Oral contraceptives may prevent acne, too

Las Vegas - Hormonal therapy with an estrogen-progestin oral contraceptive (OC) can be a useful adjunct for acne treatment in adult women who fail to respond to traditional topical and systemic therapies, according to Julie C. Harper, M.D., at the Fall Clinical Dermatology Conference.

"Acne is a complex, multifactorial disease, and an OC will only target one of the four known causes. Therefore, it should not be used as first-line treatment or to replace other agents, but in properly selected patients, an OC can be a useful addition to an already comprehensive treatment plan," says Dr. Harper, assistant professor of dermatology, University of Alabama Medical Center, Birmingham, Ala.

OC choice

In theory, however, other products within this category should be effective as they all suppress ovarian
function and increase sex hormone-binding globulin and thereby decrease free testosterone.

Available OCs contain ethinyl estradiol in doses between 20 mcg and 50 mcg and any of a number of progestins, including norethindrone acetate, levonorgestrel, desogestrel, norgestimate and drospirenone. Since risks associated with OCs increase with increasing estrogen dose, it is best to choose a product containing a low dose of estrogen (less than 35 mcg ethinyl estradiol).

Dr. Harper notes that in her own practice, she especially likes to prescribe the OC containing ethinyl estradiol 30 mcg and the novel progestin drospirenone 3 mg (Yasmin [Berlex]) because drospirenone is a spironolactone analog of spironolactone with antiandrogenic activity equivalent to that provided by 25 mg of spironolactone.

"The potent antiandrogenic component of this OC is a unique feature, and while there are some studies that found its efficacy was not different compared with other OCs, my own personal experience suggests it is superior," Dr. Harper tells Dermatology Times.

Risk evaluation

The primary risks associated with estrogen-progestin OCs include ve-nous thromboembolism, stroke and myocardial infarction.

Those risks increase with in-creasing patient age and estrogen dose and are also elevated by the presence of hypertension, cigarette smoking and migraine.

"Taken collectively, this information indicates that OCs are used most safely in women under 35 years of age who do not smoke, do not have migraine headaches and who are normotensive. The good news is that while 12 percent of women age 25 to 44 have acne, the prevalence rate drops to only 5 percent for women 45 and older," Dr. Harper says.

Currently, the jury is still out on whether OC use affects breast cancer risk, whereas OCs can have benefits aside from their affects on acne. Available evidence indicates that they can protect against ovarian cancer and endometrial cancer as well as pelvic inflammatory disease, uterine leiomyomas and ovarian cysts, while they also help regulate the menstrual cycle.

Common questions

One concern among those who would prescribe OCs is whether these agents can be used safely by women taking oral antibiotics.

In that regard, there are reassuring results from two studies that found the pregnancy rate was not increased among women using an OC plus an antibiotic compared with those re-ceiving an OC alone.

"The major exception for concomitant antibiotic prescribing is rifampin, which is a potent CYP450 inducer and increases estrogen metabolism to decrease OC efficacy. However, there appears to be no interaction between OCs and the antibiotics that are typically prescribed for skin infections and acne management," Dr. Harper says.

For physicians wondering if a laboratory work-up is indicated to determine whether a patient being considered as an OC treatment candidate has elevated androgen levels, the answer is that such testing is only recommended for women who have signs of hyperandrogenism, such as hirsutism, voice deepening or al-opecia.

"Women with acne do not need to have abnormal hormone levels in order to benefit from hormonal therapy with an OC, and in fact, most of these patients have normal levels of circulating hormone," Dr. Harper says.