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FA L L C L I N I C A L D E R M AT O L O G Y C O N F E R E N C E P R O C E E D I N G S
TREATING ACNE WITH ORAL
CONTRACEPTIVES
A GUIDE FOR SAFE, EFFECTIVE AND EFFICIENT PRESCRIBING
BY JULIE C. HARPER, M.D.
UNIVERSITY OF ALABAMA – BIRMINGHAM
BIRMINGHAM, AL
While some dermatologists
have been prescribing
oral contraceptives
for the treatment of acne
for many years with much success,
others are resistant. The
goal of this article is to assure the
safe, effective and efficient prescription
of oral contraceptives for
acne patients, which will result in
Julie C. Harper, M.D. i m p rovements in patients’ acne
and their overall quality of life.
Acne is a complex multifactorial disord e r. Since there are
4 diff e rent causes in the pathogenetic process, combination
t reatments that target the multiple pathogenetic factors will
o ffer the greatest improvement in the shortest amount of
time. Oral contraceptives can be added to the armamentarium
as another option for treatment.
The 4 causes of acne are follicular epidermal hyperpro l i f e r a-
tion, excess sebum, P ropionibacterium acnes and inflammation.
During follicular epidermal hyperproliferation, plugging
causes the development of comedones and micro c o m e d o n e s .
For excess sebum, hormonal therapy, whether it is spiro n o l a c-
tone, flutamide or oral contraceptives, creates an antiandro g e n
e ffect that has most of its impact on the sebaceous gland.
While probably not the first event in the pathogenetic pro c e s s ,
P ropionibacterium acnes certainly is a cause. Also, whether or
not inflammation is the first event in the process or it is secondary
to P. acnes is a difficult question to answer.
Oral contraceptives are not monotherapy for acne; rather,
they fall into the mix of topical retinoids, benzoyl peroxides,
and antibiotics. The type of oral contraceptive prescribed for
acne is a combination of ethinyl estradiol and a progestin.
Ethinyl estradiol varies in dose from pill to pill from 20 micrograms
to 50 micrograms in a pill. The amount of ethinyl estradiol
is important, because many of the risk factors associated
with birth control pills are associated with higher doses of
ethinyl estradiol. The progestins in combination birth control
pills vary widely but may include norethindrone acetate, levonorgestrel,
desogestrel, norgestimate, and drospirenone
among others. Drospirenone is the only progestin available in
the United States that is antiandrogenic alone. Some other
progestins can be proandrogenic.
Oral contraceptives are antiandrogenic because ethinyl
estradiol in combination birth control pills increases sex hormone
binding globulin. Sex hormone binding globulin acts as
a sponge — it soaks up free testosterone and decreases the
amount that is free and circulating and capable of having its
impact at the sebaceous gland, for example. Also, there is a
negative feedback to the hypothalamus and pituitary, which
results in decreased production and release of gonadotropin
releasing hormone, luteinizing hormone and follicle stimulating
hormone. This then results in decreased ovarian production
of hormone. Also, because ovulation is blocked, the ovary
produces less androgen.
The novel progestin, dro s p i renone, is equivalent to about
25 mg of spironolactone when it is in a 3 mg dose, which
is available in 2 birth control pills that are on the market now
in the United States. Dro s p i renone has antimineralocorticoid
properties as well.
Attendees focus on new clinical information.
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