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Should we use more hormonal therapy?

Presented by
Dr Julie Claire Harper, Dermatology & Skin Care Center, USA
AAD 2019
“At the moment, hormonal therapy in acne is considered an ‘alternative treatment’,” said Dr Julie Claire Harper (Dermatology & Skin Care Center, USA) [1]. However, both oral contraceptives and spironolactone have been shown to be effective in acne.

The oral contraceptives norgestimate, norethindrone acetate, and drospirenone have been FDA approval for women ≥15 years of age who desire contraception and are unresponsive to topical anti-acne medications. Unfortunately, all combined oral contraceptives (COCs) increase the risk of venous thromboembolism and breast cancer [2,3].

A Japanese study showed, that spironolactone is also effective in acne [4]. In total, 64 females completed the 20-week study. All of the patients exhibited clinical improvement, which was considered excellent in 53% and good in 47% of patients [4]. Due to the development of gynecomastia in 3 males, treatment was discontinued in all male subjects. The aldosterone antagonist spironolactone has no FDA approval for the treatment of acne. Side effects are dose-related. Routine potassium monitoring is unnecessary for healthy women taking spironolactone for acne as one study showed a risk of hyperkalaemia of 0.72% in this population [5]. “To be on the safe side, you should check potassium levels in older women or in those with renal or cardiac disease,” recommended Dr Harper.

Data from a Danish drug registry has shown that there is no evidence of increased risk of breast, uterus, or ovarian cancer with spironolactone use [6]. For acne, dosages between 25 and 200 mg spironolactone should be used. “I prefer a maximum dose of 100 mg because higher doses cause higher rates of side effects,” said Dr Harper. The concomitant use of oral contraceptive lessens menstrual irregularities, the most frequent side effect during spironolactone intake. In addition, pregnancy is prevented, which is mandatory as spironolactone can lead to feminisation of male foetuses.

With both COCs and spironolactone, it can take 3 months to see a meaningful response. “However, I think we should get to hormonal therapy faster, also to spare antibiotics,” concluded Dr Harper.

1. Harper JC. Session S043, AAD Annual Meeting, 1-5 March 2019, Washington DC, USA.
2. Reidl RL. J Obstet Gynecol Can 2011;33:1150-55.
3. Morch et al. New Engl J Med 2017;377:2228-2239.
4. Sato et al. Aesth Plast Surg 2006;30:689-694.
5. Plovanich M et al. JAMA Dermatol 2015;151:941-944.
6. Biggar RJ et al. Cancer Epidemiol 2013;37:870-875.

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