Effect of cyproterone acetate-ethinyl estradiol treatment on the proportions of linoleic and sebaleic acids in various skin surface lipid classes

The cutaneous effects of androgens and androgen-mediated sebum production and their pathophysiologic and therapeutic importance in acne vulgaris

Background: The recognition of an association between the development of acne vulgaris (AV) and pubertal hormonal changes during adolescence dates back almost 100 years. Since these formative observations, a significant role of circulating hormones in the pathophysiology of AV and other cutaneous disorders has been established.Aims: This review article aims to provide an overview of clinical and preclinical evidence supporting the influences of androgens on the skin and their therapeutic importance in AV pathophysiology.Results: The cutaneous effects of hormones are attributable, to a large extent, to the influence of steroid hormones, particularly androgens, on sebocyte development and sebum production in both sexes. Androgen-mediated excess sebum production is implicated as a necessary early step in AV pathophysiology and is therefore considered an important therapeutic target in AV treatment. Although the local production and/or activity of androgens within the skin is believed to be important in AV pathophysiology, it has received limited therapeutic attention.Conclusions: We have summarized the current evidence in support of the therapeutic benefits of targeted hormonal treatment to decrease androgen-stimulated sebum production for the effective and safe treatment of AV in both male and female patients.

Is hormonal treatment still an option in acne today?

Hormonal treatment is indicated in cases of papulopustular, nodular and conglobate acne in females with identified hyperandrogenism, in adult women who have monthly flare-ups and when standard therapeutic options are unsuccessful or inappropriate. This review summarizes the latest information on hormonal therapies including: combined oral contraceptives; anti-androgens, such as cyproterone acetate, spironolactone and flutamide; low-dose glucocorticoids and gonadotropin-releasing hormone agonists. It also shares the authors' recommendations for treatment based on the studies discussed here, and personal experience.

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.

Cutaneous lesions of the nose

Skin diseases on the nose are seen in a variety of medical disciplines. Dermatologists, otorhinolaryngologists, general practitioners and general plastic and dermatologic surgeons are regularly consulted regarding cutaneous lesions on the nose. This article is the second part of a review series dealing with cutaneous lesions on the head and face, which are frequently seen in daily practice by a dermatologic surgeon. In this review, we focus on those skin diseases on the nose where surgery or laser therapy is considered a possible treatment option or that can be surgically evaluated.

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.

Treatment of hirsutism and acne in hyperandrogenism

Hirsutism and acne are common and highly distressing complaints in women with polycystic ovary syndrome (PCOS). Drugs are only partially effective on terminalized hairs, and removal of these hairs is usually required. Therefore, management of hirsutism is generally based upon a dual approach: a pharmacological therapy to reduce androgen secretion and/or androgen action, and removal of terminal hair already present. Ovarian suppression of androgen secretion with oral contraceptives is widely used in these women, but its efficacy appears limited. The most effective medical therapy for hirsutism is by anti-androgen drugs. Electrolysis and laser photothermolysis are considered the most effective cosmetic procedures, although the effects of these methods should not be considered permanent. Acne may be treated with different tools, according to the severity of the condition and other characteristics of the patient. These tools include topical and systemic retinoids and antibiotics, topical antibacterial agents, androgen suppression by oral contraceptives, and anti-androgen drugs.

Hormonal Therapy for Acne Using Oral Contraceptive Pills

The etiology of acne vulgaris is multifactorial and complex. The four key factors involved in the development of acne include follicular plugging, inflammation, the presence and activity of Propionibacterium acnes, and sebum. Androgen hormones stimulate the sebaceous gland and promote sebum excretion. Therefore, therapies that have an overall antiandrogen effect, like combination oral contraceptive pills, may be useful in the management of acne vulgaris. Numerous combination oral contraceptive pills have been evaluated in the treatment of acne vulgaris and have been found to be effective. With a thorough understanding of their proper use and potential associated risks, these hormonal treatments may be prescribed safely and effectively to women with acne.

Acne: hormonal concepts and therapy

Acne vulgaris is the most common skin condition observed in the medical community. Although we know that hormones are important in the development of acne, many questions remain unanswered regarding the mechanisms by which hormones exert their effects. Androgens such as dihydrotestosterone (DHT) and testosterone, the adrenal precursor dehydroepiandrosterone sulfate (DHEAS), estrogens such as estradiol, and other hormones, including growth hormone and insulin-like growth factors (IGFs), may be important in acne. It is not known whether these hormones are taken up from the serum by the sebaceous gland, whether they are produced locally within the gland, or whether a combination of these processes is involved. Finally, the cellular and molecular mechanisms by which these hormones exert their influence on the sebaceous gland have not been fully elucidated. Hormonal therapy is an option in women with acne not responding to conventional treatment or with signs of endocrine abnormalities.

Comedone formation: Etiology, clinical presentation, and treatment

An important feature in the etiology of acne is the presence of pilosebaceous ductal hypercornification, which can be seen histologically as microcomedones (Fig 1) and clinically as blackheads, whiteheads, and other forms of comedones, such as macrocomedones. There is a significant correlation between the severity of acne and the number and size of microcomedones (follicular casts), the presence of which is a measure of comedogenesis. This correlation can be demonstrated by skin surface biopsy using cyanoacrylate gel. In this procedure, microcomedones are sampled by applying cyanoacrylate gel to the skin surface. A glass microscopic slide is then applied on top of the gel and pressed firmly onto the skin for 1 minute(1-3). The glass slide is gently removed, taking with it the upper part of the stratum corneum and microcomedones, which are then analyzed by low-power microscopy or digital image analysis.(1-3)

Endocrinological evaluation and hormonal therapy for women with difficult acne

Acne vulgaris is the most common skin condition observed in the medical community. Convention is to treat this condition with a combination of comedolytics, anti-inflammatory and antibacterial topical agents, or if indicated, oral antibiotics or retinoids. In addition to these therapies, hormonal therapy is potentially an option in women whose acne is not responding to conventional treatment or if signs of endocrine abnormalities are present. This paper focuses on the use of hormonal therapy in women with severe or recalcitrant acne. After a brief description of the pathogenesis of acne vulgaris, and the conventional treatment modalities, indications for hormonal therapy are discussed. This is followed by an outline of a suggested endocrine evaluation, and interpretation of the evaluation test results. Various options for hormonal therapy are then described, including a further discussion of oral contraceptives (OCs) in the treatment of acne.

The comedo skin reaction to radiotherapy

A 50-year-old man had a maxillectomy and post-operative radiotherapy for squamous carcinoma of the maxilla. The acute skin reaction merged at 2 months into a chronic comedo-type acneiform skin reaction in the irradiated area. Previous literature on this reaction to radiation is reviewed. The reaction is rare and occurs mostly in the head and neck area, more commonly in patients who have received acneigenic drugs, and with a latent period of between 2 weeks and 6 months from completion of radiotherapy. The pathogenesis of acne is discussed and a mechanism of post-irradiation acne is suggested.

Post-acne scarring: a short review of its pathophysiology

The onset of acne is an expected phenomenon in adolescence. However, its arrival produces long-term psychological and physical sequelae for the individual. A review of available data illustrates the pathophysiological sequence of the advent of post-acne scarring from its humble beginnings as a microscopic comedone to its eventual devastating end point of indented or exophytic scars. Acne scarring shows many different forms and is explainable by the depth and severity of the antecedent inflammation and the ability of the individual to heal these lesions. Post-acne scarring is debilitating and socially disabling for many and is the avoidable outcome of untreated or inadequately treated acne. Treatment will depend on the resultant scar topography.

Comedogenesis: some new aetiological, clinical and therapeutic strategies

Hypercornification is an early feature of acne and precedes inflammation. It is associated with ductal hyperproliferation and there are many controlling factors such as androgens, retinoids and cytokines. Cycling of normal follicles and of comedones may explain the natural resolution of comedones and, in the longer term, resolution of the disease itself. There is a need to tailor treatment according to comedonal type. Suboptimal therapy can often result from inappropriate assessments of comedones, especially microcomedones, missed comedones, sandpaper comedones, submarine comedones and macrocomedones. Macrocomedones can produce devastating acne flares, particularly if patients are inappropriately prescribed oral isotretinoin. Gentle cautery under topical local anaesthesia is a useful therapy in the treatment of such lesions. The newer retinoids and new formulations of all-trans-retinoic acid show a better benefit/risk ratio. Evidence-based studies are required to allow adequate comparisons.

Topical spironolactone reduces sebum secretion rates in young adults

The effects of topically applied spironolactone on the sebum secretion rates (SSR) of young adults were investigated. SSR was expressed as the ratio of wax esters/[cholesterol+cholesterol esters] (WE/[C+CE]) and the amount of sebaceous lipids (squalene, triacylglycerol and wax esters). Topical spironolactone 5% gel applied to the right cheeks of the subjects produced a significant reduction in the SSR at 12 weeks (4 weeks after termination of application), but not at 8 weeks (the end of treatment). Untreated "control" areas (the left cheeks of the subjects) showed no significant change during the study. None of the subjects experienced skin rash or signs of local irritation. This results suggests that topical spironolactone may be effective in the treatment of acne patients with high SSR.

Essential fatty acids in clinical dermatology

A deficiency of essential fatty acid intake can produce severe cutaneous abnormalities but is exceedingly rare in clinical practice. Recent research has shown that abnormalities in essential fatty acid metabolism may play a role in atopic eczema, acne, and psoriasis. Therapeutic innovations have already resulted from this knowledge, and more are likely to emerge.

Fatty acids of acylceramides from comedones and from the skin surface of acne patients and control subjects

Comedonal lipids and skin surface lipids were collected from six acne patients and surface lipids were collected from sex- and age-matched controls without acne. Six series of ceramides were found in each sample, the relative amounts of which were determined by thin-layer chromatography/photodensitometry. Acylceramides (ceramide 1) were isolated by preparative thin-layer chromatography and their ester-linked fatty acids were analyzed by gas-liquid chromatography. The comedonal acylceramides contained higher proportions of 16:0, 16:1 delta 6, and 18:1 delta 6 + delta 8 and much less linoleate (18:2 delta 9,12) than the acylceramides from the skin surface. In the surface lipids from legs, acylceramides from the acne patients contained less linoleate than the acylceramides from control subjects. Free fatty acids from the comedones were also isolated and analyzed, and had a composition very similar to the esterified fatty acids of comedonal acylceramides. The results confirm that fatty acids derived from sebum become incorporated into comedonal acylceramides, displacing linoleate, and show that this process even affects the acylceramides of surface epidermis, more so in acne patients than in normal subjects.

Skin lipids: an update

The stratum corneum lipids, responsible for the epidermal water barrier, consist principally of ceramides, cholesterol, cholesteryl sulfate, and free fatty acids. These lipids are arranged in multiple intercellular lamellae that provide an efficient water barrier because of the crystalline array of the straight and predominantly saturated lipid chains. Interlamellar linkages provided by lipids based on 30-carbon omega-hydroxyacids may be responsible for holding together the intercellular lamellae as well as for assembly of the lamellar granules of the granular cells. The normally ordered exfoliation of corneocytes as they arrive at the surface seems to require hydrolysis of the cholesteryl sulfate to free cholesterol. The sebaceous glands secrete continuously, producing sebum that consists predominantly of triglycerides, wax esters, and squalene. High rates of sebum production per sebocyte result in low levels of linoleate in the sebaceous esters, subjecting the follicular epithelium to essential fatty acid deficiency and the characteristic hyperkeratosis that results in comedo formation. Suppression of sebum production by drugs elevates sebum linoleate concentration and relieves follicular hyperkeratosis. Thus, sebum continues to be a prime suspect in the crime of acne. Low levels of sebaceous gland activity are not correlated with the occurrence of dry skin.