Androgens, estrogen and acne development
How does hormonal treatment work?
As compared to other forms of acne therapy such as oral isotretinoin or oral antibiotics, hormonal therapy does have a longer period of time before results are seen; usually around three to six months after initiation of treatment. Hence, it is crucial for the medical practitioner to adequately educate the patient on this and set realistic expectations for them. To add on, hormonal therapy should be prescribed alongside other treatment forms such as topical treatment in order to optimise the end result.
What are the examples of such therapy?
There are various types of hormonal therapies available in the market. However, only the three most commonly used ones will be touched on in this article. They are namely: oral contraceptives, metformin and spironolactone.
Estrogen and progestin are the two main components in an oral contraceptive. The estrogen component itself exerts a few effects. Not only does it retard the production of androgens by the ovaries, it aids in elevating the amount of androgen-binding-proteins as well. In so doing, the level of androgens circulating in the body decreases. Although the progestin component stimulates the production activity of androgens, its function is counteracted by the very fact that all low-dose combination oral contraceptives have more estrogen than progestin in it. In fact, progestins of later generations’ e.g fourth or fifth generation tend to be used more as they have a lower stimulatory effect on androgens.
Till this date, the United States Food and Drug Administration has only approved three oral contraceptives to be used as hormonal therapy for acne. These drugs go by the name of Estrostep, Ortho Tri-Cyclen and Yaz.
While oral contraceptive are anti-androgenic and hence effective in treating acne, it comes with some notable side effects as well. Some minor ones include an increase in weight and breast tenderness, while more major ones comprise of an increase in thromboembolic risk and development of breast lumps. In view of these side effects, it is thus important to ensure that the patient does not have any cardiovascular risk factors, current or previous history of breast cancer or a surgery of some sort that requires a long period of immobilisation before putting them on oral contraceptives.
Metformin comes across as a rather unorthodox drug choice for the treatment of hormonal acne because it is originally used to treat diabetes. However, in recent years, its function has been broadened to include treatment for acne in individuals with PCOS or hyperinsulinemia. With either condition, a person has a surplus of a hormone called the insulin-like growth factor 1 (IGF-1). IGF-1 unfortunately has a positive correlation with the amount of facial sebum secreted. Hence, such patients tend to have the tendency to develop acne to varying severity. Metformin thus comes in useful to reduce the levels of IGF-1 in these individuals and thus its downstream effects as well. In this way, acne in patients with PCOS or hyperinsulinemia can be effectively targeted and treated.
The drug spironolactone is likewise an unconventional medication for hormonal acne. It was originally used as an antihypertensive agent but is used less nowadays due to the invention of another drug—eplerenone which has fewer side effects. Spironolactone has secondary functions that aids in reducing sebum secretion in an individual and is thus efficacious in treating acne. These secondary functions include being an androgen receptor blocker and preventing the conversion of testosterone to its more potent form – dihydrotestosterone. Additionally,
studies have also reported that it is able to treat hirsutism too which once more lowers the propensity for acne to develop.
There are however some noteworthy side effects. For one, the use of spironolactone is highly discouraged in men. Reason being the drug interacts with androgen receptors which are essentially male sex hormone receptors.
Thus, severe potential side effects experienced in a male taking this drug can ensue and these include gynecomastia, impotence and benign prostatic hyperplasia. Women however are not affected in such ways. Side effects that can be expected in both sexes include nausea, vomiting, diarrhoea and large variations in blood pressure which changes with position.
Apart from the aforementioned hormonal therapies, there are other medications that can influence hormones in the body as well and result in less acne. Glucocorticoids is one such example. They are used particularly for patients with congenital adrenal hyperplasia which results in an underwhelming production of a hormone cortisol and an excessive amount of androgens. In the process of correcting this derangement of hormones, glucocorticoids thus concomitantly aids in treating acne (if present) that can potentially be caused by the high levels of androgens.
Hormonal treatment vs oral antibiotic therapy
Based on a few conducted studies, it has been found that both oral antibiotic therapy and hormonal therapy are equally efficacious in treating acne in patients. However, a significant finding would be the shorter period of time required by oral antibiotics to deliver results as compared to hormonal therapy. Certainly, limitations to these studies have been cited and more research has to be done in order to draw a more definitive comparison between the two types of treatment.
Ultimately, whether or not a patient is a suitable candidate for a particular medication depends on a few of his/her own personal factors. Some of these include which drug they failed to respond to previously, individual risk factors that prevent them from taking certain drugs and also family planning should oral contraceptives be used. Apart from systemic medications, it is also important for patients with acne to adhere to a proper skincare regimen which includes topical treatments in order to supplement the battle against acne. Lastly, it is always prudent for individuals to seek medical advice from a relevant clinician and have a proper discussion on the type of acne treatment most appropriate for them and their goals of care as well.