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Hormonal therapy with oral contraceptives or

spironolactone for adolescent acne

By Sarah Chamlin MD

Diane Thiboutot MD from Penn State University spoke on the hormonal treatment of adolescent

acne (Thiboutot D. Hormonal therapy for adolescent acne. Paper presented at SPD 2016).

Screen prepubertal children who have clinical signs of androgen

excess with a hand film for bone age. This screen can be done

before specific hormone testing. If the bone age is advanced, further

evaluation is needed, such as specific hormone testing.

Specific hormone testing includes DHEAS (high in adrenal tumours

and congenital adrenal hyperplasia), total and free testosterone

(elevated in PCO and ovarian tumours), LH/FSH ratio, and

17-hydroxyprogesterone. It is suggested that this testing be an early

morning draw and not done near ovulation, and a patient should

be off oral contraceptives for at least 6 weeks (

J Am Acad Dermatol

2016;74:945-973.e33).

Indications for hormonal therapy for acne in young females: ovarian

or adrenal hyperandrogenism; as second-line/alternative therapy

with moderate or severe acne and normal serum androgens; and as

an alternative to repeat courses of isotretinoin or antibiotics.

Hormonal treatment choices include oral contraceptives that will

block ovarian androgen production and antiandrogens, such as

spironolactone and flutamide, to block skin androgen receptors. In

addition, patients with documented adrenal hyperandrogenismmay

benefit from low-dose oral corticosteroids for treatment of acne.

Practitioners who prescribe oral contraceptives should review the

WHO contraindication list. The most relevant contraindication for

teens is headaches/migraines with focal neurological symptoms.

Low-dose oestrogen-containing oral contraceptives early in the teen

years may undermine the accrual of bone mass. They should be

avoided, in general, until within 2 years of starting menses and

before the age of 14 years.

Rifampin and griseofulvin are the only anti-infective agents that

lessen the efficacy of oral contraceptives.

Spironolactone dosing of 25 to 100 mg twice daily is suggested,

with side effects of breast tenderness and menstrual irregularity.

While animal studies suggest carcinogenicity, a large Danish study

concluded that use of spironolactone did not increase the risk for

breast, uterine, and ovarian cancer.

Routine potassium monitoring was investigated in a 2015 study,

and a rate of hyperkalemia of 0.72% was reported (

JAMA Dermatol

2015;151:941-944). This was compared with the baseline rate of

0.76% in the control group, and the authors suggest that routine

potassium monitoring is not needed in healthy young women.

DECEMBER 2016

SPD 2016

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