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Acne in female adolescents: Using combined oral contraceptives (COCs)

Hormone replacement, Skin Conditions, Women's Health | May 27, 2015 | Author: The Super Pharmacist

Skin conditions, women, skin

Acne in female adolescents: Using combined oral contraceptives (COCs)

Almost every teenager can expect to experience acne at some point in their lives and it typically tends to occur in adolescence when hormones are in a state of flux. It is usually mild, although moderate to severe acne affects approximately 20% of all young people. In girls, it may flare up when they are premenstrual and it can also be associated with polycystic ovarian syndrome (1).  Acne vulgaris is a disorder of the pilosebaceous follicles and it is often triggered when there is an excessive amount of sebum that is produced by glands within the skin. The sebum clogs pores within the skin, facilitating the growth of bacteria which in turn can lead to the development of acne. A group of hormones, known as androgens, stimulate the skin to produce sebum. In 99% of all cases acne will affect the face, the back in 60%, and across the chest in 15% of cases (2).

Treatment options available

There are a number of different treatment options available including topical cream preparations, antibiotics, topical retinoids and oral antibiotics. In more severe cases of acne, photodynamic therapies, laser treatments and chemical peels have also been used, but there is no significant evidence to suggest that such treatments are successful in reducing the effects of acne (3). Birth control pills are commonly used. Pills that contain oestrogen and progesterone function by significantly lowering the amount of androgens in the body, and subsequently the amount of sebum and severe acne that many adolescents experience. Birth control pills are the most commonly prescribed anti-androgen treatment. 

Birth control pills for acne

Generally, the prescribing of birth control pills for the treatment of acne is most often offered to otherwise healthy women who also require contraception. However, in practice many general practitioners prescribe combined oral contraceptives (COCs) off label for the full range of acne, from low level through to severe. It is advised that birth control pills are only offered after other treatment options, such as topical creams and antibiotics, have been attempted without success. Combined oral contraceptives (COCs) containing the hormones progestin (synthetic progesterone) and oestrogen are the most commonly prescribed for the treatment of acne, and combined treatments are often the only licensed options available. This is as a result of studies that have shown birth control pills that only contain progesterone can actually make acne worse and more severe in nature. Each type of COC that is used for the treatment of acne always contains a low dose of the same form of oestrogen, but different forms of progesterone.

Most effective treatment option

Although there is a relatively limited evidence base in this particular area, a systematic review undertaken by The Cochrane Collaboration in 2012 reviewed a range of studies concerning the impact of birth control pills on adolescent acne (4). The review included studies that measured a range of outcomes including reductions in the amount of acne and the severity of acne, and considered a total of 31 trials with over 12,500 participants. The review found that all trials that compared COCs with a placebo found the COC to reduce the amount of acne lesions, severity and patient-reported levels of acne when compared directly with placebo.

A levonorgestrel-COC was evidenced to have fewer lesions and non-inflammatory lesion counts when compared with the same dose of norethrindrone acetate-COCs (5). Similar studies regarding the efficacy of drospirenone and dienogest-COCs found them to have a greater percentage decrease in total lesion counts when compared to placebo (6).

Whilst the evidence regarding COCs versus placebo is unequivocal, there is considerably less evidence that directly compares different COCs in order to evaluate their comparative effectiveness. A limited number of studies found that products containing chlormadinone acetate were more effective than levonorgestrel at improving self-reported acne appearance and reducing lesions, yet the measured amounts were so small as to not be statistically significant (7). Levonorgestrel showed a slight improvement in acne outcomes when compared with desogestrel, but other studies had conflicting results.

Overall, the systematic review concluded that the studies that compared different type of COCS and their effect on acne outcomes yielded results that were not statistically significant, with no important and consistent differences observed between different contraceptives (6). This is reflected in the prescribing guidance of most regulatory bodies around the world who generally recommend 3-4 different COCs for the control of acne but offer no further evidence or guidance in regards to which is the most effective (8).

There is little available evidence regarding the use of COCs in conjunction with other treatment options for acne, although this is common prescribing practice among many medical practitioners. This is in response to the fact that COCS only address excessive sebum in the body, whereas other treatment options such as topical antibiotics or creams help to clear up the acne itself. More research is required in this area in order to better understand the optimal combination of different treatment options and how they are best used.

The long term use of some topical antibiotics is discouraged, as gram-negative folliculitis can occur as a result of long-term erythromycin or tetracycline use (9). It is clear that COCs are an effective method of controlling acne in adolescent females. However, there remains limited evidence available regarding the COC that is clinically the most effective at reducing lesions, visible acne and self-reported levels of acne, and more research in this particular area is required.

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References

1. Bhate K, Williams HC (2013) Epidemiology of acne vulgaris Br J Dermatol 168(3):474-85

2. Bergler-Czop B, Brzezinska-Wcislo L (2013) Dermatological problems of puberty Postepy Dermatol Alergol 30(3):178-87

3. Kim RH, Armstrong AW (2011) Current state of acne treatment: highlighting lasers, photodynamic therapy, and chemical peels

4. Tyler KH, Zirwas MJ (2013) Contraception and the dermatologist J Am Acad Dermatol 68(6):1022-9

5. Thorneycroft IH, Gollnick H, Schellschmidt I (2004) Superiority of a combined contraceptive containing drospirenone to a triphasic preparation containing norgestimate in acne treatment Cutis 74(2):123-30

6. Arowojulu AO, Gallo MF, Lopez LM, Grimes DA (2012) Combined oral contraceptive pills for treatment of acne Cochr Lib Sys Rev OI: 10.1002/14651858.CD004425.pub6 (last accessed 14th May 2015)

7. Zouboulis CC, Piqero-Martin J (2003) Update and future of systemic acne treatment Dermatology 206(1):37-53

8. FDA Drug Safety Communications: Safety Review of possible increased risk of blood clots with birth control pills containing drospirenone. Available online at http://www.fda.gov/Drugs/DrugSafety/ucm257164.htm (last accessed 15th May 2015)

9. Lehrhoff S, Yost J, Robinson M, Patel R, Sanchez M (2012) Serratia marcesens folliculitis and concomitant acne vulgaris Dermatol Online J 15:18(12):19

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