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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).
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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
17