NEW ORLEANS — Oral contraceptives are a safe and effective treatment for acne but are best used as adjunct therapy, Julie C. Harper, M.D., reported at the annual meeting of the American Academy of Dermatology.
Topical retinoids such as adapalene, tazarotene, and tretinoin remain the first-line treatment for all grades of acne, followed by oral or topical antibiotics, and then hormonal therapy.
“[Oral contraceptives] are fabulous to add to your acne treatment, but they aren't stand-alone medications or first-line treatments,” Dr. Harper said.
Ortho Tri-Cyclen (norgestimate/ethinyl estradiol) and Estrostep (norethindrone acetate/ethinyl estradiol) have been approved by the Food and Drug Administration for the treatment of acne.
Newer contraceptives such as Yasmin, which contains the novel progestin drospirenone, and Diane-35 (cyproterone acetate), which is not available in the United States, also are effective, said Dr. Harper of the department of dermatology at the University of Alabama, Birmingham.
A recent study showed that Yasmin was superior to Ortho Tri-Cyclen in reducing the total number of skin lesions in women with mild to moderate acne vulgaris after 6 months, and was rated superior by investigators for its therapeutic effect (Cutis. 2004;74:123-30).
Yasmin may “top” the other OCs in treating acne, but the difference is not dramatic, Dr. Harper said. It may take several months to see an improvement in acne on Yasmin, and she recommends a minimum of 3 months of treatment.
Yasmin combines ethinyl estradiol and 3 mg of drospirenone, a spironolactone analogue that has antimineralocorticoid and antiandrogenic activity. Androgens stimulate sebaceous epithelial cell (sebocyte) differentiation and sebum production. Excess sebum is a key factor in the development of acne.
All combined oral contraceptives, including seasonal pills taken only 4 times a year, have the potential to improve acne because they increase sex hormone-binding globulin, thereby decreasing serum androgen. This is true even when a woman's serum levels are in the normal range.
Most men and women with acne have normal circulating levels of androgen hormones, she said, adding that scientists now suspect an end-organ hyperresponsiveness to androgens in patients with acne.
OCs are used most safely to treat acne in younger women who don't smoke, do not have a history of migraines, and are normotensive. Dr. Harper will not prescribe OCs to women who smoke, are aged 35 years or older, or on rifampin. But she has prescribed them for use in girls as young as 13 years with acne.
Spironolactone 50-100 mg is recommended for women who aren't candidates for OCs and have failed conservative treatments.
She suggested that physicians prescribe 6 months of OCs when treating acne to make sure patients are following up with their gynecologist and receiving regular breast exams. The relative risk of breast cancer is 1.24 times higher in current OC users, she said.
The relative risk of stroke is 2.5 times higher in current contraceptive users, although there has been no evidence that either Yasmin or Diane-35 (cyproterone acetate/ethinyl estradiol) significantly increases thrombolytic events, compared with other OCs, Dr. Harper said.