NEW YORK – Almost all women with acne will have at least a fair response to therapy with oral contraceptive pills.
Most should experience at least a 50% reduction in lesions, Dr. Bethanee Schlosser said at the American Academy of Dermatology summer meeting.
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“From baseline, you are generally speaking about a 50% decrease in inflammatory and noninflammatory lesions and total lesion count,” said Dr. Schlosser of Northwestern University, Chicago. “The important thing, though, is that you have to tell a patient this is not an overnight thing. You have to wait at least three cycles before you make any kind of judgment on whether it’s working.”
The improvement will be seen on all affected areas, not just the face, she said.
“This is important. It’s not just facial acne that’s hormonally sensitive. For us to say it’s just the facial distribution that’s hormonally sensitive is ridiculous. We all know as dermatologists that all acne is androgen driven, and it’s all hormonally sensitive.”
Oral contraceptives can be used alone, as Dr. Schlosser usually initiates treatment, or they can be used in conjunction with spironolactone or antibiotics. Three OCs are approved by the FDA for the treatment of acne.
“I often get asked which OC is the best,” she said. “Just because the FDA approved some for acne doesn’t mean they are better. It means the company had the studies done and basically paid for this labeling indication.”
A 2012 Cochrane review examined 31 studies that compared different OCs to placebo and to each other. The investigators found that all the OCs were consistently more effective than placebo (Cochrane Database Syst Rev. doi: 10.1002/14651858.CD004425.pub6). The head-to-head comparisons produced conflicting results with no clear advantage of one formulation over another.
“I would say use what you are comfortable with,” Dr. Schlosser said.
Some personal and family history and health screenings are necessary before prescribing OCs, although leading women’s health associations, as well as the FDA have said there’s no need for a pelvic exam and Pap smear. “You do have to make sure they are not pregnant, hypertensive, or at risk for stroke or heart disease.”
Spironolactone is usually prescribed at 100-150 mg/day and rarely up to 200 mg/day, she noted. It can be added to an OC regimen if the patient has not adequately responded to monotherapy. It can also be combined with drospirenone, an antibiotic, or with both OCs and antibiotics.
Since spironolactone is a diuretic, women should be monitored for increased thirst and urination, and signs of hypokalemia (lethargy, muscle cramps, dizziness, and increased heart rate). In utero exposure can cause feminization of a male fetus, so reliable contraception is a must.
The drug does carry a boxed warning, as it was carcinogenic in rat studies – but only when given at 50-100 times the usual human dose.
Dr. Schlosser disclosed that she is an investigator with Galderma and Allergan.