Rebecca returns after she has been seen by her gynecologist several months later. Her diagnosis of PCOS is confirmed based on Rotterdam criteria. She has been taking her spironolactone daily, as well as applying topical treatment for her acne. In follow-up, she shares with you that her acne has finally cleared up and how happy she is. She is much more confident.
She tells you that she is surprised not all acne are treated the same way, “I always thought that acne was acne, and the treatment was the same for everyone”. In her case, her management was personalized based on her clinical presentation and underlying cause. It is the key of successfully treating acne.
Objectives:
List some of the cutaneous manifestations of PCOS (e.g. acne, excess hair growth, pattern hair loss).
Discuss topical and systemic management of acne vulgaris, specifically focusing on anti-androgenic therapy.
Discuss indications and contraindications for combined oral contraceptives.
Understand the role of spironolactone in treating hormonal acne and its common side effects.
Appreciate comedolytic vs anti-inflammatory treatments for acne vulgaris.
Take home messages:
There is a broad differential diagnosis for acneiform eruptions. If acne is the most likely cause, it is important to determine the type of acne and its severity.
A complete history, including signs of hyperandrogenism in females, diet, psychological impact, prior acne treatments and adherence should be explored.
For acne from PCOS, anti-androgenic therapy should be considered, including combined oral contraceptives and spironolactone, and referral to gynecology for management of PCOS is crucial.
Prior to prescribing combined oral contraceptives for acne, patient should be evaluated for contraindications.
Topical treatments for acne should be selected based on a patient’s clinical presentation (mostly non-inflammatory comedones and/or inflammatory lesions) and counselling regarding the proper use of topical therapy is crucial to achieve optimal treatment outcome.
References
Biggar RJ, Andersen EW, Wohlfahrt J, Melbye M. Spironolactone use and the risk of breast and gynecologic cancers. Cancer Epidemiol. 2013;37(6):870-5.
Consensus IA. Acne in India: Guidelines for management. Indian J Dermatol Venereol Leprol. 2009 Jan;75:1.
Shaw JC, White LE. Long-term safety of spironolactone in acne: results of an 8-year followup study. Journal of cutaneous medicine and surgery. 2002;6(6):541-5.
Zaenglein AL, Pathy AL, Schlosser BJ, Alikhan A, Baldwin HE, Berson DS, et al. Guidelines of care for the management of acne vulgaris. Journal of the American Academy of Dermatology. 2016;74(5):945-73.e33.
