Transgender adolescents and acne: A cases series

We describe the difficulties of treating acne in a series of female‐to‐male transgender adolescents, including concerns about potential hepatotoxicity with concomitant use of testosterone with isotretinoin or tetracyclines. Acne is a foreseeable adverse effect of testosterone treatment in transgender adolescents, so monitoring for acne is advised. The treatment of acne in transgender adolescents is important given that severe acne and transgenderism are associated with higher rates of depression and suicide.     

Hormonal therapy for acne

Acne affects more than 40 million people, of which more than half are women older than 25 years of age. These women frequently fail traditional therapy and have high relapse rates even after isotretinoin. Recent advances in research have helped to delineate the important role hormones play in the pathogenesis of acne. Androgens such as dihydrotestosterone and testosterone, the adrenal precursor dehydroepiandrosterone sulfate, estrogens, growth hormone, and insulin-like growth factors may all contribute to the development of acne. Hormonal therapy remains an important part of the arsenal of acne treatments available to the clinician. Women dealing with acne, even those without increased serum androgens, may benefit from hormonal treatments. The mainstays of hormonal therapy include oral contraceptives and antiandrogens such as spironolactone, cyproterone acetate, or flutamide. In this article, we discuss the effects of hormones on the pathogenesis of acne, evaluation of women with suspected endocrine abnormalities, and the myriad of treatment options available.     

Acne vulgaris treatment : the current scenario

Acne Vulgaris is one of the most common skin disorders which dermatologists have to treat. It mainly affect adolescent, though may present at any age. In recent years, due to better understanding of the pathogenesis of acne, new therapeutic modalities and various permutation and combinations have been designed. In topical agents; benzoyl peroxide, antibiotics, retinoids, etc are the mainstay of treatment; can be given in combinations. While systemic therapy includes oral antibiotics, hormonal therapy, and isotretinoin, depending upon the need of patients it has to be selected. Physical treatment in the form of lesion removal, photo-therapy is also helpful in few of them. Since various old and new topical and systemic agents are available to treat acne, it sometime confuse treating dermatologist. To overcome this, panel of physicians and researchers worked together as a global alliance and task force to improve outcomes in acne treatment. They have tried to give consensus recommendation for the treatment of acne. Successful management of acne needs careful selection of anti-acne agents according to clinical presentation and individual patient needs.     

Contraceptive use in acne

Acne vulgaris is an inflammatory disorder of the pilosebaceous follicle. It is well established that androgen hormones play a major role in sebum production and excretion, and are vital in the pathogenesis of acne. Isotretinoin notwithstanding, hormonal therapies such as combined oral contraceptives (COCs) and spironolactone are the only treatments that can affect sebum production and the androgen component of acne. Contraceptives are also used during isotretinoin therapy for pregnancy prevention. It is important for a dermatologist to be familiar with all the available methods of contraception to provide essential counseling to patients. The aim of this paper is to review the role of hormones in acne pathogenesis, discuss the use of hormonal therapies for acne, and detail various alternative contraceptive methods in relation to isotretinoin treatment and pregnancy prevention.     

Efficacy of diode laser for treating acne keloidalis nuchae

Acne keloidalis nuchae is usually treated with oral antibiotics, local antiseptics or intralesional steroids but with limited success. I assessed the efficacy of diode laser for treating the inflammatory and keloidal papules of acne keloidalis nuchae in two cases. The lesions in both the cases showed about 90 to 95% clearance after 4 treatment sessions at one to one and half month intervals. No new lesions were observed during the follow up period of six months after the last laser treatment. Thus, after clearing bacterial infection, laser hair epilation can be used as the first line of therapy for treating papules of acne keloidalis nuchae. This is the first attempt at treating acne keloidalis nuchae with a diode laser.     

Acne in the adult female patient: a practical approach

Acne vulgaris is a common reason why adult women present to dermatologists and can be a clinical challenge to treat. It may also be an important sign of an underlying endocrine disease such as Polycystic Ovary Syndrome (PCOS). Although standard acne therapies can be successfully used to treat acne in adult female patients, hormonal treatment is a safe and effective therapeutic option that may provide an opportunity to better target acne in this population, even when other systemic therapies have failed. In this article, a practical approach to the adult female patient with acne will be reviewed to enhance the dermatologist’s ability to use hormonal acne therapies and to better identify and evaluate patients with acne in the setting of a possible endocrine disorder.     

Practical Approach to the Hormonal Treatment of Acne

Acne is a disease of the pilosebaceous units and these are mainly under hormonal control. In female patients, hormonal therapy is a unique opportunity for the treatment of acne. Several combined oral contraceptives (COCs), cyproterone acetate, spironolactone, flutamide, and others, have been tried for the control of acne. An overview on the use of the most useful drugs in clinical practice was conducted. COCs are thoroughly discussed, also taking into consideration their potential side effects. A practical approach with guidelines on the use of COC in acne is proposed.     

Practical approach to the hormonal treatment of acne

Acne is a disease of the pilosebaceous units and these are mainly under hormonal control. In female patients, hormonal therapy is a unique opportunity for the treatment of acne. Several combined oral contraceptives (COCs), cyproterone acetate, spironolactone, flutamide, and others, have been tried for the control of acne. An overview on the use of the most useful drugs in clinical practice was conducted. COCs are thoroughly discussed, also taking into consideration their potential side effects. A practical approach with guidelines on the use of COC in acne is proposed.     

Assessment of androgens in women with adult-onset acne

BACKGROUND: Acne is generally recognized as a disorder of young adults; however, the referral of patients aged over 25 years with acne is increasing. Disturbed androgen production in the ovaries or adrenal gland and impaired plasma transport of androgens in women with adult-onset acne or acne associated with hirsutism have been described. METHODS: Thirty-five white women with adult-onset acne (onset after the age of 25 years) and hirsutism (A + H), 35 white women with adult acne without hirsutism (A - H), and 35 age-matched white female controls were recruited in this case-control study. Serum levels of luteinizing hormone (LH), follicle-stimulating hormone (FSH), total testosterone, dihydroepiandrosterone sulfate (DHEA-S), and sex hormone binding globulin (SHBG) were determined in all patients and compared. RESULTS: The mean SHBG, free androgen index (FAI), and DHEA-S were significantly different between A + H and control subjects. The only significant difference between A - H and control subjects was observed for DHEA-S. CONCLUSION: DHEA-S plays a key role in the pathogenesis of adult-onset acne. Measurement of circulating androgens, including DHEA-S, especially in patients presenting with adult-onset acne and hirsutism, is helpful, and patients with elevated levels can benefit from hormonal therapy.     

Pharmacologic modulation of sebaceous gland activity: mechanisms and clinical applications

Acne vulgaris is a common skin condition seen by physicians. It primarily affects adolescents, but can continue into adulthood. A key factor in the pathogenesis of acne is sebum production. Typical therapy includes combinations of topical retinoids and antimicrobials for mild acne, with the addition of oral antibiotics for moderate to severe disease. In the most recalcitrant cases or for nodulocystic acne, oral retinoids are indicated. In women who fail to respond to conventional treatment, hormonal therapy is often used adjunctively. Only isotretinoin and hormonal therapy improve acne via their action on the sebaceous glands. This article focuses on the mechanisms by which these treatment modalities act on the sebaceous glands and their clinical use in the practice of medicine.     

Hormonal Profiles and Prevalence of Polycystic Ovary Syndrome in Women with Acne

One of the important etiologic factors in acne is an increase in sebaceous gland activity, which is androgen dependent. Acne is a common manifestation of hyperandrogenemia. Therefore, acne may not only cause cosmetic concern but may also be a sign of underlying disease. In females, the most common cause of hyperandrogenemia is polycystic ovary syndrome (PCOS). The purpose of this study was to determine the hormonal profiles of women with acne and the prevalence of PCOS in women attending the dermatological clinic with acne problems. The diagnostic criteria of PCOS were clinical findings of menstrual disturbances and hyperandrogenism (acne, seborrhea, hirsutism), pelvic ultrasound imaging of PCO (multiple subcapsular ovarian cysts 2–8 mm. in diameter, with dense echogenic stroma), and an elevated luteinizing hormone (LH) to follicle stimulating hormone (FSH) ratio. There were 51 women with acne; 20 regularly menstruating volunteers without acne served as a control group. PCOS was found in 19 out of 51 patients with acne (37.3%) and none of the control group. Twenty acne patients had abnormal menstruation (39.2%). Acne cases had higher mean levels of serum total testosterone (T), free T, dehydroepiandrosterone sulfate (DHEAS) and prolactin (PRL). No statistically significant difference was observed for LH, FSH or sex hormone binding globulin (SHBG). Because of this high prevalence of PCOS in women with acne, all women presenting with acne should be asked about their menstrual pattern and examined for other signs of hyperandrogenemia. Hormonal profile determination as well as pelvic ultrasonography for ovarian visualization should be performed to confirm the diagnosis of PCOS in female acne patients who have menstrual disturbances.     

Should dermatologists prescribe hormonal contraceptives for acne?

One of the primary factors contributing to the development of acne vulgaris is excess sebum. Sebaceous glands and sebum excretion are regulated, at least in part, by androgen hormones. Acne treatments that block this androgen effect include spironolactone and combination oral contraceptives (COC). Three COC are now FDA approved to treat moderate acne. Dermatologists must become experts at prescribing these hormonal contraceptives. Likewise, it is vital to be aware of contraindications to hormonal contraceptive therapy. Proper patient selection relies on an appropriate medical history and an assessment of blood pressure. A pelvic exam and/or Papanicolaou smear are not required prior to initiating therapy with a COC. It is important to counsel patients about potential adverse effects of COC pills and to establish appropriate expectations concerning acne improvement.     

Practical Approach to the Hormonal Treatment of Acne

Acne is a disease of the pilosebaceous units and these are mainly under hormonal control. In female patients, hormonal therapy is a unique opportunity for the treatment of acne. Several combined oral contraceptives (COCs), cyproterone acetate, spironolactone, flutamide, and others, have been tried for the control of acne. An overview on the use of the most useful drugs in clinical practice was conducted. COCs are thoroughly discussed, also taking into consideration their potential side effects. A practical approach with guidelines on the use of COC in acne is proposed.

     

Profiling and Hormonal Therapy for Acne in Women

Acne vulgaris is the most common condition treated by physicians worldwide. Though most acne patients remit spontaneously, for the ones that do not or are unresponsive to conventional therapy or have obvious cutaneous signs of hyperandrogenism, hormonal therapy is the next option in the therapeutic ladder. It is not strictly indicated for only those patients who have cutaneous or biochemical evidence of hyperandrogenism, but can be used even without any evidence of hyperandrogenism, for therapy-resistant acne. It can be prescribed as monotherapy, but when used in combination with other conventional therapies, it may prove to be more beneficial. Hormonal evaluation is a prerequisite for hormonal therapy, to identify the cause behind hyperandrogenism, which may be ovarian or adrenal. This article reviews guidelines for patient selection and the various available hormonal therapeutic options, their side-effect profile, indications and contraindications, and various other practical aspects, to encourage dermatologists to become comfortable prescribing them.     

Acne: endocrinologic aspects

Acne is dependent for its development on several factors, one of which is hormonal. The principal and possibly sole mechanistic link between hormones and acne is sebum, the secretory product of the sebaceous glands which is highly androgen-sensitive. Some but not all, patients with acne can be shown to have systemic androgen abnormalities. In addition, there is evidence to suggest that androgens are metabolized abnormally in the skin, possibly resulting in excessive sebaceous gland secretion. Systemic endocrine therapy of acne is designed to reduce the androgenic stimulation of the sebaceous gland. Such treatment includes the peroral cyclic administration of estrogen for ovarian inhibition and the use of low-dosage glucocorticoid for adrenocortical androgen suppression. Combined estrogen-glucocorticoid treatment induces the most telling effect in reducing sebaceous gland activity.     

Treatment of mild to severe acne with 1726 nm laser: A safe alternative to traditional acne therapies

Introduction

Acne is the most common reason for dermatology consultation in adolescents and young adults. Consultation is often delayed despite unsuccessful self-treatment. Postponing effective treatment places acne sufferers at higher risk for permanent acne scars and post-inflammatory pigment changes.

Aim

This review discusses clinical challenges with present therapeutic options for acne treatment and the role of a 1726 nm laser for acne.

Methods

Current acne treatment guidelines were reviewed. A literature review was conducted for trials of light-based acne therapy. The selectivity of previous light-based therapies was reviewed.

Results

Available acne therapy is effective, but treatment-related side effects are common. Acne treatment guidelines do not include recommendations for light-based treatments. Different types of light-based treatments have been tried but until now no wavelength specifically targeted sebaceous glands.

Conclusion

The 1726 nm laser is safe and effective for treating mild to severe acne in all Fitzpatrick skin types. Acne resolution is apparent within the first month and improves for up to 2 years beyond treatment.     

Ovarian morphology and prevalence of polycystic ovary syndrome in reproductive aged women with or without mild acne

Background Acne and hirsutism are common manifestations of hyperandrogenemia. They may also be a sign of underlying severe diseases. Aim To compare ovarian morphology and prevalence of polycystic ovary syndrome (PCOS) in reproductive aged women with or without mild acne and hirsutism. Methods 52 women with mild acne and 59 age‐matched controls were included in this study. Main outcome measures were the prevalence of PCOS, ovarian morphology, and ovarian stromal thickness in both groups, and acne and hirsutism subgroups. Patients in both groups were taking no hormonal therapy at that time. Androgen profiles were compared between the two groups. Results The prevalence of PCOS was 17.1% (19/111) in all women included in this study. In the acne group, the prevalence of PCOS was 26.9% (14/52), and significantly more prevalent than in control group [8.4% (5/59), P = 0.001]. Total ovarian volume was significantly larger and stromal thickness of the ovary was thicker in women with acne than women without acne. There were no statistically significant difference between the two groups in terms of dehydroepiandrosterone sulfate, and 17‐hydroxyprogesterone, respectively, while serum total testosterone levels were significantly higher (P < 0.05) in women with acne than those women in the control group. Conclusions Acne and hirsutism may not only cause cosmetic concern but may also be a sign of underlying PCOS. Therefore, women presenting with acne and/or hirsutism should be evaluated in terms of PCOS.     

Possible gender differences in the quality of life and choice of therapy in acne

Background Acne is a very common skin disease that has major impact on the patients’ quality of life. Although the disease has been extensively studied we still need more knowledge of factors influencing the decisions for choice of therapy. Objective To evaluate the relationships between clinical severity, patients’ self‐reported quality of life, treatment choice and the outcome of therapy in a structured out‐patient acne clinic. Methods In total 211 consecutive patients (143 females, 68 males) at a structured acne clinic were included. At the first visit a clinical assessment was conducted, therapy was initiated and the patients answered a quality‐of‐life questionnaire (Dermatology Life Quality Index, DLQI). A follow up was performed after six months, when patients once again answered the DLQI questionnaire and the clinical outcome was assessed by the physician. Results The quality of life was improved after treatment at a group level. At the first visit, the quality of life showed a gender difference (females scoring worse) but did not correlate to the clinical grading nor to the choice of therapy. At six months the DLQI correlated with clinical outcome. Patients with isotretinoin therapy showed a significantly greater improvement in quality of life. There was a tendency to gender difference in the choice of therapy, as in females 32% of the patients were treated with isotretinoin although they were clinically graded as moderate. The corresponding figure for males was 23%. A correlation was found between the initial clinical grading and gender, age and the choice of therapy. Conclusion DLQI can be used to evaluate treatment effects in acne. However, the self‐reported quality of life will depend on several factors including age, gender, psychosocial factors and clinical severity.