A Review of hormone-based therapies to treat adult acne vulgaris in women

Decoding Acne Vulgaris: Insights into Pathogenesis, Treatment Modalities, Diagnosis and Recent Advancements

BACKGROUND

Acne vulgaris, an alternative term for acne, is a persistent inflammatory skin condition affecting the pilosebaceous unit. Its development involves a combination of factors, including increased sebum production, changes in keratinization leading to comedone formation, colonization of hair follicles by Propionibacterium acnes (P. acnes), and the release of inflammatory mediators in the vicinity of the pilosebaceous unit.

OBJECTIVE

This review provides a concise overview of acne, covering its pathogenesis, epidemiology, diagnosis, treatment options, and recent advancements involved in acne.

DISCUSSION

Various therapeutic approaches, encompassing topical, systemic, combination, and hormonal treatments, are employed to address acne. Prolonged use of synthetic medications is common in acne therapy, but their potential for severe side effects prompts a preference for herbal- based treatments. Herbal remedies utilizing extracts of natural origin are considered safer due to their lower toxicity and reduced likelihood of adverse drug reactions. Recent advancements, particularly in personalized medicine and microbiome research have enhanced our understanding and opened new avenues for more effective management.

CONCLUSION

Decoding acne vulgaris has provided insights into its pathogenesis, treatment modalities, diagnostics, and recent advancements. Integrating synthetic and herbal treatments, personalized medicine, microbiome research, and advanced modeling techniques offer promising acne management strategies.

Hormonal Therapies for Acne: A Comprehensive Update for Dermatologists

INTRODUCTION

Acne impairs quality of life, often leads to permanent scars, and causes psychological distress. This review aims to update dermatologists on the Federal Drug Administration (FDA)-approved and off-label use of combined oral contraceptives (COC), clascoterone, spironolactone, and emerging hormonal therapies for acne treatment.

METHODS

We reviewed current literature on hormonal acne treatments and discussed common patient concerns, barriers to care, and individualized care needs.

RESULTS

Different brands and dosings of COC have generally similar efficacy in treating acne. Dermatologists should discuss contraceptive options and provide individualized shared decision-making with patients based on patient preferences, contraceptive needs, comorbidity profile, access, and cost. Spironolactone is an effective acne treatment with clinical trial data to support its use as a first-line acne treatment for women with acne. Potassium monitoring is of low value for patients on spironolactone unless patients have specific risk factors for hyperkalemia. Clascoterone is a safe and effective topical anti-androgen for the treatment of acne in men and women with limited systemic effects on reproductive hormones.

CONCLUSION

Hormonal therapies are essential strategies to treat acne. Clinicians should expand the use of existing and emerging hormone therapy as part of their acne treatment strategies.

A Prospective Randomized Trial Comparing Quality of Life in Adult Female Acne Treated with Azelaic Acid 15% Gel versus Oral Spironolactone

Introduction

In several countries, recent research has shown an increase in the prevalence of adult female acne (AFA), defined as the acne that appears in women aged over 25. This disease brings some particularities and challenges, such as a greater impact on quality of life (QoL) and chronicity. A negative impact on QoL has been observed, as well as anxiety, depression, anger, low self-esteem, and feelings of embarrassment and frustration.

Purpose

To quantify AFA's impact on QoL and the influence of two dermatological treatments.

Material and Methods

A prospective study including 40 women, aging from 25 to 44 years old, with mild-to-moderate acne was conducted. Participants underwent clinical, laboratory, and photographic evaluations. They were randomized into two treatment groups: group 1 - azelaic acid (AZA) 15% gel twice daily; group 2 - spironolactone (SPIRO) 100 mg/day and treated for 6 months. At baseline and at the end of treatments, a specific QoL questionnaire for acne, already translated and validated for Brazilian Portuguese (Acne-QoL-BR), was applied. It contains 19 questions allotted in four domains. Each item within a domain is scored from 0 to 6. The total score ranges from 0 to 114 and domains are distributed as follows: 0-30 (self-perception), 0-30 (role-emotional), 0-24 (role-social), 0-30 (acne-symptoms). Higher scores reflect better QoL.

Results

The mean age was 32.7 (SD: 5.42); 85% presented persistent acne. After treatment regardless of group, there was a significant improvement in total score and all domains' scores of acne QoL-BR (p < 0.001), with no difference between groups, despite one treatment being topical and the other systemic (p=0.918).

Conclusion

Acne-QoL-BR is a useful tool for quantifying the impact of acne and should be used as an efficacy parameter in clinical trials.

Improvement of adult female acne with a novel weekly oestradiol-loaded peel-off mask: a split-face placebo-controlled study

BACKGROUND

Adult female acne (AFA) is characterized by a relapsing eruption of acne in women aged ≥ 25 years. It can be slower to respond to traditional adolescent acne treatments. Usually, androgens promote acne by stimulating sebum production, while oestrogens have the -opposite effect by reducing sebum output when present in adequate quantities. Oestradiol is a female sex hormone that has its highest absolute serum levels and highest oestrogenic activity during the reproductive years. Peel-off facial masks have been suggested to intensify the effect of added active ingredients by forming an occlusive film after drying.

OBJECTIVES

To study the safety and efficacy of weekly topical oestradiol 0.05% in the treatment of AFA.

METHODS

Twenty women with AFA were subjected to once-weekly application of an oestradiol 0.05% mask or placebo mask to either side of their face for 8 weeks. An acne lesion count was performed at baseline, at each visit and 8 weeks post-treatment.

RESULTS

At the end of the treatment period, the treated side showed significant improvement in comedones, papules and pustules. Although lesion counts increased 2 months post-treatment, they remained significantly less common on the oestradiol-treated side compared with the side of the face treated with placebo. No side-effects were reported. Limitations included the small number of patients studied and the short follow-up period. The oestradiol effect was not studied at the cellular or molecular levels.

CONCLUSIONS

Topical oestradiol peel-off masks may be a promising convenient, safe and effective treatment for AFA.

Experts' view on the role of oestrogens in combined oral contraceptives: emphasis on oestetrol (E4)

Introduction

The evolution of contraception has been crucial for public health and reproductive well-being. Over the past 60 years, combined oral contraceptives (COCs) have remained an important part of the contraceptive landscape worldwide; continued development has worked toward maintaining efficacy and improving safety.

Methods

Seven global experts convened to discuss the clinical relevance of the oestrogen in COCs, focusing on the impact of the new oestrogen, oestetrol (E4). Participants then commented through an online forum on the summary content and other participants' feedback. We prepared this report to describe the experts' views, their follow-up from the open forum and the evidence supporting their views.

Results

Ethinylestradiol (EE) and oestradiol (E2) affect receptors similarly whereas E4 has differential effects, especially in the liver and breast. Adequate oestrogen doses in COCs ensure regular bleeding and user acceptability. EE and E4 have longer half-lives than E2; accordingly, COCs with EE and E4 offer more predictable bleeding than those with E2. Oestrogen type and progestin influence VTE risk; E2 poses a lower risk than EE; although promising, E4/DRSP VTE risk is lacking population-based data. COCs alleviate menstrual symptoms, impact mental health, cognition, libido, skin, and bone health.

Conclusion

Oestrogens play an important role in the contraceptive efficacy, bleeding patterns, and overall tolerability/safety of COCs. Recent studies exploring E4 combined with DRSP show promising results compared to traditional formulations, but more definitive conclusions await further research.

Correlating the Gut Microbiota and Circulating Hormones with Acne Lesion Counts and Skin Biophysical Features

Acne vulgaris is a common inflammatory condition that is multi-factorial and impacted by both intrinsic and extrinsic features. Several previous studies have assessed for correlations between factors such as circulating hormones, stress, or the microbiome. However, there have not been any correlations specifically against lesion counts or differentiating correlations between inflammatory and non-inflammatory lesion counts. Here, we correlate several factors against acne lesions. Twenty men and women with mild to moderate acne were recruited, and their hormonal levels and their gut microbiome were collected and correlated against their inflammatory and non-inflammatory lesions of acne. Facial non-inflammatory lesions were weakly correlated to sebum excretion rate and weakly inversely correlated to forehead and cheek hydration. We examined stress through the use of a normalized peak-to-trough ratio (higher numbers indicated less stress), which correlated with skin hydration and inversely correlated with sebum excretion rate. Sebum excretion rate was weakly correlated to testosterone levels, and facial hydration correlated with estradiol levels. Correlations with the gut microbiome showed differential correlations with inflammatory and non-inflammatory lesions, with Clostridium sp AF 23-8 correlating to inflammatory lesion counts, while Actinomyces naeslundii str Howell 279 correlated to non-inflammatory lesions. Overall, measures of stress and circulating hormones correlate to skin biophysical properties and acne lesion counts. Also, different gut bacteria correlate with either inflammatory or non-inflammatory lesion counts. We hope that our findings stimulate further work on the gut-mind-stress-skin axis within acne.

Combined oral contraceptives and mental health: Are adolescence and the gut-brain axis the missing links?

Combined oral contraceptives (containing synthetic forms of estradiol and progestins) are one of the most commonly used drugs among females. However, their effects on the gut-brain axis have not been investigated to a great extent despite clear evidence that suggest bi-directional interactions between the gut microbiome and endogenous sex hormones. Moreover, oral contraceptives are prescribed during adolescence, a critical period of development during which several brain structures and systems, such as hypothalamic-pituitary-gonadal axis, undergo maturation. Considering that oral contraceptives could impact the developing adolescent brain and that these effects may be mediated by the gut-brain axis, further research investigating the effects of oral contraceptives on the gut-brain axis is imperative. This article briefly reviews evidence from animal and human studies on the effects of combined oral contraceptives on the brain and the gut microbiota particularly during adolescence.

Androgen Receptor Inhibitors in the Treatment of Acne Vulgaris: Efficacy and Safety Profiles of Clascoterone 1% Cream

The purpose of this narrative review is to provide a summary of the clinical trials on the efficacy and safety of clascoterone 1% cream (Winlevi) to grant providers an understanding of which patients will benefit most from this novel topical antiandrogen medication. Clascoterone 1% cream (Winlevi) offers a new and exciting treatment approach for a difficult and common skin condition such as acne vulgaris. This topical androgen antagonist is the first of its kind but will hopefully provoke investigations into other androgen receptor antagonists with similar or better efficacy.

Androgens and acne: perspectives on clascoterone, the first topical androgen receptor antagonist

Introduction: Increased circulating androgens are key to the multifactorial pathogenesis of acne. Clascoterone is the first topical androgen antagonist developed to treat acne in both male and female patients and the first such agent to receive U.S. Food and Drug Administration (FDA) approval for treatment of acne. Androgens directly stimulate sebaceous gland growth and increased sebum production, creating a nourishing medium in which anaerobic Cutibacterium acnes (C. acnes) bacteria flourish. Androgens may directly contribute to inflammation in the sebaceous gland.Areas covered: In this review, the author assesses clascoterone's potential role in the management of acne. With a 4-ring backbone identical to dihydrotestosterone (DHT) and spironolactone, topically applied clascoterone binds androgen receptors (ARs) in the sebaceous glands and hair follicles, interfering with the pathogenesis of acne and reducing acne lesions with no reported systemic effects.Expert opinion: Phase III study results confirmed the safety and efficacy of topical clascoterone for acne, with considerable reductions in absolute non-inflammatory and inflammatory lesion counts at week 12. The approval of a first-in-class topical androgen antagonist is indeed a 'game-changer' for acne management. This topical agent is expected to be quickly adopted in clinical practice, likely within combination regiments, yet to be formally evaluated.

Clascoterone cream (1%) topical androgen receptor inhibitor for the treatment of acne in patients 12 years and older

INTRODUCTION

The efficacy of clascoterone cream was demonstrated in two phase three vehicle-controlled clinical trials that enrolled over 1,400 subjects. Its safety profile allowed it to be approved for treating patients as young as 12 years old. During clinical trials, the occurrence of local skin reactions (edema, erythema, pruritus, dryness) was similar to treatment with vehicle alone.

AREAS COVERED

All publications describing the clinical development of clascoterone cream (cortexolone 17α-propionate) are reviewed and discussed in relation to with existing topical and systemic therapies for acne vulgaris.

EXPERT OPINION

Clascoterone 1% cream is a novel first-in-class topical androgen receptor inhibitor for the treatment of acne vulgaris. Topical clascoterone 1% cream represents the first new type of therapy for acne treatment in almost 40 years and may become first-line therapy.

Pharmacologic Treatments for PCOS Patients

Polycystic ovarian syndrome is the most common endocrinopathy in reproductive-aged women and has a vast array of clinical manifestations. Common clinical presentations of the disorder include anovulatory infertility, menstrual disorders, cutaneous symptoms secondary to androgen excess, metabolic abnormalities and mental health issues. If the condition is left unaddressed or inadequately treated, long-term sequelae such as endometrial hyperplasia, diabetes mellitus and dyslipidemia may ensue, therefore it is imperative for clinicians to address each component of the syndrome. When initial lifestyle changes and dietary modifications do not suffice or fail, pharmacologic therapy should be considered, and when deemed appropriate treatment should be initiated. This review describes the pharmacologic options available to combat the various sequelae commonly seen in women with polycystic ovarian syndrome.

Vulval acne: a case series describing clinical features and management

Intermittent inflammation of the vulval pilosebaceous units is common and usually self-limiting, but some patients experience recurrent and more troublesome symptoms. There is a scarcity of information on this problem. We describe the clinical and histological features in these patients and the response to treatment. A retrospective, observational study of 16 patients with this phenomenon of recurrent, protracted folliculocentric inflammation of the vulval pilosebaceous unit was performed. Details on the clinical features, histology and response to treatment were collected. Mean age at presentation was 32 years (range 21-45). All patients reported recurrent painful papules and pustules on the labia majora and labia minora. Nine patients reported a cyclical pattern to the development of lesions, with premenstrual exacerbation being most common. Histological examination of these lesions showed a folliculocentric microabscess formation surrounded by an acute and chronic inflammatory cell infiltrate, with a focal foreign-body granulomatous reaction. All our patients responded well to tetracycline, antiandrogenic or retinoid therapy. We propose the term 'vulval acne' for this condition and propose a stepwise approach to its management. We hope to highlight this as a common but underreported entity.

Levonorgestrel vs combined oral contraceptive pills in treatment of female acne and hirsutism

Combined oral contraception was used in many studies for treatment of acne and hirsutism. However, levonorgestrel (LNG) alone has not been evaluated before. Our objective is to evaluate the efficacy of oral contraceptive (OC) pills containing LNG and ethinyl estradiol (EE) compared with LNG only for the treatment of acne and hirsutism in a randomized, controlled prospective clinical trial. Eighty females (20 with acne, 20 with hirsutism, and 40 healthy females) received LNG + EE or LNG only for 6 months. Assessment of acne by global acne grading system (GAGS) and hirsutism by modified Ferriman-Gallwey scale (MFGS) grading system and serum free testosterone was measured before and 6 months after treatment. Serum free testosterone was significantly higher before treatment in acne and hirsutism patients compared to control group (P < .000). In acne patients, after 6 months of treatment with LNG/EE, serum free testosterone, and (GAGS), were significantly decreased compared to LNG only (P < .000). In hirsutism group, after 6 months of treatment with LNG/EE, serum free testosterone and (MFGS), were nonsignificantly decreased compared to LNG only. OCs containing either LNG/EE or LNG seem to be effective and safe treatment for acne and hirsutism.

Pharmacogenomics/updated for precision medicine in dermatology

Pharmacogenomics, a key part of precision medicine, has the potential to tailor drug therapy with the high safety margins and optimized response. Before the Human Genome Project in 2003, articles on pharmacogenomics were limited. The last 15 years have seen significant growth in the field, with gene variant discoveries that play essential roles in individuals' drug response. Dermatology has started to take advantage of this information. This overview shows how pharmacogenomic databases have expanded in the treatment of skin diseases and provides a list of current dermatologic drugs with their FDA-approved biomarkers and clinical implementation.

Dermatologic Conditions in Transgender Populations

Transgender persons receiving gender-affirming hormone therapy and procedures may face specific skin conditions. Skin diseases in transgender patients often are underdiagnosed and underrecognized despite their important impact on quality of life and mental health. This article discusses pathophysiology, diagnosis, and treatment of common skin diseases in the transgender populations. For transmasculine patients, conditions include acne vulgaris and male pattern hair loss. For transfeminine patients, conditions include hirsutism, pseudofolliculitis barbae, and melasma. Postprocedural keloids and other cutaneous complications are discussed. Unique aspects of skin health in transgender persons should be considered in the context of multidisciplinary gender-affirming care.

Screening and evaluation of antiviral compounds against Equid alpha-herpesviruses using an impedance-based cellular assay

Equid alpha-herpesviruses (EHV) are responsible for different diseases in equine population. EHV-1 causes respiratory diseases, abortions and nervous disorders, EHV-4 causes respiratory diseases and sporadic abortion, while EHV-3 is responsible of equine coital exanthema. In view of the lack of efficacy of vaccines against EHV-1 and EHV-4 and in the absence of vaccines against EHV-3, the use of antiviral treatment is of great interest. In this study, we documented the interest of the Real-Time Cell Analysis (RTCA) technology to monitor the cytopathic effects induced by these viruses on equine dermal cells, and established the efficacy of this method to evaluate the antiviral effect of aciclovir (ACV) and ganciclovir (GCV). In addition, the RTCA technology has also been found appropriate for the high-throughput screening of small molecules against EHV, allowing the identification of spironolactone as a novel antiviral against EHV.

A review of diagnosis and treatment of acne in adult female patients

This review focuses on the treatment options for adult female patients with acne. Acne in adult female patients may start during adolescence and persist or have an onset in adulthood. Acne has various psychosocial effects that impact patients’ quality of life. Treatment of acne in adult women specifically has its challenges due to the considerations of patient preferences, pregnancy, and lactation. Treatments vary widely and treatment should be tailored specifically for each individual woman. We review conventional therapies with high levels of evidence, additional treatments with support from cohort studies and case reports, complementary and/or alternative therapies, and new agents under development for the treatment of patients with acne.

Associations Between Type and Route of Hormone Use on Urinary Incontinence and Pelvic Organ Prolapse in Premenopausal and Postmenopausal Women

OBJECTIVE

The aim of this study was to evaluate the associations between type and route of hormone use and urinary incontinence (UI) and pelvic organ prolapse (POP) in premenopausal and postmenopausal women.

METHODS

The authors used the National Health and Nutritional Examination Survey database for data from 2005-2006, 2007-2008, 2009-2010, and 2011-2012. Seven thousand sixty-six of the women included were premenopausal, and 5387 were postmenopausal. Premenopausal women were younger than 51 years and reported menstrual periods in the last 12 months. Postmenopausal women reported being in natural or surgical menopause. Urinary incontinence was defined as experiencing urinary leakage "less than once a month" or more. Pelvic organ prolapse was defined as an affirmative response to "experience bulging in the vaginal area." Hormone route and use were stratified in years. Pearson χ and Pearson correlations were used, with P < 0.05 considered significant.

RESULTS

In premenopausal women, birth control pills, estrogen/progestin pills, and estrogen-only patch use are associated with UI (P < 0.05). Birth control pills are associated with both UI and POP in premenopausal women (P < 0.05 for UI and POP). In postmenopausal women, estrogen-only pills, and estrogen/progestin pill use are associated with UI (P < 0.05). Birth control pill use is associated with POP in postmenopausal women (P = 0.029). Neither estrogen patch nor estrogen/progestin patch is associated with UI or POP in postmenopausal women.

CONCLUSIONS

Type and route of hormone use have varied associations with UI and POP in premenopausal and postmenopausal women. Prospective studies are needed to further evaluate the effect of hormone type and route on UI and POP in premenopausal and postmenopausal women.