Efficacy of a low-dose oral contraceptive containing 20 microg of ethinyl estradiol and 100 microg of levonorgestrel for the treatment of moderate acne: A randomized, placebo-controlled trial

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.

Guidelines of care for the management of acne vulgaris

BACKGROUND

Acne vulgaris commonly affects adults, adolescents, and preadolescents aged 9 years or older.

OBJECTIVE

The objective of this study was to provide evidence-based recommendations for the management of acne.

METHODS

A work group conducted a systematic review and applied the Grading of Recommendations, Assessment, Development, and Evaluation approach for assessing the certainty of evidence and formulating and grading recommendations.

RESULTS

This guideline presents 18 evidence-based recommendations and 5 good practice statements. Strong recommendations are made for benzoyl peroxide, topical retinoids, topical antibiotics, and oral doxycycline. Oral isotretinoin is strongly recommended for acne that is severe, causing psychosocial burden or scarring, or failing standard oral or topical therapy. Conditional recommendations are made for topical clascoterone, salicylic acid, and azelaic acid, as well as for oral minocycline, sarecycline, combined oral contraceptive pills, and spironolactone. Combining topical therapies with multiple mechanisms of action, limiting systemic antibiotic use, combining systemic antibiotics with topical therapies, and adding intralesional corticosteroid injections for larger acne lesions are recommended as good practice statements.

LIMITATIONS

Analysis is based on the best available evidence at the time of the systematic review.

CONCLUSIONS

These guidelines provide evidence-based recommendations for the management of acne vulgaris.

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.

Androgens in women: Hormone-modulating therapies for skin disease

Androgen-mediated cutaneous disorders (AMCDs) in women, including acne, hirsutism, and female pattern hair loss, can be treated with hormone-modulating therapies. In the second article in this Continuing Medical Education series, we discuss the hormone-modulating therapies available to dermatologists for the treatment of AMCDs, including combined oral contraceptives, spironolactone, finasteride, dutasteride, and flutamide. Available hormone-modulating treatments used for each AMCDs are reviewed, along with mechanisms of androgen modulation, safety profile, contraindications, monitoring parameters, and evidence of efficacy. Medications discussed include those that are approved by the US Food and Drug Administration for certain AMCDs and some that are used off-label. Despite the ubiquity of hormone-modulating therapies used for AMCDs, this review highlights the need for more rigorous studies to evaluate these therapies for acne, hirsutism, and female pattern hair loss.

Endocrine disorders and hormonal therapy for adolescent acne

PURPOSE OF REVIEW

Acne vulgaris is a global disease with increasing prevalence in adolescents. It has a profound impact on their quality of life, especially when endocrine disorders are also involved. Recent concerns regarding antibiotic stewardship, failures with antibiotic usage, and the development of antibiotic-resistant Propionibacterium acnes have led clinicians to consider other therapeutic options for acne treatment. The present review explores hormonal therapies for the treatment of acne vulgaris.

RECENT FINDINGS

There are now four different combined oral contraceptive pills that are FDA approved for the treatment of acne since its first introduction in 1960. Recent literature has provided more information on the efficacy of different generations of combined oral contraceptive pills, their side-effects, and cancer risks. Furthermore, spironolactone has been gaining wider use among dermatologists in adolescents with endocrine dysfunction. New diagnostic guidelines and treatment recommendations have also been suggested.

SUMMARY

Hormonal therapies are effective and well tolerated options for the treatment of acne vulgaris in adolescents with and without endocrine disorders. They can be used as monotherapy or in conjunction with benzoyl peroxide, topical retinoic acid, or antibiotics.

Spironolactone for the treatment of acne in women, a retrospective study of 110 patients

BACKGROUND

There is limited evidence on the safety and efficacy of spironolactone in the treatment of women with acne. Thus, for many dermatologists spironolactone remains an alternative rather than a mainstay treatment for female patients with acne.

METHODS

An electronic medical records search tool was used to select data from a group of women who received spironolactone to treat acne and were evaluated with the comprehensive acne severity scale (CASS) before treatment and at all follow-up visits. Data points were collected for CASS scores at each follow-up visit, concurrent and previous treatments, and side effects. These data points were used to draw conclusions about the safety and efficacy of spironolactone in this patient population.

RESULTS

There were 110 patients that met all eligibility requirements. Of these, 94 patients saw an improvement in their CASS score and 61 patients completely cleared their score to 0. There were 16 patients who did not improve and six who relapsed after initial improvement. The women saw an average improvement in their acne by 73.1% for the face, 75.9% for the chest, and 77.6% for the back. Fifty-one women experienced side effects, but only six found them bothersome enough to stop taking spironolactone.

CONCLUSION

A majority of women in this study saw a dramatic improvement in their acne while treated with spironolactone. There were low rates of relapse or discontinuation of the medication. To further promote the use of spironolactone as a first-line systemic treatment for women with acne, there must be more prospective controlled trials.

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

Hormone-based therapies including combined oral contraceptive medications and spironolactone are considered effective therapies to treat adult acne in women. Our objective is to provide a concise and comprehensive overview of the types of hormonal therapy that are available to treat acne and comment on their efficacy and safety profiles for clinical practice. A systematic search using the PubMed Database was conducted to yield 36 relevant studies for inclusion in the review and several conclusions were drawn from the literature. Treatment with oral contraceptive pills leads to significant reductions in lesion counts across all lesion types compared with placebo. There were no consistent differences in efficacy between the different combined oral contraceptive formulations. In terms of risk, oral contraceptive pill users had three-times increased odds of venous thromboembolism versus non-users according to a recent meta-analysis (95% confidence interval 2.46-2.59). Data on oral contraceptive pill use and breast cancer risk are conflicting but individual patient risk factors and histories should be discussed and considered when prescribing these medications. However, use of these medications does confer measurable protection from endometrial and ovarian cancer. Spironolactone was also shown to be an effective alternative treatment with good tolerability. Combined oral contraceptive medications and spironolactone as adjuvant and monotherapies are safe and effective to treat women with adult acne. However, appropriate clinical examinations, screening, and individual risk assessments particularly for venous thromboembolism risk must be conducted prior to initiating therapy.

Optimizing Non-Antibiotic Treatments for Patients with Acne: A Review

Acne is a very common non-infectious skin condition that is frequently treated in dermatological practices. Because acne is often chronic and may persist for years, safe and effective long-term maintenance therapy is often required. Given the increasing frequency of antibiotic-resistant bacteria and the gravity of the consequences of this trend, it behooves dermatologists to maximize use of non-antimicrobial therapy when treating acne. In this review of the literature we present data regarding the efficacy and appropriate use of non-antimicrobial treatments for acne. A variety of topical and oral treatment options exist that can be used in a step-wise manner according to the patients’ severity and therapeutic response. Non-antimicrobial treatments can be highly efficacious at controlling acne, especially when used as maintenance therapy. While antibiotics have a role in acne treatment, they should not be used as monotherapy, and lengthy courses of antibiotic use are discouraged.

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.

Efficacy and safety of a 24-day regimen of drospirenone-containing combined oral contraceptive in Korean women

This study assesses the efficacy and safety of a 24-day regimen of drospirenone-containing combined oral contraceptive, and demonstrates that it is an effective and safe option for contraception, releasing symptom of premenstrual dysphoric disorder and acne in Korean women.

Evidence-based approach to cutaneous hyperandrogenism in women

Hirsutism, acne, and androgenetic alopecia are classically considered signs of cutaneous hyperandrogenism (CHA). These common skin findings have significant impacts on the quality of patients' lives and pose the diagnostic challenge of excluding underlying disorders. Many with CHA have normal serum androgen levels. Hirsutism is more strongly associated with hyperandrogenism than are acne or androgenetic alopecia. Variable association of CHA with hyperandrogenemia results from the complexity of the underlying pathophysiology, including factors local to the pilosebaceous unit. CHA often occurs in the setting of polycystic ovary syndrome, the most common disorder of hyperandrogenism, but can also present in uncommon conditions, including nonclassic adrenal hyperplasia and androgen-producing tumors. A thorough history and full skin examination are important to guide appropriate diagnostic evaluation. Oral contraceptive pills with or without antiandrogens can provide therapeutic benefit for hirsutism and acne. Medical options for androgenetic alopecia remain limited. Multidisciplinary approaches may be needed given endocrine, metabolic, reproductive, and psychiatric disorders associated with CHA. More high-quality studies into the mechanisms of CHA and the benefits of antiandrogenic therapies are needed. We provide an evidence-based review of key diagnostic and therapeutic considerations in the treatment of women with CHA.

Carrier-based drug delivery system for treatment of acne

Approximately 95% of the population suffers at some point in their lifetime from acne vulgaris. Acne is a multifactorial disease of the pilosebaceous unit. This inflammatory skin disorder is most common in adolescents but also affects neonates, prepubescent children, and adults. Topical conventional systems are associated with various side effects. Novel drug delivery systems have been used to reduce the side effect of drugs commonly used in the topical treatment of acne. Topical treatment of acne with active pharmaceutical ingredients (API) makes direct contact with the target site before entering the systemic circulation which reduces the systemic side effect of the parenteral or oral administration of drug. The objective of the present review is to discuss the conventional delivery systems available for acne, their drawbacks, and limitations. The advantages, disadvantages, and outcome of using various carrier-based delivery systems like liposomes, niosomes, solid lipid nanoparticles, and so forth, are explained. This paper emphasizes approaches to overcome the drawbacks and limitations associated with the conventional system and the advances and application that are poised to further enhance the efficacy of topical acne formulations, offering the possibility of simplified dosing regimen that may improve treatment outcomes using novel delivery system.

Nonclassic congenital adrenal hyperplasia and the heterozygote carrier

This article discusses the difficulty of differentiating three causes of adult androgen excess including nonclassic congenital adrenal hyperplasia caused by 21-hydroxylase deficiency, polycystic ovarian syndrome and heterozygote carrier of CYP21 mutations based on clinical findings. It also reviews the screening modalities that discriminate patients with nonclassic congenital adrenal hyperplasia and the heterozygote carrier of CYP21 mutations from the normal population. In addition, the current management of hyperandrogenism and ovulatory dysfunction in these patients is described.

Harnessing the power of crowds: crowdsourcing as a novel research method for evaluation of acne treatments

BACKGROUND

Crowdsourcing is a novel process of data collection that can provide insight into the effectiveness of acne treatments in real-world settings. Little is known regarding the feasibility of crowdsourcing as a means of collecting dermatology research data, the quality of collected data, and how the data compare to the published literature.

OBJECTIVE

The objective of this analysis is to compare acne data collected from a medical crowdsourcing site with high-quality controlled studies from peer-reviewed medical literature.

METHODS

Crowdsourced data was collected from 662 online acne patients. Online patients reported data in a Likert-type format to characterize their symptom severity (740 total responses) and their treatment outcomes (958 total responses). The crowdsourced data were compared with meta-analyses and reviews on acne treatment from August 20, 2010 to August 20, 2011.

RESULTS

We compared topical, oral systemic, alternative, phototherapy, and physical acne treatments of crowdsourced data to published literature. We focused on topical tretinoin due to the large number of online patient responses. While approximately 80% of tretinoin users observed clinical improvement after a 12-week treatment period in clinical trials, 46% of online users reported improvement in an unspecified time period. For most topical treatments, medication with high efficacy in clinical trials did not produce high effectiveness ratings based on the crowdsourced online data.

CONCLUSION

While limitations exist with the current methods of crowdsourced data collection, with standardization of data collection and use of validated instruments, crowdsourcing will provide an important and valuable platform for collecting high-volume patient data in real-world settings.

Combined oral contraceptive pills for treatment of acne

BACKGROUND

Acne is a common skin disorder among women. Although no uniform approach to the management of acne exists, combination oral contraceptives (COCs), which contain an estrogen and a progestin, often are prescribed for women.

OBJECTIVES

To determine the effectiveness of combined oral contraceptives (COCs) for the treatment of facial acne compared to placebo or other active therapies.

SEARCH METHODS

In January 2012, we searched for randomized controlled trials of COCs and acne in the computerized databases of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, POPLINE, and LILACS. We also searched for clinical trials in ClinicalTrials.gov and the International Clinical Trials Registry Platform (ICTRP) (Aug 2011). For the initial review, we wrote to researchers to seek any unpublished or published trials that we might have missed.

SELECTION CRITERIA

We considered randomized controlled trials reported in any language that compared the effectiveness of a COC containing an estrogen and a progestin to placebo or another active therapy for acne in women.

DATA COLLECTION AND ANALYSIS

We extracted data on facial lesion counts, both total and specific (i.e., open or closed comedones, papules, pustules and nodules); acne severity grades; global assessments by the clinician or the participant, and discontinuation due to adverse events. Data were entered and analyzed in RevMan. For continuous data, we calculated the mean difference (MD) and 95% confidence interval (CI). For dichotomous data, we calculated the Peto odds ratio (OR) and 95% CI.

MAIN RESULTS

The review includes 31 trials with 12,579 participants. Of 24 comparisons made, 6 compared a COC to placebo, 17 different COCs, and 1 compared a COC to an antibiotic. Of nine placebo-controlled trials with data for analysis, all showed COCs reduced acne lesion counts, severity grades and self-assessed acne compared to placebo. A levonorgestrel-COC group had fewer total lesion counts (MD -9.98; 95% CI -16.51 to -3.45), inflammatory and non-inflammatory lesion counts, and were more likely to have a clinician assessment of clear or almost clear lesions and participant self-assessment of improved acne lesions. A norethindrone acetate COC had better results for clinician global assessment of no acne to mild acne (OR 1.86; 95% CI 1.32 to 2.62). In two combined trials, a norgestimate COC showed reduced total lesion counts (MD-9.32; 95% CI -14.19 to -4.45), reduced inflammatory lesion and comedones counts, and more with clinician assessment of improved acne. For two combined trials of a drospirenone COC, the investigators' assessment of clear or almost clear skin favored the drospirenone group (OR 3.02; 95% CI 1.99 to 4.59). In one trial, the drospirenone-COC group showed greater (more positive) percent changes for total lesion count (MD 29.08; 95% CI 3.13 to 55.03), inflammatory and non-inflammatory lesion counts, and papule and closed comedone counts. A dienogest-COC group had greater percentage decreases in total lesion count (MD -15.30; 95% CI -19.98 to -10.62) and inflammatory lesion count, and more women assessed with overall improvement of facial acne. A CMA-COC group had more 'responders,' those with 50% or greater decrease in facial papules and pustules (OR 2.31; 95% CI 1.50 to 3.55)Differences in the comparative effectiveness of COCs containing varying progestin types and dosages were less clear, and data were limited for any particular comparison. COCs that contained chlormadinone acetate or cyproterone acetate improved acne better than levonorgestrel. A COC with cyproterone acetate showed better acne outcomes than one with desogestrel, but the studies produced conflicting results. Likewise, levonorgestrel showed a slight improvement over desogestrel in acne outcomes, but results were not consistent. A drospirenone COC appeared to be more effective than norgestimate or nomegestrol acetate plus 17β-estradiol but less effective than cyproterone acetate.

AUTHORS' CONCLUSIONS

This update yielded six new trials but no change in conclusions. The six COCs evaluated in placebo-controlled trials are effective in reducing inflammatory and non-inflammatory facial acne lesions. Few important and consistent differences were found between COC types in their effectiveness for treating acne. How COCs compare to alternative acne treatments is unknown since only one trial addressed this issue. The use of standardized methods for assessing acne severity would help in synthesizing results across trials as well as aid in interpretation.

Combined oral contraceptive pills for treatment of acne

BACKGROUND

Acne is a common skin disorder among women. Although no uniform approach to the management of acne exists, combination oral contraceptives (COCs), which contain an estrogen and a progestin, often are prescribed for women.

OBJECTIVES

To determine the effectiveness of combined oral contraceptives (COCs) for the treatment of facial acne compared to placebo or other active therapies.

SEARCH METHODS

In January 2012, we searched for randomized controlled trials of COCs and acne in the computerized databases of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, POPLINE, and LILACS. We also searched for clinical trials in ClinicalTrials.gov and the International Clinical Trials Registry Platform (ICTRP) (Aug 2011). For the initial review, we wrote to researchers to seek any unpublished or published trials that we might have missed.

SELECTION CRITERIA

We considered randomized controlled trials reported in any language that compared the effectiveness of a COC containing an estrogen and a progestin to placebo or another active therapy for acne in women.

DATA COLLECTION AND ANALYSIS

We extracted data on facial lesion counts, both total and specific (i.e., open or closed comedones, papules, pustules and nodules); acne severity grades; global assessments by the clinician or the participant, and discontinuation due to adverse events. Data were entered and analyzed in RevMan. For continuous data, we calculated the mean difference (MD) and 95% confidence interval (CI). For dichotomous data, we calculated the Peto odds ratio (OR) and 95% CI.

MAIN RESULTS

The review includes 31 trials with 12,579 participants. Of 24 comparisons made, 6 compared a COC to placebo, 17 different COCs, and 1 compared a COC to an antibiotic. Of nine placebo-controlled trials with data for analysis, all showed COCs reduced acne lesion counts, severity grades and self-assessed acne compared to placebo. A levonorgestrel-COC group had fewer total lesion counts (MD -9.98; 95% CI -16.51 to -3.45), inflammatory and non-inflammatory lesion counts, and were more likely to have a clinician assessment of clear or almost clear lesions and participant self-assessment of improved acne lesions. A norethindrone acetate COC had better results for clinician global assessment of no acne to mild acne (OR 1.86; 95% CI 1.32 to 2.62). In two combined trials, a norgestimate COC showed reduced total lesion counts (MD-9.32; 95% CI -14.19 to -4.45), reduced inflammatory lesion and comedones counts, and more with clinician assessment of improved acne. For two combined trials of a drospirenone COC, the investigators' assessment of clear or almost clear skin favored the drospirenone group (OR 3.02; 95% CI 1.99 to 4.59). In one trial, the drospirenone-COC group showed greater (more positive) percent changes for total lesion count (MD 29.08; 95% CI 3.13 to 55.03), inflammatory and non-inflammatory lesion counts, and papule and closed comedone counts. A dienogest-COC group had greater percentage decreases in total lesion count (MD -15.30; 95% CI -19.98 to -10.62) and inflammatory lesion count, and more women assessed with overall improvement of facial acne. A CMA-COC group had more 'responders,' those with 50% or greater decrease in facial papules and pustules (OR 2.31; 95% CI 1.50 to 3.55)Differences in the comparative effectiveness of COCs containing varying progestin types and dosages were less clear, and data were limited for any particular comparison. COCs that contained chlormadinone acetate or cyproterone acetate improved acne better than levonorgestrel. A COC with cyproterone acetate showed better acne outcomes than one with desogestrel, but the studies produced conflicting results. Likewise, levonorgestrel showed a slight improvement over desogestrel in acne outcomes, but results were not consistent. A drospirenone COC appeared to be more effective than norgestimate or nomegestrol acetate plus 17β-estradiol but less effective than cyproterone acetate.

AUTHORS' CONCLUSIONS

This update yielded six new trials but no change in conclusions. The six COCs evaluated in placebo-controlled trials are effective in reducing inflammatory and non-inflammatory facial acne lesions. Few important and consistent differences were found between COC types in their effectiveness for treating acne. How COCs compare to alternative acne treatments is unknown since only one trial addressed this issue. The use of standardized methods for assessing acne severity would help in synthesizing results across trials as well as aid in interpretation.

A narrative review of medical, chiropractic, and alternative health practices in the treatment of primary dysmenorrhea

OBJECTIVE

Primary dysmenorrhea and related issues are discussed as they influence the gynecological and social health of females during adolescence, adulthood, and senior maturity. Health practitioners are exposed to multiple approaches towards the management of menstrual pain. Clinical and social viewpoints target the causation, development, diagnosis, manifestation and management of primary dysmenorrhea. This narrative review includes the topic of the doctor-patient relationship in efforts of cultivating effectively communicative health practitioners. Controversial topics related to primary dysmenorrhea and the quality of life for women are addressed.

DATA SOURCES

A search for literature reviews, case studies, laboratory research, and clinical trials from 1985-2004 was performed using the MEDLINE database. Sources of additional information included textbooks, national organizational literature and contemporary articles.

DISCUSSION

Menstrual pain is a prevalent experience yet it is socially taboo for conversation; as such, it poses a hindrance to its management. The communication between the doctor and patient is a critical barrier point between establishing a diagnosis and determining an appropriate treatment plan. A multi-disciple treatment plan varies as much as patients themselves vary in personal experiences, needs, and preferences.

CONCLUSIONS

Medicinal prophylactics, physical therapeutics, non-acidic diets, herbal supplements, eastern therapies and the chiropractic manual adjustments of the spine are effective methods for the management of primary dysmenorrhea. The non-invasive management of primary dysmenorrhea includes the chiropractic adjustment with complimentary modalities, and other alternative health care practices. Medicinal prophylactics are invasive and pose a higher risk to long-term chemical exposure, side effects or irreversible conditions.

Management strategies for acne vulgaris

CLINICAL QUESTION

What are the most effective treatment(s) for mild, moderate, severe, and hormonally driven acne?

RESULTS

Mild acne responds favorably to topical treatments such as benzoyl peroxide, salicylic acid, and a low-dose retinoid. Moderate acne responds well to combination therapy comprising-topical benzoyl peroxide, antibiotics, and/or retinoids, as well as oral antibiotics in refractory cases and oral contraceptive pills for female acne patients. Severe nodulocystic acne vulgaris responds best to oral isotretinoin therapy. In female patients with moderate to severe acne, facial hair, loss of scalp hair and irregular periods, polycystic ovarian syndrome should be considered and appropriate treatment with hormonal modulation given. Adjunctive procedures can also be considered for all acne patients.

IMPLEMENTATION

PITFALLS TO AVOID WHEN TREATING ACNE: treatment of acne in women of child-bearing age; familiarization of all acne treatments in order to individualize management for patients; indications for specialist referral.

Interaction and efficacy of Keigai-rengyo-to extract and acupuncture in male patients with acne vulgaris: a study protocol for a randomized controlled pilot trial

BACKGROUND

In consideration of patients seeking to use traditional Chinese medicine, an evidence-based potentiality for safe and effective use of herbal medicine and acupuncture in treatment of acne vulgaris has been suggested. However, despite common use of a combination of herbal medicine and acupuncture in clinical practice, the current level of evidence is insufficient to draw a conclusion for an interaction and efficacy of herbal medicine and acupuncture. Therefore, considering these methodological flaws, this study was designed to assess the interaction and efficacy of an available herbal medicine, Keigai-rengyo-to extract (KRTE), and acupuncture for treatment of acne using the 2 × 2 factorial design and the feasibility of a large clinical trial.

METHODS/DESIGN

A randomized, assessor single blinded, 2 × 2 factorial pilot trial will be conducted. Forty four participants with acne vulgaris will be randomized into one of four groups: waiting list group (WL), KRTE only group (KO), acupuncture only group (AO), and KRTE and acupuncture combined treatment group (KA). After randomization, a total of 8 sessions of acupuncture treatment will be performed twice a week in the AO- and KA groups, respectively. Patients in the KO- and KA groups will be prescribed KRTE 3 times a day at a dose of 7.4 g after meals for 4 weeks. The following outcome measurements will be used in examination of subjects: the mean percentage change and the count change of inflammatory and non-inflammatory acne lesions, the Skindex 29, visual analogue scale (VAS) and investigator global assessment (IGA) from baseline to the end of the trial.

TRIAL REGISTRATION

The trial is registered with the Clinical Research Information Service (CRiS), Republic of Korea: KCT0000071.

Efficacy and safety of combined ethinyl estradiol/drospirenone oral contraceptives in the treatment of acne

Acne is a common disorder affecting the majority of adolescents and often extends into adulthood. The central pathophysiological feature of acne is increased androgenic stimulation and/or end-organ sensitivity of pilosebaceous units leading to sebum hypersecretion and infundibular hyperkeratinization. These events lead to Propionibacterium acnes proliferation and subsequent inflammation. Hormonal therapy, including combined oral contraceptives (OCs), can attenuate the proximate androgenic trigger of this sequence. For many women, hormonal therapy is a rational option for acne treatment as it may be useful across the spectrum of severity. Drospirenone (DRSP) is a unique progestin structurally related to spironolactone with progestogenic, antimineralocorticoid, and antiandrogenic properties. It is available in 2 combined OC preparations (30 μg EE/3 mg DRSP; Yasmin^® in a 21/7 regimen; and 20 μg EE/3 mg DRSP; Yaz^® in a 24/4 regimen). These preparations are bereft of the fluid retentional side effects typical of other progestins and their safety has been demonstrated in large epidemiological studies in which no increased risk of vascular thromboembolic disease or arrhythmias was observed. In acne, the efficacy of DRSP-containing OCs has been shown in placebo-controlled superiority trials and in active-comparator non-inferiority trials.

Combined oral contraceptive pills for treatment of acne

BACKGROUND

Acne is a common skin disorder among women. Although no uniform approach to the management of acne exists, combination oral contraceptives (COCs), which contain an estrogen and a progestin, often are prescribed for women.

OBJECTIVES

To determine the effectiveness of combined oral contraceptives (COCs) for the treatment of facial acne compared to placebo or other active therapies.

SEARCH STRATEGY

We searched for randomized controlled trials of COCs and acne in the computerized databases of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, POPLINE, and LILACS. We also searched for clinical trials in ClinicalTrials.gov and the International Clinical Trials Registry Platform (ICTRP). We wrote to authors of identified trials to seek any unpublished or published trials that we might have missed.

SELECTION CRITERIA

All randomized controlled trials reported in any language that compared the effectiveness of a COC containing an estrogen and a progestin to placebo or another active therapy for acne in women were eligible.

DATA COLLECTION AND ANALYSIS

We extracted data on total and specific (i.e., open or closed comedones, papules, pustules and nodules) facial lesion counts; acne severity grades; global assessments by the clinician or the participant and discontinuation due to adverse events. Data were entered and analyzed in RevMan.

MAIN RESULTS

The search yielded 25 trials: 7 placebo-controlled trials made 4 different comparisons, 17 trials made 13 comparisons between 2 different COC regimens, and 1 additional trial compared a COC to an antibiotic. COCs reduced acne lesion counts, severity grades and self-assessed acne compared to placebo. Differences in the comparative effectiveness of COCs containing varying progestin types and dosages, though, were less clear. COCs that contained chlormadinone acetate or cyproterone acetate improved acne better than levonorgestrel, although this apparent advantage was based on limited data. A COC with cyproterone acetate might result in better acne outcomes than one with desogestrel; however, the three studies comparing these COCs produced conflicting results. Likewise, levonorgestrel showed a slight improvement over desogestrel in acne outcomes in one trial, but a second trial found the COC groups were similar.

AUTHORS' CONCLUSIONS

The four COCs evaluated in placebo-controlled trials are effective in reducing inflammatory and non-inflammatory facial acne lesions. Few important differences were found between COC types in their effectiveness for treating acne. How COCs compare to alternative acne treatments is unknown since limited data were available regarding this question.

Physiologic and psychologic symptoms associated with use of injectable contraception and 20 microg oral contraceptive pills

OBJECTIVE

The objective of the study was to compare menstrual, physiologic, and psychologic symptoms over 2 years among women initiating use of depot medroxyprogesterone acetate or an oral contraceptive pill with a reduced pill-free interval and those not using hormonal contraception.

STUDY DESIGN

A total of 608 women reported their experience regarding 17 symptoms prior to initiating contraception and every 6 months thereafter for 24 months. Longitudinal relationships between symptoms and contraceptives were assessed after adjusting for age, visits, and baseline status of symptoms.

RESULTS

Oral contraceptive pills were protective against mastalgia (odds ratio [OR], 0.7), cramping (OR, 0.5), hair loss (OR, 0.6), acne (OR, 0.4), nervousness (OR, 0.5), and mood swings (OR, 0.7). Depot medroxyprogesterone acetate (DMPA) was protective against bloating (OR, 0.5) and mood swings (OR, 0.7) but caused weight gain (OR, 2.3), bleeding episodes more than 20 days (OR, 13.4), and missed periods (OR, 96.9). Both methods caused intermenstrual bleeding.

CONCLUSION

Evidence-based data regarding beneficial and adverse symptoms associated with these methods may help clinicians counsel patients appropriately prior to contraceptive initiation.

Adolescent female acne: etiology and management

Acne vulgaris, a multifactorial condition often conferring significant psychosocial morbidity, affects an estimated 40 million people in the United States. The majority of these individuals are adolescents and young adults. The pathophysiology of the condition is still not fully known, but it is believed to be related in part to excess sebum production, follicular hyperkeratinization, microbial colonization by P acnes, and inflammation. Prior to initiating treatment in a female patient, a hyperandrogenic state must be considered and ruled out through history, physical exam, and laboratory evaluation if necessary. Treatment options are vast and include hormonal therapy among others. Hormonal therapies have long been noted to reduce acne lesions and offer a valuable adjuvant to standard therapy. Hormonal agents are thought to improve acne by blocking the androgen receptor and/or decreasing circulating androgens which leads to decreased sebum production. Hormonal treatment options include spironolactone, other antiandrogens, and oral contraceptives. The use of these agents to effectively treat acne has been demonstrated in several randomized, placebo-controlled clinical trials. Optimal results are often achieved with combination therapy with the goal of targeting multiple pathogenic pathways in acne development.

Guidelines of care for acne vulgaris management

DISCLAIMER

Adherence to these guidelines will not ensure successful treatment in every situation. Furthermore, these guidelines should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific therapy must be made by the physician and the patient in light of all the circumstances presented by the individual patient.

Combined oral contraceptive pills for treatment of acne

BACKGROUND

Acne is a common skin disorder among women. Although no uniform approach to the management of acne exists, combination oral contraceptives (COCs), which contain an estrogen and a progestin, often are prescribed for women.

OBJECTIVES

To determine the effectiveness of combined oral contraceptives (COCs) for the treatment of facial acne compared to placebo or other active therapies.

SEARCH STRATEGY

We searched the computerized databases of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, POPLINE, Biological Abstracts and LILACS for randomized controlled trials of COCs and acne. We wrote to authors of identified trials to seek any unpublished or published trials that we might have missed.

SELECTION CRITERIA

All randomized controlled trials reported in any language that compared the effectiveness of a COC containing an estrogen and a progestin to placebo or another active therapy for acne in women were eligible.

DATA COLLECTION AND ANALYSIS

We extracted data on total and specific (i.e., open or closed comedones, papules, pustules and nodules) facial lesion counts; acne severity grades; global assessments by the clinician or the participant and discontinuation due to adverse events. Data were entered and analyzed in RevMan.

MAIN RESULTS

The search yielded 23 trials: 5 placebo-controlled trials made 3 different comparisons, 17 trials made 13 comparisons between 2 different COC regimens, and 1 additional trial compared a COC to an antibiotic. COCs reduced acne lesion counts, severity grades and self-assessed acne compared to placebo. Differences in the comparative effectiveness of COCs containing varying progestin types and dosages, though, were less clear. COCs that contained chlormadinone acetate or cyproterone acetate improved acne better than levonorgestrel, although this apparent advantage was based on limited data. A COC with cyproterone acetate might result in better acne outcomes than one with desogestrel; however, the three studies comparing these COCs produced conflicting results. Likewise, levonorgestrel showed a slight improvement over desogestrel in acne outcomes in one trial, but a second trial found no difference between the COCs.

AUTHORS' CONCLUSIONS

The three COCs evaluated in placebo-controlled trials are effective in reducing inflammatory and non-inflammatory facial acne lesions. Few differences were found between COC types in their effectiveness for treating acne. How COCs compare to alternative acne treatments is unknown since limited data were available regarding this question.

Treating acne with oral contraceptives: use of lower doses

Oral contraceptives (OCs) have been shown to effectively treat acne. Clinical trials of various doses of ethinyl estradiol (EE) combined with progestins such as levonorgestrel, desogestrel, norgestimate, gestodene, cyproterone acetate and drospirenone in monophasic, triphasic and combiphasic formulations used to treat acne in women are reviewed here. Open-label and comparative studies beginning in the 1980s were the first to demonstrate objective and subjective reductions in the incidence of acne, severity of existing acne and seborrhea. Placebo-controlled trials have corroborated these findings with a trend toward effective acne treatment with declining doses of EE. Significant reductions in total, inflammatory and noninflammatory lesions compared with placebo have been demonstrated with an OC containing the low dose of 20 microg of EE. Collectively, these findings support the use of low-dose OCs for the treatment of acne.

FFPRHC Guidance (July 2005): The use of contraception outside the terms of the product licence

This Guidance provides information for clinicians and women considering the use of contraception outside the terms of the product licence. A key to the grades of recommendations, based on levels of evidence, is given at the end of this document. Details of the methods used by the Clinical Effectiveness Unit (CEU) in developing this Guidance and evidence tables summarising the research basis of the recommendations are available on the Faculty website (www.ffprhc.org.uk). Abbreviations (in alphabetical order) used include: CEU, Clinical Effectiveness Unit; COC, combined oral contraception/contraceptive; DMPA, depot medroxyprogesterone acetate; ENG, etonogestrel; IUD, copper-bearing intrauterine contraceptive device; LNG-IUS, levonorgestrel-releasing intrauterine system; NET-EN, norethisterone enantate; PGD, Patient Group Direction; PIL, Patient Information Leaflet; POC, progestogen-only contraception/contraceptive; POEC, progestogen-only emergency contraception; POP, progestogen-only pill; RCT, randomised controlled trial; SPC, Summary of Product Characteristics; UPSI, unprotected sexual intercourse; WHO, World Health Organization; WHOMEC, WHO Medical Eligibility Criteria for Contraceptive Use; WHOSPR, WHO Selected Practice Recommendations for Contraceptive Use.

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.

Practical Approach to the Hormonal Treatment of Acne

Acne is a disease of the pilosebaceous units and these are mainly under hormonal control. In female patients, hormonal therapy is a unique opportunity for the treatment of acne. Several combined oral contraceptives (COCs), cyproterone acetate, spironolactone, flutamide, and others, have been tried for the control of acne. An overview on the use of the most useful drugs in clinical practice was conducted. COCs are thoroughly discussed, also taking into consideration their potential side effects. A practical approach with guidelines on the use of COC in acne is proposed.

Hormonal treatment of acne: review of current best evidence

BACKGROUND

Recent controlled clinical trials have demonstrated the efficacy of various hormonal preparations, including oral contraceptives, in treatment of acne.

OBJECTIVE

The goal of this article is to evaluate the best current evidence on the efficacy of hormonal treatment of acne.

METHODS

English-language controlled clinical trials of systemic hormonal treatment of acne were sought by search of references of general dermatology texts, reviews on acne, drug product monographs, and computer-assisted search of MEDLINE, CINAHL, and COCHRANE databases between 1970 and 2003 using the key words hormonal, oral contraceptive, acne, spironolactone, cyproterone, flutamide, and therapy. For each agent, studies fulfilling the highest level of evidence were selected for further evaluation.

RESULTS

The literature search recovered two placebo-controlled random controlled trials (RCTs) each of ethinyl estradiol 0.035 mg and norgestimate and ethinyl estradiol 20 microg and leonorgestrel 100 microg, three active-comparator RCTs of ethinyl estradiol 0.035 mg and cyproterone acetate 2 mg, one active comparator RCT of ethinyl estradiol 30 mug and drosperinone 3 mg, three small placebo-controlled RCTs of spironolactone, and one active-comparator RCT of flutamide.

CONCLUSIONS

The efficacy of Tri-Cyclen and Alesse in acne is supported by high-quality RCTs (level A evidence). Evidence for the efficacy of Diane-35, spironolactone, and flutamide is derived from lower-quality RCTs (level B evidence). Results from a population-based epidemiological study suggests that Diane-35 is the most effective of these oral contraceptives in the treatment of acne (level B evidence; epidemiological study).

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.