Issues in Dermatology
This Expert SharesProblem-Solving Insights About a Challenging Acne Case
September 2002
A 27-year-old woman presented with moderate to severe papulo-nodular acne involving her face. She had received isotretinoin (Accutane) during the previous year, but had stopped treatment because of fatigue and headaches. Systemic antibiotics in the past resulted in vaginal candidiasis. She was interested in treatments other than isotretinoin. Review of her history revealed a long course of acne with a positive family history of severe acne. She had regular menstrual periods with no pre-menstrual worsening, moderate facial seborrhea and no complaints of hair growth on the face or elsewhere on her body. On examination, she had papulo-nodular acne on the face with some scarring (see photo). Her back and chest were minimally involved.
Diagnosis and Treatment
Her diagnosis was nodular acne, moderate severity, with early signs of scarring. Because she wasn’t interested in isotretinoin, we considered a hormonal therapy approach. Lab results showed normal testosterone, free testosterone, and dehydroepandrosterone sulfate. We started her on contraceptive norgestimate-ethinyl estradiol (OrthoTri-Cyclen) and the agent spironolactone (Aldactone) 100 mg/day, which we increased to 150 mg/day after 1 month. Over the next 3 months, she had reasonable improvement, with continued improvement for 6 months (see photo). She tolerated the treatment well.
Discussion
In a patient who has moderate nodular acne and early scarring, the treatment of choice would normally be oral isotretinoin. This case illustrates the value of hormonal therapy as an alternative to isotretinoin in selected patients. The patient was intolerant of both antibiotics and isotretinoin.
Although tests didn’t reveal an endocrin-opathy such as polycystic ovary syndrome, a hormonal approach was implemented and her response was excellent. She has remained on this regimen for several years.
Oral contraceptives can be used alone in cases such as this, although most studies show improvement in the range of 50%, which is often inadequate. Oral contraceptives reduce androgen effect through suppression of ovarian androgen secretion, elevation of steroid hormone binding globulin, and possibly some androgen receptor blockade and 5-alpha reductase inhibition. The addition of the androgen-receptor blocker, spironolactone, to an acne regimen of oral contraceptives results in 70% improvement or more. Usually a dose of 50 mg to 100 mg/day is effective and well tolerated. Long-term safety profiles of oral contraceptives and spironolactone are high, allowing prolonged therapy if required. Side effects with spironolactone can include menstrual irregularities, breast tenderness and a mild diuretic effect.
A 27-year-old woman presented with moderate to severe papulo-nodular acne involving her face. She had received isotretinoin (Accutane) during the previous year, but had stopped treatment because of fatigue and headaches. Systemic antibiotics in the past resulted in vaginal candidiasis. She was interested in treatments other than isotretinoin. Review of her history revealed a long course of acne with a positive family history of severe acne. She had regular menstrual periods with no pre-menstrual worsening, moderate facial seborrhea and no complaints of hair growth on the face or elsewhere on her body. On examination, she had papulo-nodular acne on the face with some scarring (see photo). Her back and chest were minimally involved.
Diagnosis and Treatment
Her diagnosis was nodular acne, moderate severity, with early signs of scarring. Because she wasn’t interested in isotretinoin, we considered a hormonal therapy approach. Lab results showed normal testosterone, free testosterone, and dehydroepandrosterone sulfate. We started her on contraceptive norgestimate-ethinyl estradiol (OrthoTri-Cyclen) and the agent spironolactone (Aldactone) 100 mg/day, which we increased to 150 mg/day after 1 month. Over the next 3 months, she had reasonable improvement, with continued improvement for 6 months (see photo). She tolerated the treatment well.
Discussion
In a patient who has moderate nodular acne and early scarring, the treatment of choice would normally be oral isotretinoin. This case illustrates the value of hormonal therapy as an alternative to isotretinoin in selected patients. The patient was intolerant of both antibiotics and isotretinoin.
Although tests didn’t reveal an endocrin-opathy such as polycystic ovary syndrome, a hormonal approach was implemented and her response was excellent. She has remained on this regimen for several years.
Oral contraceptives can be used alone in cases such as this, although most studies show improvement in the range of 50%, which is often inadequate. Oral contraceptives reduce androgen effect through suppression of ovarian androgen secretion, elevation of steroid hormone binding globulin, and possibly some androgen receptor blockade and 5-alpha reductase inhibition. The addition of the androgen-receptor blocker, spironolactone, to an acne regimen of oral contraceptives results in 70% improvement or more. Usually a dose of 50 mg to 100 mg/day is effective and well tolerated. Long-term safety profiles of oral contraceptives and spironolactone are high, allowing prolonged therapy if required. Side effects with spironolactone can include menstrual irregularities, breast tenderness and a mild diuretic effect.
A 27-year-old woman presented with moderate to severe papulo-nodular acne involving her face. She had received isotretinoin (Accutane) during the previous year, but had stopped treatment because of fatigue and headaches. Systemic antibiotics in the past resulted in vaginal candidiasis. She was interested in treatments other than isotretinoin. Review of her history revealed a long course of acne with a positive family history of severe acne. She had regular menstrual periods with no pre-menstrual worsening, moderate facial seborrhea and no complaints of hair growth on the face or elsewhere on her body. On examination, she had papulo-nodular acne on the face with some scarring (see photo). Her back and chest were minimally involved.
Diagnosis and Treatment
Her diagnosis was nodular acne, moderate severity, with early signs of scarring. Because she wasn’t interested in isotretinoin, we considered a hormonal therapy approach. Lab results showed normal testosterone, free testosterone, and dehydroepandrosterone sulfate. We started her on contraceptive norgestimate-ethinyl estradiol (OrthoTri-Cyclen) and the agent spironolactone (Aldactone) 100 mg/day, which we increased to 150 mg/day after 1 month. Over the next 3 months, she had reasonable improvement, with continued improvement for 6 months (see photo). She tolerated the treatment well.
Discussion
In a patient who has moderate nodular acne and early scarring, the treatment of choice would normally be oral isotretinoin. This case illustrates the value of hormonal therapy as an alternative to isotretinoin in selected patients. The patient was intolerant of both antibiotics and isotretinoin.
Although tests didn’t reveal an endocrin-opathy such as polycystic ovary syndrome, a hormonal approach was implemented and her response was excellent. She has remained on this regimen for several years.
Oral contraceptives can be used alone in cases such as this, although most studies show improvement in the range of 50%, which is often inadequate. Oral contraceptives reduce androgen effect through suppression of ovarian androgen secretion, elevation of steroid hormone binding globulin, and possibly some androgen receptor blockade and 5-alpha reductase inhibition. The addition of the androgen-receptor blocker, spironolactone, to an acne regimen of oral contraceptives results in 70% improvement or more. Usually a dose of 50 mg to 100 mg/day is effective and well tolerated. Long-term safety profiles of oral contraceptives and spironolactone are high, allowing prolonged therapy if required. Side effects with spironolactone can include menstrual irregularities, breast tenderness and a mild diuretic effect.
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