LAS VEGAS — Oral contraceptives can be effective for the treatment of acne in women, but should be used as an adjunct to an existing therapy regimen instead of first-line or stand-alone therapy, Dr. Julie C. Harper said at the Fall Clinical Dermatology Conference.
“I never start with these,” said Dr. Harper, of the University of Alabama at Birmingham. “I start with a topical retinoid and add systemic or topical antibiotics, or an antimicrobial like benzoyl peroxide. If the patient does not respond, I don't stop those and then add a birth control pill. I add the birth control pill into the mix.”
Dr. Harper said that 12% of women aged 25–44 have acne, while only 5% of women still have the condition after age 45.
All combination ethinyl estradiol/progestin oral contraceptives (OCs) have the potential to improve acne because their antiandrogenic properties decrease circulating free testosterone by increasing sex hormone-binding globulin.
It's important to weigh the benefit of OCs against the documented risks, which include:
▸ Venous thromboembolism. The risk is tripled in current users of oral contraceptives, and that risk increases with higher doses of ethinyl estradiol. The mortality rates double for OC users aged 35–45.
▸ Stroke. Women aged 20–24 who use OCs face a 2.5-fold higher risk of ischemic stroke, compared with their peers who do not use them. The risk is directly proportional to the estrogen dose used and increases with age.
“These risks are probably not as significant now as they were several years ago when all of the birth control pills contained ethinyl estradiol doses near 50 micrograms,” Dr. Harper noted. “Now we're seeing [ethinyl estradiol dosages] at 25, 30, and 35 micrograms. Hypertension, cigarette smoking, and migraine headaches also substantially increase this [stroke] risk.”
▸ Myocardial infarction. Eighty percent of heart attacks that occur in women who are on an OC can be attributed to cigarette smoking. “The remainder occurs in people who are taking birth control pills who have other known risks, like hypertension or diabetes,” she said, adding that she does not prescribe OCs to smokers.
Nor does Dr. Harper, a dermatologist, feel comfortable prescribing OCs to women over the age of 35. Instead, she says she encourages these women to see an ob.gyn. or their primary care provider and to get the birth control pill prescription from them.
▸ Breast cancer. According to a World Health Organization metaanalysis, the relative risk of breast cancer for current oral contraceptive users is 1.24, while the relative risk of cancer that has spread vs. remained localized is 0.88. That means that the disease was found earlier in women who were on an OC than in those who were not.
“The message to me there is, we need to be sure that women who are getting birth control pills are getting well-woman exams,” Dr. Harper said at the meeting, which was sponsored by the Center for Bio-Medical Communications Inc. “I start somebody on a birth control pill and I give them a 6-month supply. I tell them, 'If this is working, you need to get your second 6-month supply from someone who can do that well-woman exam.'”
Another option for acne treatment that Dr. Harper uses in older women is spironolactone, an aldosterone antagonist that binds to the androgen receptor and inhibits androgen biosynthesis in the gonads and adrenal glands. She starts with a dosage of 50–100 mg/day.
“If the woman is able to bear children, I think this needs to be coadministered with a birth control pill,” she said. “If the woman becomes pregnant while on spironolactone, there is risk of feminization of the male fetus.”
Spironolactone can also cause menstrual irregularities. “That's another reason to coadminister with a birth control pill,” she said.