Author:
James Q. Del Rosso, DO, Dermatology Residency Director, Valley Hospital Medical Center, Las Vegas, Nevada

Introduction

The Dermatology Seminar-at-Sea, a Continuing Medical Education Course directed by Eric Baum, MD, through the Alabama Dermatology Society, was held from August 2 – 9,2008 in Tahiti/French Polynesia.

Highlights from the meeting are reviewed below.,

Hormonal Therapy in Females with Acne Vulgaris

Julie C. Harper, MD, a dermatologist in private practice in Birmingham, Alabama, and Clinical Associate Professor of Dermatology at the University of Alabama-Birmingham, discussed the use of hormonal therapy in female patients with acne vulgaris (AV). Dr. Harper reviewed results from studies which have evaluated the prevalence of post-teenage AV. One study reported that after the age of 25 years, 12% of females are affected by AV as compared to 3% of males.¹ A more recent publication reported results from a large survey inclusive of 540 females and 473 males.² Interestingly, 68.5% of males and 66.8% of females reported having teenage AV, with no statistically significant intergroup difference noted. However,  in groups older than age 20 years, more women reported having post-teenage AV than men, with statistical significance noted at all time points within each decade through age 50 years and older.

The potential value of hormonal therapy in females with AV is supported by the facts that: (1) AV develops around the time when androgen hormones are being produced by gonadal and adrenal tissues; (2) individuals who are androgen insensitive do not develop AV; (3) disease states associated with hyperandrogenism, such as polycystic ovary disease and androgen secreting tumors, often present with AV; and (4) exogenous androgen administration is associated with development of an acneiform eruption. Importantly, anti-androgenic therapies such as oral contraceptives (OCs) and oral spironolactone have been shown to improve AV.

Why are oral contraceptives effective for treating acne vulgaris in women?

The primary therapeutic component of OCs is ethinyl estradiol (EE), the estrogenic component of OCs. EE increases sex hormone binding globulin (SHBG) and therefore decreases circulating free testosterone levels. Also, inhibition of ovulation decreases ovarian production of androgenic hormone. At present, three OCs are FDA-approved for the treatment of AV: Estrostep^® (EE20/30/35/Norethindrone), Ortho Tri-Cyclen^® (EE35/Norgestimate), and Yaz^® (EE20/Drospirenone).  Yaz^® differs from Yazmin^® (EES30/Drospirenone), which is not FDA approved for AV, as it contains a higher amount of EE and utilizes a 21 day active/7 day placebo cycle program, with 7 hormone-free days, as compared to a 24 day active/4 day placebo cycle with Yaz^®, which has 4 hormone-free days. In addition, as opposed to the other two OCs that are FDA-approved for AV, Yaz^® contains the progestational agent drospirenone, which exhibits anti-androgenic activity. This contrasts with the other two progestational agents found in other OCs (norethindrone and norgestimate) which are not anti-androgenic.,

Evaluating the efficacy of oral contraceptives for acne vulgaris

Dr. Harper emphasized the importance of stressing to female patients with AV who are prescribed OCs that "studies evaluated the efficacy of OCs for AV over 6 – 9 monthly cycles". Thus, it may take 3 to 6 months for improvement to be observed.  One study compared the efficacy of women treated for AV with either EE30/Drospirenone (n=568) versus EE35/Norgestimate (n=586).³ EE30/Drospirenone exhibited a superior reduction in total lesion counts and investigators' assessment of therapeutic effect, however, reduction in inflammatory lesions was similar in both study groups. EE20/Drospirenone over a duration of 6 monthly cycles provides a 50% mean reduction in inflammatory acne lesions.