Androgen excess in women with acne alone compared with women with acne and/or hirsutism

An updated clinico-investigative approach to diagnosis of cutaneous hyperandrogenism in relation to adult female acne, female pattern alopecia & hirsutism a primer for dermatologists

INTRODUCTION

Hyperandrogenism is a clinical state consequent to excess androgen production by the ovary, adrenals, or increased peripheral conversion of androgens. The varied manifestations of hyperandrogenism include seborrhea, acne, infertility, hirsutism, or overt virilization of which adult female acne, hirsutism, and female pattern hair loss are of clinical relevance to dermatologists.

AREAS COVERED

We limited our narrative review to literature published during period from 1 January 1985 to Dec 2022 and searched PubMed/MEDLINE, Web of Science (WOS), Scopus, and Embase databases with main search keywords were 'Hyperandrogenism,' 'Female,' 'Biochemical,' 'Dermatological', and 'Dermatology.' We detail the common etiological causes, nuances in interpretation of biochemical tests and imaging tools, followed by an algorithmic approach which can help avoid extensive tests and diagnose the common causes of hyperandrogenism.

EXPERT OPINION

Based on current data, total testosterone, sex hormone binding globulin, DHEAS, prolactin, free androgen index, and peripheral androgenic metabolites like 3-alpha diol and androsterone glucuronide are ideal tests though not all are required in all patients. Abnormalities in these biochemical investigations may require radiological examination for further clarification. Total testosterone levels can help delineate broadly the varied causes of hyperandrogenism. Serum AMH could be used for defining PCOM in adults.

Management of Acne Vulgaris: A Review

IMPORTANCE

Acne vulgaris is an inflammatory disease of the pilosebaceous unit of the skin that primarily involves the face and trunk and affects approximately 9% of the population worldwide (approximately 85% of individuals aged 12-24 years, and approximately 50% of patients aged 20-29 years). Acne vulgaris can cause permanent physical scarring, negatively affect quality of life and self-image, and has been associated with increased rates of anxiety, depression, and suicidal ideation.

OBSERVATIONS

Acne vulgaris is classified based on patient age, lesion morphology (comedonal, inflammatory, mixed, nodulocystic), distribution (location on face, trunk, or both), and severity (extent, presence or absence of scarring, postinflammatory erythema, or hyperpigmentation). Although most acne does not require specific medical evaluation, medical workup is sometimes warranted. Topical therapies such as retinoids (eg, tretinoin, adapalene), benzoyl peroxide, azelaic acid, and/or combinations of topical agents are first-line treatments. When prescribed as a single therapy in a randomized trial of 207 patients, treatment with tretinoin 0.025% gel reduced acne lesion counts at 12 weeks by 63% compared with baseline. Combinations of topical agents with systemic agents (oral antibiotics such as doxycycline and minocycline, hormonal therapies such as combination oral contraception [COC] or spironolactone, or isotretinoin) are recommended for more severe disease. In a meta-analysis of 32 randomized clinical trials, COC was associated with reductions in inflammatory lesions by 62%, placebo was associated with a 26% reduction, and oral antibiotics were associated with a 58% reduction at 6-month follow-up. Isotretinoin is approved by the US Food and Drug Administration for treating severe recalcitrant nodular acne but is often used to treat resistant or persistent moderate to severe acne, as well as acne that produces scarring or significant psychosocial distress.

CONCLUSIONS AND RELEVANCE

Acne vulgaris affects approximately 9% of the population worldwide and approximately 85% of those aged 12 to 24 years. First-line therapies are topical retinoids, benzoyl peroxide, azelaic acid, or combinations of topicals. For more severe disease, oral antibiotics such as doxycycline or minocycline, hormonal therapies such as combination oral conceptive agents or spironolactone, or isotretinoin are most effective.

A prospective study of anti-mullerian hormone and other ovarian and adrenal hormones in adult female acne

Polycystic ovarian syndrome (PCOS) diagnosis in adult female acne (AFA) is tough owing to unreliable ultrasonography in virgins or obese females and inconsistent hyperandrogenemia. We analyzed hormones in AFA and established a diagnostic cut-off value of anti-mullerian hormone (AMH) for PCOS. Female acne patients aged ≥25 years were assessed with total testosterone (TT), sex hormone binding globulin (SHBG), free androgen index (FAI), AMH, 17-hydroxyprogesterone (17-OHP), dehydroepiandrosterone sulfate (DHEAS), follicle stimulating hormone (FSH), and luteinizing hormone (LH). Rotterdam's criteria defined PCOS. AMH was measured (Access AMH assay) to calculate the diagnostic cut off value using receiver operating characteristic (ROC) curve. Of 120 cases, 25.83% had PCOS. This group had significant clinical hyperandrogenism, truncal and adolescent acne, polycystic ovarian morphology (PCOM), and raised hormones (AMH, TT, FAI, LH, and LH/FSH). AMH levels were significantly higher in the PCOS group (6.91 ± 3.85 ng/mL) and positively correlated with TT, FAI, 17OHP, LH, and LH/FSH ratio. AMH at >5.1 ng/mL (sensitivity-70.97% and specificity-82.02%) predicted PCOS and correlated with PCOM. AMH (>5.1 ng/mL) is useful for diagnosing PCOS and surrogate for hyperandrogenemia and PCOM. Its correlation with hormones in non PCOS AFA highlights its sensitivity to diagnose endocrinological derangements.

FASCE, the benefit of spironolactone for treating acne in women: study protocol for a randomized double-blind trial

Background

Acne vulgaris has increased in women over the past 10 years; it currently affects 20–30% of women. The physiopathology of adult female acne is distinguished from that of teenagers essentially by two factors: hormonal and inflammatory. On a therapeutic plan, the four types of systemic treatment approved for female acne include cyclines (leading to bacterial resistance); zinc salts (less effective than cyclines); and antiandrogens (risks of phlebitis). The last alternative is represented by isotretinoin, but its use in women of childbearing potential is discouraged because of the teratogen risks. In this context, spironolactone could represent an interesting alternative. It blocks the 5-alpha-reductase receptors at the sebaceous gland and inhibits luteinizing hormone (LH) production at the pituitary level. It has no isotretinoin constraints and does not lead to bacterial resistance. Currently, very few studies have been performed in a limited number of patients: the studies showed that at low doses (lower than 200 mg/day), spironolactone can be effective against acne. In that context, it is clearly of interest to perform the first double-blind randomized study of spironolactone versus cyclines, which remains the moderate acne reference treatment, and to demonstrate the superiority of spironolactone’s efficacy in order to establish it as an alternative to cyclines.

Methods

Two hundred female patients will be included. They must have acne vulgaris with at least 10 inflammatory lesions and no more than 3 nodules. After randomization, the patients will be treated by spironolactone or doxycycline for 3 months and after placebo. The study will be blind for the first 6 months and open for the last 6 months.

Discussion

The treatment frequently used in female acne is systemic antibiotics with many courses, as it is a chronic inflammatory disease. In the context of the recent World Health Organisation (WHO) revelation about the serious, worldwide threat to public health of antibiotic resistance, this trial could give the physician another alternative in the treatment of adult female acne instead of using isotretinoin, which is more complex to manage.

Trial registration

ClinicalTrials.gov: NCT03334682. Registered on 7 November 2017.

A prospective study examining isolated acne and acne with hyperandrogenic signs in adult females

BACKGROUND

Adult female acne (AFA) occurs beyond 25 years of age and can present either as isolated acne or with hyperandrogenic signs.

METHODS

120 females aged ≥ 25 years were evaluated for acne, hirsutism and androgenetic alopecia. Hormonal assessment included total testosterone (TT), sex hormone binding globulin (SHBG), free androgen index (FAI), Anti Mullerian Hormone (AMH), 17-hydroxyprogesterone (17-OHP), dehydroepiandrosterone sulfate (DHEAS), follicle stimulating hormone (FSH), luteinizing hormone (LH), thyroid stimulating hormone (TSH) and prolactin. Polycystic ovary syndrome (PCOS) was diagnosed using Rotterdam's criteria.

RESULTS

The mean GAGS score was 15.57 ± 4.04.71.66% females had acne with hyperandrogenic signs (hirsutism, 55.81%; hyperseborrhoea, 65.12%; irregular menses, 36.05%) and 18.33% had increased androgen levels. The group with hyperandrogenic signs had longer duration of disease, truncal acne, significant adolescent acne history, stress, inappropriate diet and PCOS compared to the isolated acne group. The mean androgen levels were higher in the former but the difference was statistically insignificant.

CONCLUSIONS

Adult female acne can be associated with hyperandrogenic features though routine hormonal tests may not reveal an underlying abnormality except PCOS. End-organ hypersensitivity is the most plausible explanation and thus justifies the use of antiandrogens in its management.

Update on Management of Polycystic Ovarian Syndrome for Dermatologists

Polycystic ovarian syndrome (PCOS) is the commonest endocrine disorder in women having wide range of clinical manifestation. These women may present with reproductive, dermatological, metabolic, psychological, or neoplastic implications from adolescence to menopause. The common dermatological manifestations include hirsutism, acne, alopecia, or acanthosis nigricans. Women presenting with these dermatological manifestations must be evaluated for PCOS. A multidisciplinary team approach involving a reproductive endocrinologist, dermatologist, psychologist/psychiatrist, dietician, and sometimes a bariatric surgeon should be undertaken for long-term management of these patients. Unless metabolic and underlying endocrinal disturbances arecorrected and simultaneous life-style modification is adopted, cosmetic treatment would give only temporary relief.

Serum levels of androgens in acne & their role in acne severity

Objectives

To correlate acne severity with elevated androgen levels and to compare androgen levels between cases and controls.

Methods

This case-control study was carried out in the Department of Dermatology, Mayo Hospital, Lahore from March 2016 - March 2017. Two hundred and seventy patients and eighty age and gender-matched controls were recruited after ethical approval and informed consent and categorized into mild, moderate and severe acne. Severity was correlated with serum Testosterone, Dihydrotestoststerone and Dihydroepiandrosterone Sulphate levels. Quantitative variables were expressed as median and percentiles, comparisons done by Mann-Whitney and correlations by Spearman correlation. P value of < 0.05 was considered statistically significant.

Results

There were 142 (41%) males and 208 (59%) females. Ninety-Seven patients had mild, 108 moderate and 65 had severe disease. Median hormonal levels were 3.5ng/ml, 184pg/ml and 0.82ug/dl for Testosterone, Dihydrotestosterone and Dihydroepiandrosterone Sulphate respectively which differed significantly between cases and controls. There was no correlation with severity but the levels differed significantly between the different grades in case of Testosterone and DHEAS.

Conclusion

Androgens are not directly correlated with acne severity, but affect acne severity as seen in difference between their levels in different grades of acne. Anti-androgens may be initiated early in acne resistant to conventional therapy.

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.

Comparison of adrenocortical steroidogenesis in women with post-adolescent severe acne and polycystic ovary syndrome

BACKGROUND

Increased adrenocortical production appears to be associated with acne and hirsutism in acne and polycystic ovary syndrome (PCOS). However, the aetiological role of androgens in the pathogenesis of acne per se is far from being clear.

OBJECTIVE

We aimed to evaluate adrenocortical function in women with post-adolescent severe acne in comparison with patients with PCOS and healthy women.

METHODS

The study included 32 women with post-adolescent severe acne, 32 women with PCOS and 32 age and body mass index (BMI)-matched healthy controls (age 17-34 years, BMI: 20.8 ± 1.9 kg/m²). Women with acne did not have hirsutism or ovulatory dysfunction whereas all PCOS patients had androgen excess and ovulatory dysfunction. Measurements included basal testosterone (T), sex hormone-binding globulin (SHBG) and dehydroepiandrosterone sulphate (DHEAS) levels and serum 17-hydroxyprogesterone (17-OHP), androstenedione (A4), DHEA and cortisol levels in response to corticotropin (ACTH) stimulation.

RESULTS

T, free androgen index, DHEAS levels, basal and AUC (area under the curve) values for A4 were significantly higher in PCOS than women with acne and controls (P < 0.05 for all), whereas three groups did not differ for basal or AUC values of DHEA and cortisol. Women with PCOS and those with severe acne had significantly and similarly higher AUC values of 17-OHP compared to controls (P < 0.05).

CONCLUSION

Women with isolated post-adolescent severe acne do not have increased levels of adrenal androgens basally or in response to ACTH. However, these women have similar secretion pattern of 17-OHP with PCOS patients suggesting increased enzymatic activity in this pathway.

The Androgen Excess and PCOS Society criteria for the polycystic ovary syndrome: the complete task force report

OBJECTIVE

To review all available data and recommend a definition for polycystic ovary syndrome (PCOS) based on published peer-reviewed data, whether already in use or not, to guide clinical diagnosis and future research.

DESIGN

Literature review and expert consensus.

SETTING

Professional society.

PATIENTS

None.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

A systematic review of the published peer-reviewed medical literature, by querying MEDLINE databases, to identify studies evaluating the epidemiology or phenotypic aspects of PCOS.

RESULT(S)

The Task Force drafted the initial report, following a consensus process via electronic communication, which was then reviewed and critiqued by the Androgen Excess and PCOS (AE-PCOS) Society AE-PCOS Board of Directors. No section was finalized until all members were satisfied with the contents, and minority opinions noted. Statements were not included that were not supported by peer-reviewed evidence.

CONCLUSION(S)

Based on the available data, it is the view of the AE-PCOS Society Task Force that PCOS should be defined by the presence of hyperandrogenism (clinical and/or biochemical), ovarian dysfunction (oligo-anovulation and/or polycystic ovaries), and the exclusion of related disorders. However, a minority considered the possibility that there may be forms of PCOS without overt evidence of hyperandrogenism, but recognized that more data are required before validating this supposition. Finally, the Task Force recognized and fully expects that the definition of this syndrome will evolve over time to incorporate new research findings.

Mulheres adultas com acne: aspectos comportamentais, perfis hormonal e ultra-sonográfico ovariano

OBJETIVOS: abordar os aspectos comportamentais, o perfil androgênico e as alterações ultra-sonográficas ovarianas de uma amostra de mulheres adultas com acne. MÉTODOS: estudo de série de casos envolvendo uma amostra de 60 mulheres, escolhidas por conveniência. As pacientes foram submetidas a exame clínico, dosagens hormonais e ultra-sonografia para avaliação da morfologia ovariana. Na análise estatística, foi aplicado o Teste de Fischer para análise de correlação entre as variáveis. RESULTADOS: a média de idade foi de 26,5 anos. Todas as pacientes referiram atitudes e sentimentos negativos em relação à acne, sendo os mais freqüentes ansiedade (88,3%) e manipulação constante das lesões (88,3%). O grau de acne mais observado foi o grau II (48,3%). Foram identificados níveis de androgênios fora da faixa de normalidade em 63,3%, com elevação mais freqüente do, dehidroepiandrosterona (57,6%). O padrão ultra-sonográfico mais observado foi o microcístico (74,6%). CONCLUSÕES: as formas clínicas leves de acne predominaram nas mulheres estudadas. Ainda assim, essas apresentaram, com grande freqüência, atitudes e sentimentos negativos em relação à doença. Foram identificados, ainda, modificação dos níveis séricos dos androgênios, bem como do padrão de normalidade do exame ultra-sonográfico.

Anti-androgenic therapy using oral spironolactone for acne vulgaris in Asians

BACKGROUND

Few studies have addressed anti-androgenic therapy using oral spironolactone for acne in Asians. Obtaining this race-specific information is important because Westerners and Asians respond differently to hormone therapy. This study aimed to examine the efficacy and safety of oral spironolactone used to treat acne in Asians.

METHODS

Spironolactone (initial dose, 200 mg/day) was administered orally to 139 Japanese patients (116 females and 23 males) with acne. Serum laboratory data, including various hormones and electrolytes, were examined for 25 of the subjects.

RESULTS

Most of the female patients who completed the 20-week regimen exhibited excellent improvement (evaluated by a photographic grading scale), although some discontinued treatment because of menstrual disturbances or other reasons. The treatment was less efficacious for the males than for the females, and because gynecomastia developed in three male patients, spironolactone treatment for males was stopped. Examination of the serum of 25 patients did not identify any toxicity associated with the treatment. Drug eruptions and edema in the lower extremities were each seen in three patients.

CONCLUSION

Oral spironolactone is effective and safe for the treatment of acne in Asian females, and can be a good option for severe, recurring, and widespread types of the condition.

Mild cutaneous manifestation in two young women with extraordinary hyperandrogenemia

Hyperandrogenism with hyperandrogenemia should be considered in those with severe acne of sudden onset or conspicuous male-pattern baldness with hairline recession, although the majority of female patients with acne or androgenetic alopecia possess no endocrine disorder. Herein we describe on the contrary 2 young women with primary amenorrhea displaying prominent hyperandrogenemia but subtle cutaneous manifestation. The first one presenting vertical alopecia had an elevated level of serum dehydroepiandrosterone sulfate (>800 microg/dl) and was suspected to be a case of late-onset, non-classical adrenal hyperplasia. The second case with mild acne had a soaring serum level of total testosterone >9,000 ng/dl derived from an androgen-secreting adrenal adenoma overexpressing steroidogenic acute regulatory protein, P450 side-chain cleavage enzyme and aromatase. A careful patient history and a complete physical examination are mandatory in each individual female case with acne or alopecia. The possibility of adrenal tumor should be explored in patients with escalated circulating testosterone.

The prevalence of androgen excess among patients with minimal unwanted hair growth

OBJECTIVE

The prevalence of androgen excess (AE) and the value of preemptive endocrine evaluation in women with minimal unwanted hair growth are unclear.

SUBJECTS

A total of 228 patients presented with minimal unwanted hair growth and a mF-G score of 5 or less. Total and free testosterone, dehydroepiandrosterone sulfate, 17-hydroxy-progesterone, sex hormone-binding globulin, and basal insulin and glucose levels were measured.

RESULTS

Of the patients, 54% demonstrated an AE disorder (50%: polycystic ovary syndrome, 2%: hyperandrogenic insulin-resistant acanthosis nigricans syndrome, 2%: nonclassic adrenal hyperplasia), 29% isolated oligoovulation, 6% isolated hyperandrogenemia, and 10% had a normal evaluation. Of the patients with menstrual irregularities, 65% had an underlying AE disorder compared with 22% of those with normal menstrual function ( P < .001). Of eumenorrheic patients, 11% had oligo-ovulation and an AE disorder.

CONCLUSION

Patients with minimal unwanted hair growth should be evaluated endocrinologically because approximately 50% of subjects demonstrate an AE disorder. Eumenorrhea does not preclude an underlying AE disorder, and ovulatory function should be assessed in these women.

Acne: effect of hormones on pathogenesis and management

In the pathogenesis of acne, androgen hormones play a crucial role. In the treatment of acne, hormonal therapies provide valuable alternatives to standard modalities in selected women. Although numerous factors contribute to the development of acne, the requirement for androgens is absolute and is one that allows for effective treatments in women through inhibition of androgen expression. The two prerequisites for androgen expression at the level of the pilosebaceous unit are the presence of androgen in the form of either testosterone or dihydrotestosterone; and functioning androgen receptors. A third component may be the metabolism of androgen precursors to active androgens within pilosebaceous units. Hormonal treatment of hyperandrogenism (acne, hirsutism, androgenetic alopecia) such as that seen in polycystic ovary syndrome, centers on reduction of circulating androgen levels and androgen receptor blockade. Combination oral contraceptives represent the primary treatment modality for reducing circulating androgens from ovarian and, to a lesser degree, adrenal sources. Newer formulations may also have clinically significant androgen receptor blocking and 5alpha-reductase inhibiting effects. Newer oral contraceptives have high safety profiles and are used widely internationally for this purpose. Androgen receptor blockers currently in use include spironolactone, cyproterone acetate, and flutamide. Androgen receptor blockers are frequently combined with oral contraceptives to achieve optimal results in selected women. In women with adrenal hyperplasia, low-dose corticosteroids may be added to reduce adrenal androgen precursors. Inhibition of enzymes of androgen metabolism in the pilosebaceous unit remain largely investigational in the treatment of acne, although the benefit of 5alpha-reductase (type 2) inhibition is established in androgenetic alopecia in men. This article reviews the essentials of hormonal influence in acne pathogenesis, discusses the hormonal therapies most utilized in the treatment of acne, and the pre-treatment evaluation of women in whom hormonal therapies are being considered.

The association of serum androsterone glucuronide with inflammatory lesions in women with adult acne

Serum androsterone glucuronide (AoG) is a metabolite of circulating androgens under the influence of 5alpha-reductase activity and has been shown to be particularly elevated in women with acne. In this study, we wanted to evaluate changes in AoG before and after treatment with an oral contraceptive or placebo, and to assess whether changes correlated with the number and type of acne lesions. In order to accomplish these aims, we obtained sera from a completed prospective randomized trial, which was designed to assess the effectiveness of an oral contraceptive compared to placebo. Assessments were carried out in 56 women with moderate acne who were treated with Ortho Tri-Cyclen (norgestimate and ethinylestradiol) (30 patients) or placebo (26 patients) for 6 months. Before and after treatment, the number and type of skin lesions, serum levels of total T, free-T, DHEAS and AoG were determined. Serum AoG increased significantly in women with moderate acne, although T, free-T and DHEAS were normal. 75% of acne patients had elevated levels of serum AoG. Ratios of serum AoG to androgen precursors were also elevated. Oral contraceptive (OC) treatment significantly reduced levels of free-T and AoG, both of which were unaffected by placebo. While both OC and placebo treatment resulted in improvement of comedones and inflammatory lesions, OC treatment decreased inflammatory lesions to a greater extent (p<0.05). After treatment, serum AoG correlated with the number of inflammatory lesions. Results showed that serum AoG is a sensitive marker of acne in women, even in those with normal circulating precursor androgens; and is lowered by OC treatment, correlating with the reduction of inflammatory lesions. We hypothesize that the increase of serum AoG in normoandrogenic acne may be related to inflammation, and serum AoG may serve as a marker of this process.

A comparison of the relative efficacy of antiandrogens for the treatment of acne in hyperandrogenic women

OBJECTIVES

To compare the relative effectiveness of two newer antiandrogens (flutamide and finasteride) with cyproterone acetate (CPA), at both low and high doses in the treatment of moderate to severe acne in hyperandrogenic women.

SUBJECTS AND DESIGN

Forty-eight hyperandrogenic women were prospectively randomized to the following treatments for 1 year: CPA 2 mg with 35 micro g ethinylestradiol; CPA 50 mg with 25 micro g ethinylestradiol (reverse sequential regimen); flutamide 250 mg daily; and finasteride 5 mg daily. Assessment of Cook scores was the primary end-point of the trial. Blood for androgens was obtained at baseline in these women and 30 ovulatory age-matched controls.

RESULTS

Serum androgens were elevated in all 48 women and was similar in each of the four treatment groups. Cook scores were significantly and equally decreased (59-71%) with flutamide and both low and high doses of CPA (P < 0.01). The decrease with finasteride (-36 +/- 2%) was statistically significant but lower than that obtained with the other agents. All treatments were well tolerated.

CONCLUSIONS

In hyperandrogenic women with moderate to severe acne, low doses of certain antiandrogens appear to be effective. Low and high doses of CPA with ethinylestradiol were equally effective and were comparable to the effects of a low dose of flutamide. Finasteride was less beneficial.

Hormonal therapies in acne

Hormones, in particular androgen hormones, are the main cause of acne in men, women, children and adults, in both normal states and endocrine disorders. Therefore, the use of hormonal therapies in acne is rational in concept and gratifying in practice. Although non-hormonal therapies enjoy wide usage and continue to be developed, there is a solid place for hormonal approaches in women with acne, especially adult women with persistent acne. This review covers the physiological basis for hormonal influence in acne, the treatments that are in use today and those that show promise for the future. The main treatments to be discussed are oral contraceptives androgen receptor blockers like spironolactone and flutamide, inhibitors of the enzyme 5 alpha-reductase and topical hormonal treatments.

[Feminine acne: dermatologic disease or endocrine disease?]

Acne is a problem of the pilo-sebaceous follicle caused by the conjunction of three factors: seborrhea, follicle obstruction, and follicle inflammation. The key element, seborrhea, is under androgenic control. Acne in women is also influenced by developments and modifications in genital life, as well as by hormonal contraceptive and replacement therapies. Acne is rare prior to puberty, when it may indicate endocrine disease. At puberty, acne is quasi-physiological, because of the relative hyperandrogenism induced by the andrenarche preceding pubarche, as well as by the relative shortage of estrogens and progesterone during the first menstrual cycles. Other signs of hyperandrogenism, such as menstrual cycle difficulties and excess weight, which favor a hormonal origin, must be sought in cases of persistent or late-onset acne in adults. There is a mirror image of puberty during the peri-menopausal period, but with decreased seborrhea, so acne is rare. Finally, a tumoral origin must be sought in the rare cases of acne occurring after menopause. Hormonal investigation of acne should not be systematic, but is justified during prepuberty when other symptoms are associated with acne that resists well-conducted dermatological treatment. The therapeutic approach should be primarily dermatological, but hormone-oriented treatment should be considered when such therapy fails, or in the presence of other signs of hyperandrogenism. Sometimes the association of isotretinoin and an anti-androgen treatment are necessary to effectively treat such acne. Finally, particular attention must be paid to contraceptive therapies and hormone treatments, which can induce or aggravate acne, especially during the peri-menopausal period.

Hyperandrogenemia in patients presenting with acne

OBJECTIVE

To determine whether acne is associated with hyperandrogenemia, regardless of age of presentation.

DESIGN

Prospective controlled study.

SETTING

Tertiary-care medical center.

PATIENT(S)

Thirty consecutive unselected women presenting with acne and no hirsutism and 24 eumenorrheic healthy controls.

INTERVENTION(S)

Serum samples was taken in all patients, and an acute 60-minute ACTH-(1-24) test was performed in 19 patients.

MAIN OUTCOME MEASURE(S)

Total and free T, sex hormone-binding globulin (SHBG), and DHEAS levels in basal samples, and ACTH-stimulated 17-hydroxyprogesterone (17-HP) response to exclude 21-hydroxylase (21-OH)-deficient nonclassic adrenal hyperplasia (NCAH) were determined.

RESULT(S)

Nonhirsute patients with acne demonstrated significantly lower levels of SHBG and higher free-T and DHEAS levels than controls. Nineteen (63%) acneic patients had at least one androgen value above the 95% of controls. In patients aged 12-18 years, 7/8 (88%) had at least one increased androgen value, compared with 12/22 (55%) patients aged 19-43 years. One patient (5.3%) was found to have 21-OH-deficient NCAH.

CONCLUSION(S)

Hyperandrogenemia was evident in a majority of nonhirsute acneic patients studied, regardless of age. These data suggest that androgen suppression may be useful in treating acne in many of these patients.

Exploratory Biochemical Data Analysis: a Comparison of Two Sample Means and Diagnostic Displays

The occurrence of acne in women with hyperandrogenemia is well known; a question remains, however, as to whether a further positive relationship can be detected between the intensity of acne and the levels of testosterone, androgen precursors and sex hormone binding globulin (SHBG). A procedure of interactive data analysis extracting relevant information from original data was applied. Exploratory data analysis (EDA) identifies basic statistical features and patterns of data using a variety of diagnostic displays. The need for this step is particularly acute in biochemical and clinical data, the distribution of which is mostly non-Gaussian and often corrupted by the outliers. The omission of EDA can lead to incorrect results and false conclusions. In the EDA (i) several graphical tools for summarizing data are applied, (ii) the peculiarities of a sample distribution are investigated, (iii) a construction of distribution is carried out, (iv) a graphical comparison of the sample distribution with selected theoretical distributions is employed. The proposed procedure is illustrated by typical case study in the evaluation of differences between mean values of serum levels of testosterone, androgen precursors and SHBG in a group of patients with mild and severe forms of acne. A knowledge of the interval estimate of the mean value in both groups enables their comparison at the chosen probability level. As will be apparent from the evaluation of inter-group SHBG differences, an incorrect approach to the determination of group mean values could result in a complete misinterpretation of the data. The results indicate that androgens are not significantly related to the intensity of acne, and that SHBG is higher in patients with more severe forms of acne.

Role of hormones in pilosebaceous unit development

Androgens are required for sexual hair and sebaceous gland development. However, pilosebaceous unit (PSU) growth and differentiation require the interaction of androgen with numerous other biological factors. The pattern of PSU responsiveness to androgen is determined in the embryo. Hair follicle growth involves close reciprocal epithelial-stromal interactions that recapitulate ontogeny; these interactions are necessary for optimal hair growth in culture. Peroxisome proliferator-activated receptors (PPARs) and retinoids have recently been found to specifically affect sebaceous cell growth and differentiation. Many other hormones such as GH, insulin-like growth factors, insulin, glucocorticoids, estrogen, and thyroid hormone play important roles in PSU growth and development. The biological and endocrinological basis of PSU development and the hormonal treatment of the PSU disorders hirsutism, acne vulgaris, and pattern alopecia are reviewed. Improved understanding of the multiplicity of factors involved in normal PSU growth and differentiation will be necessary to provide optimal treatment approaches for these disorders.

The role of androgens in determining acne severity in adult women

BACKGROUND

Although many arguments have been put forth supporting the role of androgens in the aetiology of acne, their part in determining the severity of the disease is not well established.

OBJECTIVES

The aim of our study was to evaluate the relationship between acne severity and the clinical and laboratory markers of androgenicity in a large group of patients.

METHODS

Ninety women over 17 years of age with acne were enrolled into the study. The levels of testosterone, androstenedione, dehydroepiandrosterone, dehydroepiandrosterone sulphate and sex hormone binding globulin (SHBG) were measured. Menstrual cycle regularity, hirsutism score, acne severity and ultrasound evaluation of polycystic ovaries were recorded. One-way analysis of variance, chi(2)-test and correlation analysis were used for data processing.

RESULTS

Hirsutism was documented in 19 (21%) subjects, elevated levels of at least one androgen in 73 (81%) subjects, an irregular cycle was reported by 43 (48%) women, and polycystic ovaries were found in 45 (50%) women. The patients were divided into three groups according to acne severity. Acne was graded using the Leeds technique as minor in 43 (48%) cases, mild in 27 (30%) and moderate in 20 (22%). We did not demonstrate a positive correlation between the grade of acne severity and any of the clinical or laboratory markers of androgenicity assessed. On the contrary, women with a higher grade of acne severity showed lower values of the index of free testosterone, a lower hirsutism score and higher SHBG levels.

CONCLUSIONS

Our study suggests that the severity of acne manifestation in adult women is not determined by androgen production.

Treatment of androgen excess in females: yesterday, today and tomorrow

Hirsutism, acne and androgenic alopecia represent, in females, some of the manifestations of the clinical spectrum of hyperandrogenism. These pictures represent not only cosmetic damage, but also a source of remarkable psychological distress. Often hirsutism is regarded as presumptive evidence of a lack of femininity. The major diagnostic concern is to exclude an ovarian or adrenal androgen-secreting tumor, a congenital hyperplasia or polycystic ovary disease. Ethnic background should be taken into account together with the progression of the symptoms. Following the etiology, surgery and exogenous glucocorticoids or inhibition of gonadotropin secretion have to be carefully chosen in the management of different kinds of hyperandrogenism. Several pharmacologic agents have recently shown the ability to block the androgen receptors at target organ sites, thus allowing a specific antiandrogenic treatment. In some cases cosmetic measures could be of great value. Obesity accompanied by hyperinsulinemia can represent the main cause of ovary androgen hypersecretion; therefore a reduced body weight and muscle activity represent the basis of any treatment. Some other drugs, such as long-acting analogs of somatostatin, could be considered among possible drugs for the future. The aim of this article is to provide an appraisal of what is presently known about the regulation of hair growth, the various causes of excessive androgen secretion and the current methods to solve, safely, this important feminine clinical problem.

Mild insulin resistance during oral glucose tolerance test (OGTT) in women with acne

The purpose of this study was to evaluate serum levels of basal insulin and glucose-stimulated insulin, and to evaluate their correlations with androgen levels in women with acne. Serum levels of total testosterone (T), free testosterone (FT), dihydrotestosterone (DHT), dehydroepiandrosterone sulfate (DHEA-S), sex hormone binding globulin (SHBG), insulin-like growth factor-1 (IFG-1), and immunoreactive insulin (IRI) were measured and compared in thirty women with moderate or severe acne and thirteen healthy controls. Serum FT, DHT and DHEA-S levels in the acne group were significantly higher than those in the control group. In the acne group, there were no significant correlations between insulin or IGF-1 levels and T, FT, DHT and SHBG, despite the positive correlation between insulin and IGF-1. In order to determine the effects of insulin secretion as a dynamic response to an oral glucose tolerance test (OGTT) on serum androgen levels in acne patients, we examined the responses of serum insulin and androgen levels to a 75 g, 2 hour OGTT in the acne group and in the control group. Basal insulin levels were not significantly higher than those in the control group, but the summed insulin levels during the OGTT in the acne group were significantly higher than those in the control group. Serum T and FT levels in the acne group decreased during the OGTT, but these changes were not so significant when compared to normal controls. In conclusion, we tried to demonstrate mild insulin resistance during the OGTT in acne patients. However, postmeal transient hyperinsulinemia does not seem to play an important role in determining hyperandrogenemia in acne patients.

Raised serum 11-deoxycortisol in men with persistent acne vulgaris

OBJECTIVE

Acne vulgaris is androgen dependent but the hormonal mechanisms are unclear. Although there have been many studies of serum hormones in women with acne there are few studies in men and the results are conflicting. We have therefore carried out a further study in men.

DESIGN AND PATIENTS

Fifty men with acne vulgaris were age-matched against 50 normal men.

MEASUREMENTS

Serum levels of dehydroepiandrosterone sulphate (DHEAS), 17 alpha-hydroxyprogesterone, 11-deoxycortisol, androstenedione and testosterone were measured by radioimmunoassay, sex hormone binding globulin (SHBG) by immunoradiometric assay and LH, FSH and oestradiol by automated ELISA.

RESULTS

The acne patients had higher levels of androstenedione, median 7.35 nmol/l, (interquartile range 2-7) vs 6.05 (2.3), P = 0.004; testosterone, 21.7 nmol/l (7.5) vs 17.55 (7.7), P = 0.04; and free androgen index (FAI) 78.26 (40) vs 65.06 (20), P = 0.007, but also had higher levels of 11-deoxycortisol, 13.65 nmol/l (4.3) vs 12.0 (4.3), P = 0.022. The LH, FSH, 17 alpha-hydroxyprogesterone, DHEAS, oestradiol and SHBG levels were not significantly different. Examination of the Spearman rank correlation coefficient matrices for the serum levels of 17 alpha-hydroxyprogesterone, androstenedione and 11-deoxycortisol showed that the strongest correlation was between androstenedione and 11-deoxycortisol.

CONCLUSION

Although there was overlap between the results of the acne patients and controls the acne patients tended to have higher levels of androstenedione, testosterone, free androgen index and 11-deoxycortisol. The higher levels of 11-deoxycortisol are suggestive of 11 beta-hydroyxlase dysfunction which could be due to a primary adrenal defect or a consequence of raised androgens. Also, a pathway between androstenedione and 11-deoxycortisol has been described in sheep and, although unsubstantiated in man, requires consideration.

Inflammation in acne vulgaris

Recent findings suggest that an overly vigorous immune response to Propionibacterium acnes may be the fundamental problem in patients with inflammatory acne. These data and evidence for the antiinflammatory effects of acne medications are reviewed.

Androgen status in adolescent women with acne vulgaris

Androgens are essential for the development of acne. The object of this study was to elucidate the androgen status of women with adolescent (Tanner's stage IV-V) acne alone and compare them to age-matched normal controls. We measured serum levels of total testosterone (T), free testosterone (FT), dihydrotestosterone (DHT), and dehydroepiandrosterone sulfate (DHEA-S) in 15 women with adolescent acne and 13 age-matched healthy controls. No significant differences were found between the mean levels of T, FT or DHT levels in patients and controls. However, the mean levels of DHEA-S in the patient population (1886 +/- 829 ng/ml) were significantly (p < 0.05) higher than normal controls (1287 +/- 620 ng/ml). There was also no correlation between androgen levels and acne severity. Thus it is unlikely that serum androgens play a principal role in women with adolescent acne.

Hormonal correlates of acne and hirsutism

Acne is a multifactorial disorder reflecting the role of infection, abnormal keratinization and immunologic reaction, as well as hormonal influences, on the pilosebaceous unit. Clinical studies have correlated elevated levels of androgens, originating in both the adrenal glands and ovaries, with acne. These include total and free testosterone, delta 4-androstenedione, dehydroepiandrosterone and its sulfate, and low levels of sex hormone binding globulin. The pathogenesis of acne initiation in childhood has been linked to rising serum levels of dehydroepiandrosterone sulfate. Hirsutism has been more directly correlated with increased levels of serum androgens, notably free testosterone. Underlying causes of elevated androgens in both disorders include very rare tumors, partial or late-onset forms of congenital adrenal hyperplasia, developmental adrenal abnormalities and, most commonly, polycystic ovary syndrome. Early acne treatment may include topical benzoyl peroxide, antibiotics, and tretinoin. More severe disease can be treated systemically (with antibiotics and/or isotretinoin). Very-low-dose corticosteroids can be used to eliminate the adrenal component of hyperandrogenism. Oral contraceptives, especially those that contain low-androgenic progestins, can reduce excessive androgens from any source and specifically suppress the ovary in polycystic ovary syndrome. Gonadotropin-releasing hormone agonists, with or without estrogen supplementation, and systemic or topical antiandrogens may play a more important role in the future.

Androgen biology as a basis for the diagnosis and treatment of androgenic disorders in women. II

In the May 1993 issue of the Journal we reviewed the basic science of androgen biology in women. We now discuss the evaluation of suspected hyperandrogenism and the therapeutic modalities available.

Adrenal androgen abnormalities in women with late onset and persistent acne

Androgens are an essential prerequisite for the development of acne. The present study was undertaken to characterize the androgen status of women with late onset and persistent acne only and, using the dexamethasone (dex) suppression test, to identify the source(s) of the androgen excess. We measured serum levels of total testosterone (T), free testosterone (FT), androstenedione (delta 4A), dihydrotestosterone (DHT), dehydroepiandrosterone sulphate (DHEA-S) and sex hormone binding globulin (SHBG) in 34 healthy control subjects, in 34 women with mild acne and in 29 women with moderate or severe acne. Serum FT, DHT and DHEA-S levels in patients of both acne groups were significantly higher than those in the control subjects. The other hormone levels showed no significant differences between patients and control subjects, and there were no significant differences between the two acne groups in any of the androgen levels. In order to evaluate the ovarian and adrenal contributions to serum androgens in the acne patients, the serum levels of delta 4A, T, DHT and DHEA-S were measured prior to and following 2 weeks of dex therapy. Following the dex test, the DHT and T of adrenal origin were significantly higher in the acne patients than in the control subjects. These results suggest that, in acne patients, hyperandrogenaemia is likely to develop as a result of adrenal androgen excess. In addition, since abnormally high androgen levels are frequently seen in late onset and persist acne, it seems that this condition is likely to be a sign of hyperandrogenism.

Relations between sex hormone level and characters of hair and skin in healthy young men

Total testosterone and dihydrotestosterone in blood serum as well as free testosterone in saliva were determined by radioimmunoassay in 110 healthy young men. The results were compared with the development of terminal hair on the trunk and limbs, with the disposition to balding and with the disposition to acne. No significant correlations were found between terminal hair development and absolute androgen levels; however, some significant values were observed in the case of the metabolic rate of dihydrotestosterone/testosterone and the proportion of free to total testosterone. The disposition to balding also correlates positively with the latter ratio. Yet the absolute serum androgen concentrations in men with a disposition to balding is lower than in men with no reduction of scalp hair. The widespread assumption that androgen levels are in general elevated in bald-trait men must therefore be rejected. In accordance with this finding, men with a disposition to balding are morphologically (with regard to anthropometric measures) no more masculine than those with good scalp hair growth. When body build and age are taken into consideration, the relations between terminal hair and androgen ratio are also problematical. No relationship could be found between acne and androgens.

Location of androgen receptor in human skin

The distribution of androgen receptor (AR) in human skin was studied by an immunohistochemical method using a polyclonal antibody against the human AR. Skin samples of preputial skin and male and female nongenital skin were examined. The possible correlation of AR location to acne was studied in skin biopsies from skin areas affected or unaffected by acne. In preputial skin, AR was expressed in epidermal cells as well as in fibroblasts, smooth muscle cells, and endothelial cells of blood vessels in the dermal area. AR was found located also in the flat fibroblast-like cells of Pacinian corpuscles. In nongenital skin, AR was also expressed in the basal cells and glandular cells of sebaceous glands, in the outer root sheath of hair follicles, and in eccrine sweat glands. The presence of AR in different cell types in the skin reflects the numerous direct effects androgens may have on this target tissue. The distribution of AR was similar in male and female skin.