Adult Acne Treatment

Anti-androgen and/or hormonal treatment of acne, limited to women, offers a different approach that is proving helpful when other treatments are ineffective.

Speaking today at the American Academy of Dermatology's Academy '97 Meeting, at the New York Hilton and Towers, James C. Shaw, MD, University of Chicago, Department of Dermatology, discussed the expanding field of hormonal acne treatment.

It is not known what triggers adult onset acne. The development of hormonal irregularities in the menstrual cycle may be a factor, or ovarian cysts may cause hormonal abnormalities that increase androgen productivity, resulting in acne breakouts.

Women who benefit most from hormonal treatment are typically in their 20s or 30s, and have a history of failed treatment, or an intolerance to standard acne therapies (both topical and systemic). In addition, many have a history of menstrual irregularities, premenstrual acne flare-up, and facial oiliness. Hormonal treatment is generally not used in the most severe forms of acne, nodular/cystic acne.

Most acne treatments require prolonged care, from months to years. Once improvement is achieved, a maintenance dose is usually necessary. Women who develop adult acne typically have the problem for years, frequently through menopause.

The modalities used most in hormonal acne treatment are oral contraceptives and antiandrogens (spironolactone or flutamide).

"It is common to start with oral contraceptives for one to two months," Dr. Shaw said. "Sometimes just regulating the menstrual cycle is enough to stop the acne. Often women are already on birth control pills, so we add antiandrogens. The combination is very effective."

The hormonal approach is becoming more mainstream, and it is not uncommon to use the two hormones together.

Spironolactone is a medication used primarily for the treatment of high blood pressure. Recently it has been used to treat acne and excess hair growth in women. Spironolactone and flutamide act by blocking the effects of testosterone (androgen) on the oil glands and hair follicle. It is the male hormone testosterone which triggers the acne. The result is a reduction in oil production and facial hair growth, and the improvement of acne and excessive hair growth.

The optimal dose of spironolactone varies in different individuals and may require some adjustment. The benefits are usually apparent in two to three months, but frequently within one month. This drug has been used for over 25 years and has proven quite safe and is generally well tolerated.

Serious side effects with spironolactone are extremely rare. The most common side effect is irregularity of menstrual cycles, but if the patient is taking birth control pills, this should cause minimal problems, Dr. Shaw said.

In addition to clearing acne, spironolactone treats premenstrual syndrome (PMS) and acts as a diuretic, which may counter some of the weight gain typical of birth control pills.

The treatment goal is to control the acne with therapy and then maintain that treatment as long as needed, with the lowest dose that controls the problem, Dr. Shaw said. Some form of treatment may be necessary until menopause.

"The use of hormonal treatment in acne is very individualized and usually requires considerable discussion with patients, with possible adjustments of medications and doses during the first few months of treatment," Dr. Shaw said. “Once a stable level of control is achieved, patients tend to do quite well on their own and follow-up visits may be as few as every six to 12 months.”