In the case of female patients who suffer from hormonal imbalances resulting in worsening of the condition of the skin in the form of acne and comedones, one of the medical treatments used to alleviate the symptoms are most certainly birth control pills. In what way does birth control therapy actually achieve the reduction of undesired changes on the skin and in which cases should it be avoided due to contraindications, is explained by our dear associate, Ana Vrbanović, MD
Acne appears in the area of hair and sebaceous glands. We differentiate between non-inflammatory lesions (open and closed comedones), inflammatory lesions (papules, pustules and nodules) and scarring. In as much as 85% of the cases they appear in adolescence, but they also may appear later in life. They cause a significant morbidity rate linked to remaining scars and psychological problems. Common accompanying side-effects are depression and anxiety which have a negative impact on quality of life.
There are four main reasons for the appearance of acne: decrease of follicular keratinization which leads to comedones; increased androgen-related sebum production; Propionibacterium acnes; and complex inflammation mechanisms linked to the immune system. Genetics, nutrition which includes chocolate, smoking and use of occlusive cosmetics also contribute to the pathogenesis of acne. Androgens often have an important role in adult women, especially in the context of hyperandrogenism as part of polycystic ovary syndrome.
Acne appears at any time and with various degrees of severity, mostly on the lower third of the face (on the chin and jawline). Acne is considered persistent if it continues on from adolescence into adulthood. Women with signs of hyperandrogenism, such as excessive hair growth (hirsutism) and irregular cycles, should get a check-up in order to eliminate the possibility of any type of endocrine disorder such as polycystic ovary syndrome. Evaluation of acne patients should include taking extensive medical history and performing a physical examination. Account should also be taken of the medicines and supplements the person is taking as well as habits such as smoking or drug abuse, menstrual cycle status and currently prescribed acne treatment.
Combined oral contraceptives (COC) are one method of acne treatment. It is recommended not only by gynaecologists but dermatologists as well. Androgen hormones stimulate the sebaceous glands to produce sebum; so treatment that affects androgens, such as combined oral contraceptive treatment, may be beneficial in curing acne.
All combined oral contraceptives have the capacity to improve the condition of acne and hirsutism. They suppress the production of androgen and increase globulins that bind to hormones. More precisely, oestrogen helps suppress the activity of sebaceous glands and reduce androgen synthesis; while on the other hand progesterone, if used alone, may make acne worse. COC treatment ultimately leads to decrease of free androgen in the blood, thereby reducing its side-effects. Hormone-binding globulins are produced in the liver while non-oral hormonal methods such as a contraceptive vaginal ring or contraceptive patches bypass the liver. This leads to reduction in globulin production meaning that such hormonal therapy has less of an effect on androgen symptoms. COCs pass through the liver via blood and have an effect on globulin synthesis. COC treatment includes a combination of progestin and oestrogen. Research has shown that COC treatment reduces both non-inflammatory and inflammatory facial acne.
This treatment also has certain risks and side-effects. When prescribing oral contraceptives patients must be examined for contraindications. Patients with acne who could profit from this type of treatment are women with clinical signs of hyperandrogenism, polycystic ovaries syndrome, adult acne, women with PMS acne and women who have had no response to conventional treatment. Also, women who are good candidates for isotretinoin therapy are recommended to first try COC treatment, especially those in their reproductive years, due to its teratogenic properties. In addition to helping in treating acne, research shows that COC treatment reduces the risk of endometrial cancer by 50% (1) and the risk of ovarian cancer by 40 to 80% (2). Women with a family history of cardiovascular diseases, coronary artery disease, heart failure, thromboembolic diseases, systemic lupus, nephritis and antiphospholipid syndrome are not good candidates for combined oral contraceptives.
Dermatologists should be familiar with various oral contraceptives and their efficacy in treating acne. Different combinations of hormones exist so if the patient does not respond well to one certain combination they can always try out another one (unless of course the experienced side-effect is a contraindication to continuing this kind of treatment). With a comprehensive understanding of contraceptive medication and the accompanying potential risks, hormonal therapy may be used as acne treatment, safely and successfully. Progesterone therapy on its own should not be the treatment of choice for women suffering from acne or hirsutism.
- Schlesselman JJ: Risk of endometrial cancer in relation to use of combined oral contraceptives. A practitioner’s guide to meta-analysis. Hum Reprod 12:1851-1863, 1997 31.
- Hankinson SE, Colditz GA, Hunter DJ, et al: A quantitative assessment of oral contraceptive use and risk of ovarian cancer. Obstet Gynecol 80:708-714, 1992