Acne in the Adult Female Patient: A Practical Approach

F Kamangar, K Shinkai

Int. J. Dermatol. 2012 Oct 01;51(10)1162-1174.

ABSTRACT
Acne vulgaris is a common reason why adult women present to dermatologists and can be a clinical challenge to treat. It may also be an important sign of an underlying endocrine disease such as Polycystic Ovary Syndrome (PCOS). Although standard acne therapies can be successfully used to treat acne in adult female patients, hormonal treatment is a safe and effective therapeutic option that may provide an opportunity to better target acne in this population, even when other systemic therapies have failed. In this article, a practical approach to the adult female patient with acne will be reviewed to enhance the dermatologist's ability to use hormonal acne therapies and to better identify and evaluate patients with acne in the setting of a possible endocrine disorder.

Commentary by David Rakel, MD, FAAFP
Da Cunha’s paper1 suggests that acne in adult women is often due to elevated levels of androgens. Androgens, insulin, growth hormone, and cortisol all stimulate sebum production. Traditional acne treatments often fail in adult women since they do not address this hormonal influence. Hormonal treatments include oral contraceptive pills (OCPs) and spironolactone.
OCPs work by binding circulating androgen and reducing sebum production. They also inhibit 5-alpha reductase, inhibiting testosterone. When picking an OCP, choose one with a third-generation progestin, such as norgestimate or desogestrel, because the older progestins can worsen acne. If OCPs are not helpful or are contraindicated, consider spironolactone, which has been found to be more effective than OCPs. Moderate doses (50–100 mg/day) block androgen receptors. Avoid isolated use if pregnancy is possible due to teratogen effects. Effectiveness is dose-dependent, and titration up to 200 mg is feasible.
For resistant cases of acne, consider combining 100 mg spironolactone with an OCP that contains drospirenone, a synthetic progestin and analog to spironolactone, which can increase effectiveness up to 85%. Common OCPs with drospirenone 3 mg include Yaz, Gianvi, Beyaz, and Loryna. A higher risk for blood clots is possible with these OCPs, and it is necessary to monitor for hyperkalemia if both spironolactone and drospirenone are used.2
We also want to remember that hyperandrogenic states have a cause. To reduce androgens, insulin resistance, and cortisol, counsel your patients about weight management, exercise, a plant-based diet, stress management, and adequate sleep. One should also avoid xenobiotics (hormone mimickers that some blame for the trend of menarche in younger girls). The main xenobiotics to avoid are bisphenol A (BPA) and phthalates from plastics, as well as organophosphates from pesticides and herbicides.

References

  1. Da Cunha MG, Fonseca FLA, Machado CD. Androgenic hormone profile of adult women with acne. Dermatology (Basel). 2013;226(2):167–171.
  2. Kamangar F, Shinkai K. Acne in the adult female patient: a practical approach. Int J Dermatol. 2012;51(10):1162–1174.