Polycystic ovary syndrome and acne

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in reproductive aged women. It is typically characterized by hyperandrogenism, chronic anovulation, and polycystic ovaries. Women with PCOS often experience dermatologic manifestations of hyperandrogenism, including hirsutism, acne vulgaris, and androgenic alopecia. This article will review the treatments for acne due to androgen excess in PCOS women.     

Correlation between endocrinological parameters and acne severity in adult women

Many studies demonstrate increased androgen levels and high prevalence of polycystic ovaries in women affected by acne. We evaluated the relationship between clinical features, ultrasonographic data on polycystic ovaries and hormonal parameters in 129 women >17 years of age with acne. Serum levels of androgens of ovarian and adrenal origin were measured. Menstrual cycle regularity, hirsutism, body mass index and ultrasonographic evaluation of ovaries were recorded. Raised levels of at least one androgen were evident in a majority of our patients. Only 19% of them had polycystic ovary syndrome. Hirsutism and acne severity correlated negatively with serum sex hormone-binding globulin (SHBG) levels (p<0.05). No correlation between acne severity and hirsutism was found. In post-pubertal women, severity of acne seems to depend on peripheral hyperandrogenism, with a negative relationship between the acne severity and serum SHBG levels. We strongly recommend the evaluation of serum SHBG levels in women with acne in order to select patients who can have a better response to appropriate hormonal regimes.     

Dermatologic Manifestations of Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) affects 5-10% of reproductive-aged women and is one of the most common endocrine disorders in women. The disorder is commonly characterized by elevated levels of androgen and insulin. Women with PCOS may present with a range of signs and symptoms, and face increased risks of reproductive, metabolic, cardiovascular, psychologic, and neoplastic sequelae, particularly if the condition is left unrecognized or untreated. The clinical definition of PCOS has changed in recent years and includes as one of its cardinal criteria the dermatologic manifestations of hyperandrogenism, chiefly hirsutism, acne vulgaris, and androgenetic alopecia. Acanthosis nigricans, a cutaneous sign of hyperinsulinemia, may also be present. These dermatologic features may provide early clinical clues to recognition of PCOS, and treatment of these cutaneous conditions may improve the patient's quality of life and psychologic well-being. The effects of androgen on pilosebaceous units in the skin can vary by anatomic location, producing pathophysiologic effects on hair growth and differentiation, sebaceous gland size and activity, and follicular keratinization. Treatment modalities may include hormonal therapy intended to modulate androgen production and action as well as non-hormonal therapies directed toward specific dermatologic conditions.     

Skin improvement with two different oestroprogestins in patients affected by acne and polycystic ovary syndrome: clinical and instrumental evaluation

Background Despite it is accepted that acne is mostly caused by an hyper‐responsiveness of the pilo‐sebaceous unit to normal circulating androgen hormones, in a few patients, especially women, acneic lesions can be associated with increased serum androgen levels (hyperandrogenism), of which polycystic ovary syndrome (PCOS) is the most common cause. In women with acne and proven PCOS therapy with estroprogestins (EPs) can be an excellent option. Objective The aim of the study was to assess the effects of two estroprogestins (EPs), ethinyl‐estradiol (EE) 30 mcg/drospirenone (DRSP) 3 mg, and ethinyl‐estradiol (EE) 30 mcg/chlormadinone acetate (CMA) 2 mg, both on increased serum androgen levels and on several skin parameters in women affected by mild to severe acne and polycystic ovary syndrome (PCOS). Methods Fifty‐nine women were randomized to receive EE/DRSP (n = 32) or EE/CMA (n = 27) for six months. Evaluation of serum androgen levels, grading of acne and hirsutism (respectively with Pillsbury and Ferriman‐Gallwey score) and non‐invasive assessment of skin hydration, transepidermal water loss (TEWL) and skin homogeneity were performed at baseline, at 3 and 6 months (end of treatment). Results Both treatments were well tolerated and showed a significant improvement of skin and hormonal parameters, although EE/DRSP showed a more potent effect on acne and seborrhea. Conclusions Estroprogestins represent an effective and safe treatment in women with acne and polycystic ovary syndrome (PCOS). Nevertheless, the combination EE 30 mcg/DRSP 3 mg appears to be a more potent therapeutic option.     

Hormonal therapy for acne: why not as first line therapy? facts and controversies

Standard systemic therapeutic agents used in acne include oral antimicrobials, isotretinoin, and hormonal agents. Appropriate patient selection is the key to decide when to use hormonal agents as first-line therapy as well as to achieve optimal results. Indications of hormonal therapy in acne in girls and women include proven ovarian or adrenal hyperandrogenism, recalcitrant acne, acne not responding to repeated courses of oral isotretinoin, acne tarda, polycystic ovary syndrome, or the presence of clinical signs of hyperandrogenism such as androgenic alopecia or the presence of the seborrhea, acne, hirsutism, alopecia syndrome. We describe the hormonal agents currently available for acne treatment, discuss their indications and contraindications, and address the question of whether they may be used as a first-line therapy in acne.     

Acne: effect of hormones on pathogenesis and management

In the pathogenesis of acne, androgen hormones play a crucial role. In the treatment of acne, hormonal therapies provide valuable alternatives to standard modalities in selected women. Although numerous factors contribute to the development of acne, the requirement for androgens is absolute and is one that allows for effective treatments in women through inhibition of androgen expression. The two prerequisites for androgen expression at the level of the pilosebaceous unit are the presence of androgen in the form of either testosterone or dihydrotestosterone; and functioning androgen receptors. A third component may be the metabolism of androgen precursors to active androgens within pilosebaceous units. Hormonal treatment of hyperandrogenism (acne, hirsutism, androgenetic alopecia) such as that seen in polycystic ovary syndrome, centers on reduction of circulating androgen levels and androgen receptor blockade. Combination oral contraceptives represent the primary treatment modality for reducing circulating androgens from ovarian and, to a lesser degree, adrenal sources. Newer formulations may also have clinically significant androgen receptor blocking and 5alpha-reductase inhibiting effects. Newer oral contraceptives have high safety profiles and are used widely internationally for this purpose. Androgen receptor blockers currently in use include spironolactone, cyproterone acetate, and flutamide. Androgen receptor blockers are frequently combined with oral contraceptives to achieve optimal results in selected women. In women with adrenal hyperplasia, low-dose corticosteroids may be added to reduce adrenal androgen precursors. Inhibition of enzymes of androgen metabolism in the pilosebaceous unit remain largely investigational in the treatment of acne, although the benefit of 5alpha-reductase (type 2) inhibition is established in androgenetic alopecia in men. This article reviews the essentials of hormonal influence in acne pathogenesis, discusses the hormonal therapies most utilized in the treatment of acne, and the pre-treatment evaluation of women in whom hormonal therapies are being considered.     

痤疮与胰岛素抵抗相关性的研究进展

痤疮是好发于青春期的毛囊皮脂腺慢性炎症性疾病,激素是痤疮发生的最重要内源性因素。近年来发现,除雄激素外,胰岛素抵抗及其诱导的胰岛素和胰岛素样生长因子1水平异常也与痤疮密切相关,胰岛素与胰岛素样生长因子1通过间接刺激雄激素分泌、直接诱导角质形成细胞增殖和皮脂腺细胞脂质分泌以及炎症过程参与痤疮发生。此外,痤疮作为某些系统性疾病或综合征如多囊卵巢综合征、高雄激素血症?胰岛素抵抗?黑棘皮病综合征的重要特征以及饮食、吸烟、肿瘤与痤疮的相关性也为胰岛素抵抗在痤疮发生中的潜在作用提供了依据。     

女性痤疮与多囊卵巢综合征的相关性研究

目的 检测成年女性痤疮患者体内性激素水平的变化,探讨其与多囊卵巢综合征（PCOS）的相关性。方法 采用放射免疫分析法,对50例痤疮患者进行血清性激素水平测定和妇科经阴道超声检查。以30例正常成年女性为对照。结果 痤疮组睾酮、二氢睾酮、脱氢表雄酮及黄体生成素水平增高,与正常对照组比较差异有高度显著性（P＜0．001或P＜0．01）;雌二醇、卵泡刺激素、孕酮水平变化不明显（P均＞0．05）。50例中有28例患PCOS。对其中10例应用达英－35治疗,可降低血清雄激素水平。结论 高雄激素血症和PCOS与成年女性痤疮有关,且是其长期不愈的重要原因。达英－35对此类痤疮有较好疗效。     

Acne‐associated syndromes: models for better understanding of acne pathogenesis

Acne, one of the most common skin disorders, is also a cardinal component of many systemic diseases or syndromes. Their association illustrates the nature of these diseases and is indicative of the pathogenesis of acne. Congenital adrenal hyperplasia (CAH) and seborrhoea‐acne‐hirsutism‐androgenetic alopecia (SAHA) syndrome highlight the role of androgen steroids, while polycystic ovary (PCO) and hyperandrogenism‐insulin resistance‐acanthosis nigricans (HAIR‐AN) syndromes indicate insulin resistance in acne. Apert syndrome with increased fibroblast growth factor receptor 2 (FGFR2) signalling results in follicular hyperkeratinization and sebaceous gland hypertrophy in acne. Synovitis‐acne‐pustulosis‐hyperostosis‐osteitis (SAPHO) and pyogenic arthritis‐pyoderma gangrenosum‐acne (PAPA) syndromes highlight the attributes of inflammation to acne formation. Advances in the understanding of the manifestation and molecular mechanisms of these syndromes will help to clarify acne pathogenesis and develop novel therapeutic modalities.     

Androgen excess in women with acne alone compared with women with acne and/or hirsutism

Acne is known to be one of the features of hyperandrogenism. The aim of the present work was to study women with persistent acne and without other evidence of hyperandrogenism, such as hirsutism, alopecia, or irregular menses. Among 87 female patients with acne and/or hirsutism, we defined three groups: group 1 (n = 29), patients having treatment-resistant acne without menstrual disturbance, alopecia, or hirsutism; group 2 (n = 27), patients with acne and hirsutism; and group 3 (n = 31), patients with hirsutism alone. Clinical chemistry criteria for hyperandrogenism were based on elevated values of one or more of the following parameters: plasma testosterone, delta-4-androstenedione, dehydroepiandrosterone, urinary 5 alpha-androstane 3 alpha-17 beta-diol, and 17-ketosteroids (with chromatography). Plasma and urine samples were drawn between the 18th and 25th days of the cycle. Among group 1 patients, we found 25 subjects (86%) with hyperandrogenism, according to these laboratory criteria. The etiologies were: polycystic ovary syndrome (36%), adrenal hypersecretion (40%, of which 12% showed secondary polycystic ovaries), isolated increase in 5 alpha-androstane 3 alpha-17 beta-diol (20%), and hyperandrogenism without diagnosis (4%). The parameters were found to be more elevated in these patients than in a control group of 30 normal volunteer women. In groups 2 and 3, the findings were essentially the same as in group 1, except for increased levels of testosterone and the testosterone/SHBG ratio. Furthermore, it was evident that persistent acne may be an isolated sign of hyperandrogenism.     

Polycystic ovary syndrome: a dermatologic approach

Polycystic ovary syndrome (POS) is one of the most common endocrine abnormalities affecting women of reproductive age. It is a cause of significant social embarrassment and emotional distress. The pathogenesis of the disease is not yet fully understood, but it is thought to be a complex multigenic disorder, including abnormalities in the hypothalamic-pituitary axis, steroidogenesis, and insulin resistance. The main diagnostic findings of the syndrome are: hyperandrogenism, chronic anovulation and polycystic ovarian morphology seen on ultrasound. Hyperandrogenism is generally manifested as hirsutism, acne, seborrhea, androgenic alopecia and, in severe cases, signs of virilization. Treatment may improve the clinical manifestations of excess androgen production, normalize menses and ameliorate metabolic syndrome and cardiovascular complications. This article reviews the diagnosis, clinical manifestations, metabolic complications, and treatment of the syndrome. Early diagnosis and the consequent early treatment may prevent metabolic complications and emotional distress that negatively impact the patients' quality of life.     

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.     

Acne tarda

Acne is one of the most common skin diseases in the general population, especially among adolescents. Acne tarda (adult acne) is defined as acne that develops (late-onset acne) or continues (persistent acne) after 25 years of age. The disease is more common in women. The clinical features are quite specific: inflammatory acne in the lower facial region or macrocomedones (microcysts) spread over the face. Involvement of the trunk is much more common in men. The etiology of acne tarda is still controversial, as cosmetics, drugs, smoking, stress, diet, and endocrine abnormalities have been implicated. Women with acne tarda and other symptoms of hyperandrogenism have a high probability of endocrine abnormalities such as polycystic ovary syndrome. Treatment is similar to that of acne in adolescence. Long-term treatment over years or decades may be required.     

多囊卵巢综合征临床特征和某些内分泌激素的检测

目的：比较肥胖和非肥胖性多囊卵巢综合征（PCOS）患者的皮肤病学特征和性激素水平的差异。方法：依据BMI标准将患者分为肥胖组（41例）和非肥胖组（75例）,对各组中每个妇女进行体质评估,包括体型、痤疮、多毛症、皮脂溢出、雄激素性脱发和黑棘皮病。logistic多元回归分析皮肤病学特征与激素和代谢参数的相关性。结果：肥胖和非肥胖组痤疮的发生率分别为5．2％和40．5％,多毛症为29．3％和37．0％,皮脂溢出为14．7％和22．4％,雄激素性脱发为14．7％和24．1％,黑棘皮病为1．7％和4．3％。与非肥胖组比较,肥胖组PCOS月经减少、经期延长,睾酮水平明显增高。结论：肥胖PCOS患者会出现更多的皮肤症状和排卵障碍。     

The hormonal profile of women with acne and polycystic ovaries

Most women with acne are found to have polycystic ovaries on high resolution pelvic ultrasonography, but most of these women do not manifest the other classical clinical characteristics of the polycystic ovary syndrome. We have compared the endocrinological profile of women with acne who were found to have polycystic ovaries with that of women with polycystic ovaries who presented to an endocrine clinic with hirsutes or non-dermatological manifestations of the polycystic-ovary syndrome. The group of women with acne had normal serum hormonal concentrations. Unlike other women with polycystic ovaries, they did not have significantly elevated serum concentrations of luteinizing hormone or testosterone. By clinical and endocrinological criteria, patients with acne who have polycystic ovaries appear to be a distinct sub-population of women with polycystic ovaries.     

The clinical evaluation of hirsutism

Hirsutism is a disorder of excess growth of terminal hairs in androgen-dependent areas in women. Other cutaneous conditions associated with androgen excess are androgenetic alopecia, acanthosis nigricans, and acne. Hirsutism is often associated with measurably elevated androgen levels, but not in all cases. Androgens in women arise from the ovary and adrenal glands, and peripherally from skin and fat. The most common cause of hirsutism is polycystic ovarian syndrome. Patients with "idiopathic" hirsutism have normal ovulatory cycles and androgen levels. Other causes are late onset congenital adrenal hyperplasia, Cushing's syndrome, and the HAIR-AN syndrome. Pituitary, ovarian, and adrenal tumors are important, but rare causes of hirsutism. A thorough history and examination are important. Laboratory investigation is essential in women with moderate to severe, sudden onset or rapidly progressing hirsutism. Identification of the underlying etiology does not alter management, but detects patients at risk for infertility, diabetes, cardiovascular disease and endometrial carcinoma.     

Androgen status in women with late onset or persistent acne vulgaris

The androgen status of fifty women with persistent or late onset acne vulgaris has been investigated. Abnormalities of serum androgens and sex hormone binding globulin (SHBG) alone or in combination were present in 52% of the patients. Elevated serum testosterone and low SHBG were the commonest abnormalities found (46%). Raised levels of serum dehydroepiandrosterone (DHA) and DHA sulphate were present in 16% and 12% of patients respectively, but elevation of one or other of these androgens was the sole abnormality in only 6% of patients. Serum prolactin was raised in 18% of patients but there was no correlation between prolactin and androgen levels. There was also no correlation between the androgen levels and the severity, distribution or pattern of acne or the presence of hirsuties or irregular periods. The hormonal abnormalities found in this group of patients with acne are similar to those seen in females with the polycystic ovary syndrome and idiopathic hirsuties.     

Therapie der Akne mit Antiandrogenen – Eine evidenzbasierte Übersicht

Background: Increased sebaceous gland activity with seborrhea is one of the major pathogenetic factors in acne. Antiandrogen treatment targets the androgen‐metabolizing follicular keratinocytes and the sebaceous gland leading to sebostasis, with a reduction of the sebum secretion rate of 12.5 – 65 %. Antiandrogens can be classified based on their mechanism of action as androgen receptor blockers, inhibitors of circulating androgens by affecting ovarian function (oral contraceptives), inhibitors of circulating androgens by affecting the pituitary (gonadotropin‐releasing hormone agonists and dopamine agonists in hyperprolactinemia), inhibitors of adrenal function, and inhibitors of peripheral androgen metabolism (5α‐reductase inhibitors, inhibitors of other enzymes). Methods: All original and review publications on antiandrogen treatment of acne as monotherapy or in combination included in the MedLine system were extracted by using the terms “acne”, “seborrhea”, “polycystic ovary syndrome”, “hyperandrog*”, and “treatment” and classified according to their level of evidence. Results: The combinations of cyproterone acetate (2 mg)/ethinyl estradiol (35 µg), drospirenone (3 mg)/ethinyl estradiol (30 µg), and desogestrel (25 µg)/ethinyl estradiol (40 µg) for 1 week followed by desogestrel (125 µg)/ethinyl estradiol (30 µg) for 2 weeks showed the strongest anti‐acne activity. Gestagens or estrogens as monotherapy, spironolactone, flutamide, gonadotropin‐releasing hormone agonists, and inhibitors of peripheral androgen metabolism cannot be endorsed based on current knowledge. Low dose prednisolone is only effective in late‐onset congenital adrenal hyperplasia and dopamine agonists only in hyperprolactinemia. Treatment with antiandrogens should only be considered if none of the contraindications exist. Conclusion: Antiandrogen treatment should be limited to female patients with additional signs of peripheral hyperandrogenism or hyperandrogenemia. In addition, women with late‐onset or recalcitrant acne who also desire contraception can be treated with antiandrogens as can those being treated with systemic isotretinoin. Antiandrogen treatment is not appropriate primary monotherapy for noninflammatory and mild inflammatory acne.     

Pyoderma gangrenosum,acne, suppurative hidradenitis (PASH) and polycystic ovary syndrome: Coincidentally or aetiologically connected?

The clinical triad of pyoderma gangrenosum, acne conglobata and hidradenitis suppurativa has been named PASH syndrome. Polycystic ovary syndrome (PCOS) is associated with hyperandrogenism and inflammation. Hidradenitis suppurativa, like acne vulgaris, may be a feature of hyperandrogenism. Obesity may be associated with both hidradenitis suppurativa and PCOS. We describe a possible association between PASH syndrome and PCOS.     

多囊卵巢综合征皮肤表现与生物学指标的相关性研究

目的：评价多囊卵巢综合征(PCOS)患者皮肤表现与血清总睾酮（TT）、游离睾酮指数（FAI）等生化指标的相关性。方法：检测45例PCOS和42例正常对照者的TT、FAI等激素水平。应用改良M-FG标准、痤疮评分系统和Ludwig方案对患者多毛症、痤疮和雄激素性脱发的严重程度进行评分和分级。结果： FAI对多毛症、痤疮和雄激素性脱发的敏感度和特异度分别为80.2%,68.9%,60.3%和41.5%,49.2%,36.8%,明显高于TT的20.6%,21.4%,29.8%和46.5%,44.8%,58.3%。结论：多毛症、痤疮和雄激素性脱发与FAI异常紧密相关,而与TT相关性较低,因此FAI可作为筛查高雄激素血症的重要指标。