined oral contraceptive pill prescribing practices, knowledge, and comfort level in the management of acne vulgaris: A cross-sectional survey study. J Clin Aesthet Dermatol. 2023 Jan;16(1):47-50.