A therapeutic endocrine approach may be a viable solution in many cases of female acne; especially when the role of androgens is proven or likely.
Acne is a major skin problem that affects men and women and can be attributed to a substantially acute and
chronic pilosebaceous unit inflammation evolving in a different way and involving different skin zones (constituting disease clinical features).
In women the ovary endocrine environment plays a very important role (androgen in particular) in acne pathophysiology. This understanding has enabled an integrated approach among gynecologists, endocrinologists and dermatologists with clear advantages for patients.
Acne is often detectable in young women suffering microcystic or polycystic ovary syndrome (PCOS), a condition characterized by menstrual irregularities (mainly oligo-amenorrhea) and modest hyperandrogenism of ovarian and/or adrenal origin, which can sometimes also lead hypertrichosis and hirsutism. A relationship between androgens and acne is now widely demonstrated: they (testosterone, andostenedione and other substances) would increase and make sebaceous secretion more dense thus favoring obstructive and inflammatory phenomena.
In case of a not noticeable androgens increase, it is hypothesized an increased sensitivity (genetically determined) of the pilosebaceous unit at their normal levels in blood.
The graph below shows a summary of acne pathophysiology: it is easy to notice the androgens role.
I therefore consider very useful in a woman with acne undertake a study to investigate at the endocrine level in ovarian and adrenal for a possible source of hyperandrogenism, particularly when the patient presents obesity, increased hirsutism and menstrual irregularities.
Endocrine therapy is based on the evidence that a reduction of androgen receptor stimulation on the skin can result in a dramatic improvement. This objective can be achieved through different points of “attack”:
· Determining a decreased ovarian and adrenal production;
· Increasing the androgens transport protein in blood, called Sex Hormone Binding Globulin (SHBG) and then binding a greater amount of androgens in blood without leave them free to act on peripheral receptors;
· Directly blocking the androgen receptors at the cellular level with antagonists inhibiting their action.
Medications that satisfy these action requirements are some combined oral contraceptive (pill) containing estropegestin (E/P) and particularly those that have a progestin component, a substance capable of acting directly in a “competitive” way with androgen receptors (i.e. cyproterone acetate, drospirenone). It is good to point out that the pill can not be used in all cases, and there are in fact accurate contraindications and precautions to be observed.
Metformin (an anti diabetic drug) can improve the pill’s effects, particularly in patients who are overweight or obese; the action of the drug is mainly in the ovary, further reducing the production of androgens. Since it is not yet safe to use in pregnancy, this medication should always be associated with the pill when administered to women of reproductive age.
When the pill (oral contraceptives) is contraindicated were used with success also some insulin-sensitizing agents as inositol; these dietary supplements are used sometimes in combination with other treatments.
Finasteride, Dutasteride and Flutamide are potent anti-androgen used in the male; their use in women can be dangerous and is reserved to specialized medical centers authorized to prescription (off-label use).
Finally, it is important to clarify that an endocrinological approach does not replace specific dermatological and sanitation therapies, but simply integrates them. Diet is always important; it should be low in fat and foods with high glycemic index.
Therapeutic action for acne patients requires increasingly close coordination between Gynaecologist-Endocrinologist and Dermatologist.