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  • Presentation

Controversies Surrounding Hormonal Therapy in the Management of Acne

Description

This presentation addresses the controversies surrounding hormonal therapy in acne management, focusing on who should receive hormonal workups and relevant lab tests. Different perspectives exist on whether all adult women with acne should be tested for androgens, or if only those with signs of hyperandrogenism should be. Common signs include acne, hirsutism, and irregular menses, with polycystic ovarian syndrome (PCOS) being a primary cause of androgen excess. Lab workups must exclude other conditions like thyroid dysfunction and adrenal disorders. Spironolactone, an anti-androgen effective for treating acne, lacks FDA approval for this use, and monitoring potassium levels is debated. While younger healthy individuals may not need routine checks, older patients should be monitored due to increased risks of hyperkalemia. Birth control pills are recommended for patients with irregular menses or who may benefit from additional contraception. The speaker favors prescribing combined oral contraceptives, particularly those that include drospirenone. Additionally, the discussion includes the use of clascoterone cream, which is endorsed as a supplementary treatment rather than a first-line option. The importance of personalized treatment approaches and patient education on hormonal therapy's risks and benefits is emphasized throughout.

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Conclusions

  • Hormonal work-ups for acne patients are recommended primarily for those with additional signs of androgen excess, such as hirsutism or irregular menses.
  • Current lab testing guidelines for evaluating androgen excess in acne vary among organizations, but a consensus is evolving towards a standardized approach.
  • Spironolactone is an effective anti-androgen treatment for acne, but it is not FDA-approved specifically for this use.
  • Routine potassium monitoring is not necessary for healthy women under 45 taking spironolactone, but monitoring is recommended for those over 45 due to increased risk of hyperkalemia.
  • Higher doses of spironolactone (100 mg or more) are often required to achieve significant improvement in acne, especially in patients with PCOS.
  • The risk of malignancy related to spironolactone use is not supported by substantial evidence; the black box warning regarding tumors in rodents does not translate to human risk.
  • Spironolactone is safe to use during lactation, and canrenone, its metabolite, is present in milk at negligible levels.
  • Combination oral contraceptives are effective for treating acne, with various formulations available, and all are considered to work equally well regardless of type.
  • Clascoterone is a new topical androgen receptor inhibitor effective in reducing acne, particularly in patients with sensitive skin.
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