Influence of Contraception Class on Incidence and Severity of Acne Vulgaris

Challenges in designing a randomized, double-blind noninferiority trial for treatment of acne: The SD-ACNE trial

BACKGROUND/AIMS

Excessive use of antibiotics has led to development of antibiotic resistance and other antibiotic-associated complications. Dermatologists prescribe more antibiotics per clinician than any other major specialty, with much of this use for acne. Alternative acne treatments are available but are used much less often than antibiotics, at least partially because dermatologists feel that they are less effective. Spironolactone, a hormonal therapy with antiandrogen effects that can address the hormonal pathogenesis of acne, may represent a therapeutic alternative to oral antibiotics for women with acne. However, the comparative effects of spironolactone and oral antibiotics in the treatment of acne have not been definitively studied. The Spironolactone versus Doxycycline for Acne: A Comparative Effectiveness, Noninferiority Evaluation (SD-ACNE) trial aims to answer whether spironolactone, in addition to standard topical therapy, is noninferior to doxycycline (an oral antibiotic) for women with acne. Several interesting challenges arose in the development of this study, including determining acceptability of the comparative regimens to participating dermatologists, identifying data to support a noninferiority margin, and establishing a process for unblinding participants after they completed the study while maintaining the blind for study investigators.

METHODS

We present the scientific and clinical rationale for the decisions made in the design of the trial, including input from key stakeholders through a Delphi consensus process.

RESULTS

The Spironolactone versus Doxycycline for Acne: A Comparative Effectiveness, Noninferiority Evaluation trial (NCT04582383) is being conducted at a range of community and academic sites in the United States. To maximize external validity and inform clinical practice, the study is designed with broad eligibility criteria and no prohibition of use of topical medications. Participants in the trial will be randomized to receive either spironolactone 100 mg/day or doxycycline hyclate 100 mg/day for 16 weeks. The primary outcome is the absolute decrease in inflammatory lesion count, and we have established a noninferiority margin of four inflammatory lesions. Secondary outcomes include the percentage of participants achieving Investigator Global Assessment success, change in quality of life, and microbiome changes and diversity.

CONCLUSIONS

The Spironolactone versus Doxycycline for Acne: A Comparative Effectiveness, Noninferiority Evaluation trial will have substantial implications for the treatment of acne and antibiotic stewardship. In addition, this study will provide important information on the effect of these systemic agents on the development of changes to the microbiome and antibiotic resistance in a healthy population of patients.

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.

Hormone-related side effects in new users of a levonorgestrel 52-mg intrauterine device

BACKGROUND

Although the levonorgestrel 52 mg intrauterine device is locally active and has low systemic hormone exposure, hormonal intrauterine device users sometimes report hormone-related side effects.

OBJECTIVE

Evaluate hormone-related adverse event rates among all participants and compare these among those who used combined hormonal or no hormonal contraception in the month before enrollment.

STUDY DESIGN

A total of 1714 women aged 16 to 45 years old received a levonorgestrel 52 mg intrauterine device in a multicenter phase 3 trial to evaluate contraceptive efficacy and safety for up to 10 years. This analysis evaluated a subset of participants who used combined hormonal or no hormonal contraception in the month prior to device placement. We assessed all nonexpulsion, nonbleeding-related events with ≥1% incidence at 180 days with a plan to include weight increase regardless of incidence; we excluded events considered nonhormonal. We computed 180-day side effect frequency rates based on the number of days a side effect was reported during the study period. We created a multivariable model for side effect incidence at 180 days based on age, race, ethnicity, body mass index at enrollment, parity, and contraception use in the month before enrollment. For those side effects with a P value <.2 on univariate comparison between combined hormonal and no hormonal contraception users, we secondarily evaluated 360-day event rates.

RESULTS

Overall, 644 participants used combined hormonal contraception (primarily oral [n=499, 77.5%]) and 855 used no hormonal method before intrauterine device placement. Individual side effect rates over the first 180 days did not differ between prior combined hormonal and no hormonal contraception users except for acne (84 [13.0%] vs 73 [8.5%], respectively), P=.006, odds ratio 1.61 (95% confidence interval 1.15-2.24). However, this association was weaker after adjustment for age, race, ethnicity, obesity status, and parity (adjusted odds ratio 1.40, 95% confidence interval 0.99-1.98) At 360 days, prior combined hormonal contraception users were more likely to report acne (101 [15.7%] vs 91 [10.6%], respectively, P=.005) and orgasm/libido problems (20 [3.1%] vs 12 [1.4%], respectively, P=.03). Over the first 180 days, all side effects other than acne were reported in less than 3% of days; acne was reported an average of 13 days (7.4%) per prior combined hormonal contraception user and 9 days (5.0%) per prior nonhormonal contraception user (P<.0001). Discontinuation for evaluated side effects occurred in 83 (5.5%) participants with no difference between those who used combined hormonal (36 [5.6%]) or no hormonal contraception (47 [5.5%], P=1.0) before study entry.

CONCLUSION

Using combined hormonal contraception prior to levonorgestrel 52 mg intrauterine device placement is weakly associated with reporting hormonally related side effects like acne. Only a small percentage of levonorgestrel 52 mg intrauterine device users experienced potentially hormone-related side effects during the initial 6 months of use that resulted in discontinuation.

Counseling Women About Sexual Health Effects of Contraceptives

Background: Choosing a contraceptive method is a pivotal decision for patients, whereas health care professionals (HCPs) face challenges in providing suitable recommendations. Adverse sexual effects often lead to dissatisfaction and discontinuation of contraceptives, underscoring the importance of thorough counseling and shared decision making between HCPs and patients. Objective: This article aims to investigate the relationship between contraceptive methods and female sexual function through a comprehensive review of available literature, emphasizing the importance of considering sexual health in contraceptive prescription and management. Methods: A systematic analysis of existing literature, incorporating studies utilizing validated sexual health questionnaires, was conducted to elucidate the intricate interplay between contraceptives and female sexual function. Results: The review encompasses various contraceptive methods, including combined hormonal contraceptives, progestin-only pills, depot medroxyprogesterone acetate, subdermal contraceptive implants, hormonal intrauterine devices, permanent sterilization, and barrier methods. Insights gleaned from the analysis shed light on the impact of these methods on female sexual health. Conclusion: Comprehensive understanding of the effects of contraceptives on female sexual function is crucial for both HCPs and patients. By integrating sexual health considerations into contraceptive surveillance, compliance can be improved, contraceptive efficacy optimized, and the risk of unwanted pregnancies minimized. This review underscores the significance of tailored counseling and shared decision making in contraceptive management, particularly for cisgender women.

The impact of using the levonorgestrel-releasing intrauterine device on the incidence of acne in adolescents and young women

PURPOSE

To evaluate the impact of levonorgestrel-releasing intrauterine device (LNG-IUD) use on the incidence of acne in adolescents and young women.

METHODS

A narrative review was conducted in PubMed, Embase, Cochrane, and SciELO assessing the incidence of acne in adolescents and young women using LNG-IUD (13.5, or 19.5 mg, or 52 mg). Cohort, cross-sectional studies, clinical trials, and meta-analyses were included, without a date limit. Studies that didn't evaluate women in the age of interest were excluded. Only articles in English were selected.

RESULTS

Nine articles were included in this narrative review. Only clinical trials, cohort studies, and cross-sectional studies were evaluated. Two cross-sectional studies evaluated the incidence of acne in women using any contraceptive methods, with the incidence of acne being 36% in women aged 17 to 47 using LNG-IUD in one study. In another study, acne incidence ranged from 2 to 8% in women using any contraceptive methods, with higher rates in younger women and LNG-IUD users. The incidence of acne varies and participants between 16 to 35 years were more likely to report new acne or worsening of pre-existing acne. In a prospective cohort study of women between 16 and 24 years, acne was a common adverse effect, with 44% in the first year.

CONCLUSION

The data indicate variability in the incidence of acne among LNG-IUD users, with a higher prevalence observed in younger women. Further research should focus on the effects of LNG-IUD on acne in young populations, with rigorous study designs and consideration of previous contraceptive use.

Relationship between long-acting reversible contraception and acne in a cohort of adolescents and young adults

BACKGROUND

The use of progestin-only long-acting reversible contraception (LARC) may be a risk factor for acne. Few studies have focused primarily on the effects of hormonal LARC on the development or exacerbation of acne in adolescents and young adults. We sought to understand the incidence and management of acne following hormonal LARC insertion in this adolescent/young adult population.

METHODS

A secondary data analysis was conducted of prospectively collected quality improvement (QI) data from the Adolescent Medicine LARC Collaborative. Subjects were evaluated by clinicians in adolescent medicine clinics at participating study sites, and acne severity was documented using a standardized recording instrument and scale. Descriptive statistics were reported as frequencies and percentages for categorical variables or mean and standard deviation (SD) for continuous variables. We compared demographic and clinical characteristics by those who had worsening acne, accounting for site inter-correlation using Cochran-Mantel-Haenszel chi-square tests for categorical variables and linear generalized estimating equation (GEE) regression for continuous variables.

RESULTS

Of 1319 subjects who completed LARC insertion, 28.5% (376/1319) experienced worsening acne following use of progestin-only LARC. Acne was a contributing factor to LARC removal in only 3% (40/1319), and the sole reason for removal in 0.4% (5/1319) of all subjects. As this was a secondary analysis of prospectively collected QI data, limitations of this study include incomplete or inaccurate documentation of acne severity. Moreover, LARC insertions without follow-up/removal visits or with only follow-up/removal within 8 weeks of insertion were excluded from our study, which may also bias results.

CONCLUSIONS

Adolescents and young adults seeking progestin-only LARC should be counseled about the potential for developing acne or experiencing a worsening of existing acne during LARC use. However, acne was not a common reason for LARC discontinuation.

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.

Treatment challenges in adult female acne and future directions

Introduction: Acne is a chronic, inflammatory, and immune-mediated disease of the pilosebaceous unit, highly prevalent in adolescents. However, an increasing number of adults over 25 years old with facial acne, particularly women, have been observed. It is considered a different disease when compared to acne vulgaris. Face is the mainly involved area with inflammatory lesions and more sensitive skin, pointing out the need of a holistic approach.Areas covered: We performed a comprehensive literature search on PubMed database, up to January 2021, regarding adult female acne. We synthesized data about pathogenesis; differences compared to acne vulgaris; and treatment, with focus in the management challenges and perspectives.Expert opinion: It is essential to value the negative impact on quality of life of adult female acne, independently of severity. The disease has prolonged evolution, and patient might be resilient once the improvement, regardless of the treatment option, will just be noticeable after 3 months. Aggravating factors should be clearly discussed, such as the need of changing many habits, especially lesions manipulation. The therapeutic regimen includes make-up and tailored skin care (considering proneness to sensitivity), while anti-acne drugs should be chosen in accordance with desire to be pregnant, presence of pregnancy or breastfeeding.

Lipidomics demonstrates the association of sex hormones with sebum

BACKGROUND

The regulation of sebocytes by hormones has been unanimously certified by scholars. But how sebocytes are affected has not been fully demonstrated by the regulation of multiple hormones.

AIMS

The regulation effect of sex hormone on sebocytes was further discussed.

PATIENTS/METHODS

Based on our previous studies, the changes of skin surface liposomes in different sex hormone levels were analyzed by comprehensive statistics.

RESULTS

We found that androgen can induce sebocytes to synthesis and secrete more fatty acids (FAs) and triglycerides (TGs) through comprehensive analysis of sebum content and composition, which is inhibited by estrogen.

CONCLUSIONS

We further confirmed the regulatory effect of hormones on sebocytes from a molecular point of view using lipidomics and found that sex hormones may dominate.