Medicine for acne: Oral contraceptives

Oral contraceptives.
Ovarian hypersecretion of androgens can be suppressed with oral contraceptives. Most oral contraceptives contain combinations of estrogens and progestational agents. Oral contraceptives with estrogen (ethynyl estradiol or mestranol) and progestins of low androgenic activity are the most useful. Higher dose estrogen pills are more effective but not as safe.
Most synthetic progesterones have some degree of androgenic activity, which is undesirable in patients who already have signs of androgen excess. Oral contraceptives that appear to be useful in androgenic disorders and acne include Demulen, Ovcon 35, Modicon, Brevicon, and Ortho-Novum 7/7/7. The progesterone ethynodiol diacetate in Demulen is a relatively low androgenic progesterone. Norethindrone is more androgenic, but the low doses contained in Ovcon-35, Modicon, and Brevicon make these pills relatively nonandrogenic. Triphasil, containing levonorgestrel, and Diane (available outside the United States), containing cyproterone acetate, produced a 72% reduction in acne.
The estrogenic and androgenic activity of various oral contraceptives are listed in the Formulary. In many instances acne flares after the use of oral contraceptives is discontinued. Selection of an appropriate agent may provide the benefit of effective acne therapy for women who have chosen an oral contraceptive for birth control. Women in their thirties and forties without risk factors such as smoking or a family history of premature cardiovascular disease can safely use low-dose oral contraceptives to reduce ovarian androgen secretion.
Drugs that may reduce the effectiveness of oral contraceptives
Antibiotics
ampicillin, amoxicillin, isoniazid, metronidazole, penicillin, rifampin, tetracycline
Anticonvulsant drugs
barbiturates, carbamazepine, ethosuximide, phenytoin, primidone
Sedatives and hypnotics
barbiturates, benzodiazepines, chloral hydrate
Others
antacids, antimigraine preparations, clofibrate

Medicine for acne: Antiandrogen therapy

The majority of patients with acne do not have serum androgen abnormalities. The profound sebum suppression produced by isotretinoin has to a large extent eliminated the need for antiandrogenic therapy. Antiandrogenic therapy is reserved for patients with acne who have clinical signs of androgen excess and for those in whom other treatments have failed.
Patient population.
There is a group of women with treatment-resistant, late-onset, or persistent acne. Some of these women have signs suggesting hyperandrogenism, such as hirsutism, irregular menses, or menstrual dysfunction, but others are normal. Serum androgens may or may not be elevated.
Ovulation abnormalities.
Ovulation disturbances have been found in 58.3% of women acne patients, with a prevalence of anovulation in juvenile acne and of luteal insufficiency in late-onset/persistent acne. Women affected by late-onset or persistent acne have a high incidence of polycystic ovary disease. Polycystic ovaries are not necessarily associated with menstrual disorders, obesity, or hirsutism. The presence of polycystic ovaries in acne patients does not correlate with acne severity, infertility, menstrual disturbance, hirsutes, or biochemical endocrinologic abnormalities.
Androgens.
A combination of the effects of circulating androgens and the effects of their metabolism at the hair follicle modulates sebum production and acne severity. Androgens (free testosterone [fT], dehydroepiandrosterone sulfate [DHEAS]) are the most important hormones in the pathogenesis of acne. Plasma-free testosterone is the active fraction of testosterone and determines plasma androgenicity.
Diagnosis--serum androgen levels.
fT and DHEAS are the most practical ways of evaluating hormonal influences in the female. DHEAS is the best index of adrenal androgen activity.
Treatment
Three options.
There are three options for treating acne systemically with hormone manipulation. Estrogen suppresses ovarian androgen, glucocorticoids suppress adrenal androgen, and antiandrogens (spironolactone) act at the peripheral level (hair follicle, sebaceous gland).