PracticeUpdate: Dermatology & Rheumatology

SPD 2016 17

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).

• 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.

• 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.

DECEMBER 2016