Hormonal Treatment of Acne: How They Work
Hormonal treatments, including oral contraceptives, have long been recognized by dermatologists to be an effective treatment option for women who have acne, no matter how severe.
For information about other acne treatments, click on Understand Your Acne Treatment Options.
Acne is thought to be initiated by the effect of masculinising hormones called “androgens” on oil glands that, during puberty, enlarge and become increasingly sensitive. This results in excessive oil secretion and blockage of pores, which leads to the initial non-inflamed spots of acne (whiteheads and blackheads). As the acne bacteria (Propionibacterium acnes) proliferate, the oil-rich environment in the pores leads to inflammation which becomes visibly apparent as red pimples, pustules and lumps.
Hormonal therapy for acne is, therefore, meant to interrupt this initial phase of this cascading sequence of acne development. Such preparations include oral contraceptives such as Diane-35®, Tri-Cyclen®, Alesse®, and Yasmin®; and a non-contraceptive anti-androgen, spironolactone. To learn more about hormones and acne, click on Other Hormone Therapy.
Possible Relationships Between Hormones and Acne
Androgens that play a part in causing acne include 5-dihydrodrotestosterone (DHT), testosterone (T), androstenedione (A), and dehydroepiandrosterone-sulfate (DHEA-S). The production of these androgens from ovaries and adrenal glands is mediated by gonadotrophins. Levels of testosterone are inversely related to levels of sex hormone binding globulin (SHBG), so that if T increases, SHBG decreases and when T is reduced, SHBG increases.
Polycystic ovarian syndrome is a condition found in women who have very high androgen and testosterone levels. Symptoms include obesity, infertility, scalp hair loss, increased facial and body hair, irregular periods, acne and elevated blood insulin levels. This condition affects 5-10% of women in their reproductive years. Clinical evaluation and blood testing can be performed to diagnose this disorder. In addition to exercise and weight control, hormonal therapy is often helpful in this condition.
Oral Contraceptives (OCs)
OCs, which contain estrogen and progestins, directly affect how much androgen your body produces and can therefore impact acne. Possible ways that estrogens may be working to improve acne include:
- Decreased production of adrenal (DHEA-S) and ovarian androgens (A, T);
- Inhibition of the enzyme 5-alpha-reductase, which leads to a reduction of DHT levels;
- SHBG increase, which reduces levels of T.
Progestins vary in their androgenic or testosterone-like activity and may, therefore, have variable effects on acne. Progestins with the lowest androgenic activity are more appropriate in the treatment of acne and other disoders caused by increased androgen levels (desogestrel, norgestimate). Alternatively, cyproterone acetate – an antiandrogenic progesterone derivative - may be combined with the estrogen component.
Currently available OCs such as Diane-35®, Tri-Cyclen®, Alesse®, and Yasmin® contain progestins with minimal androgenic or anti-androgenic activity, providing an important therapeutic option for women with acne. Their proven effectiveness and long-term safety profile supports their use in various grades of acne in females:
- as additional therapy with topical agents for women who have mild, non-scarring acne and who desire oral contraception;
- as primary therapy in moderate, non-scarring acne in combination with topical therapy and systemic antibiotics;
- in scarring and severe inflammatory acne as one of two preferred methods of contraception in patients treated with systemic isotretinoin.
Clinical studies in acne patients treated with Tricyclen and Alesse show that acne spots were reduced by 40-50% over a course of 6 months. The extent of improvement may be greater with Diane-35 as patients in a Canadian acne survey generally considered Diane-35â to be more effective for treating acne than Tricyclenâ. Side effects common to all oral contraceptive preparations included breast tenderness, headache, and nausea. These were typically mild and tended to resolve by the second cycle. A newly approved oral contraceptive in Canada, Yasminâ, has been shown to be as effective as Diane-35â for treating acne.
Spironolactone, a synthetic steroid, is an anti-androgen that binds to the body's androgen receptors, thus blocking the androgens from binding to the cell receptors, inhibits 5-alpha-reductase enzyme activity and reduces androgen biosynthesis. Small studies using this agent for treating acne have been shown to be effective with few side effects, but larger studies are needed for confirmation.
Dr. Jerry K. L. Tan, MD, FRCPC: Adjunct Professor, Faculty of Medicine, University of Western Ontario, Windsor, Canada. Director, Acne Research and Treatment Centre, Windsor, Canada. Area of specialty: acne and rosacea.
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