Women with Acne at Possible ‘High Risk’.(Health & Fitness)
Author/s: Andrew Bowser
New Orleans – A small but significant proportion of adult women with acne may be at risk for serious medical disorders, Anne W. Lucky, M.D., said.
“These patients may have significant health risks in later life, and many of us as dermatologists may be the first or only physicians to encounter them,” said Dr. Lucky, professor of dermatology and pediatrics, Children’s Hospital Medical Center in Cincinnati. “We should be aware and at least be able to triage them.”
Speaking at the annual meeting of the American Academy of Dermatology, Dr. Lucky said complaints of acne often cycle with the menstrual period, often with accompanying hirsutism, or irregular menses. Dr. Lucky said many of these women might have hyperandrogenism and/or polycystic ovarian disease.
The prevalence of polycystic ovarian syndrome or hormonal abnormalities has been described several times in the literature. Recently, researchers in the United Kingdom found that of 152 women more than age 25 with acne, 37 percent had features of hyperandrogenicity. The researchers noted that these patients, along with the small percent of patients with true late-onset acne (as opposed to persistent acne) might have underlying abnormalities of ovarian, adrenal, or local androgen metabolism (Goulden V., et. al., Br J Dermatol. 1997 Jan;136:66- 70).
The adverse effects of elevated androgens, sparsely described in the dermatologic literature but seen throughout the literature of internal medicine, epidemiology, and cardiology, include acne, hirsutism, androgenentic alopecia, menstrual abnormalities and infertility, obesity, and insulin resistance. Higher levels of circulating insulin can lead to early onset diabetes mellitus, lipid abnormalities, and eventually early coronary artery disease.
Women with polycystic ovary syndrome (PCOS) exhibit insulin resistance and have a high risk for glucose intolerance. A recent study of 250 women with polycystic ovary syndrome, most of whom were obese, 31.1 percent had impaired glucose intolerance and 7.5 percent had diabetes. By comparison, 80 control women matched by weight, ethnicity, and age had no diabetes and only a few cases of glucose intolerance (Legro R.S. et. al., J Clin Endocrinol Metab. 1999 Jan;84:165-9).
“When we see a patient who has the obvious signs of acne, maybe a little hirsutism, and irregular menses, especially with obesity, we may want to think about screening them for early onset diabetes,” she said.
Other studies have raised the possibility that lipid-lowering interventions might be indicated in the near future for PCOS patients. In a study of 143 New Zealand women less than age 60 undergoing cardiac catheterization, researchers found 42 percent had ovarian cysts, compared to 22 percent of controls (Birdsall M.A. et. al., Ann Intern Med. 1997 Jan;126:32-5). In addition, they found the women with PCOS had more extensive coronary artery disease.
Treatment Pearls Offered
Dr. Lucky acknowledged that treatment of adult acne will often be the dermatologist’s primary concern, and she said that when conventional treatment with topical or systemic therapy fails, hormonal or antiandrogenetic treatment may be indicated.
In particular, the antiandrogen spironolactone (Aldactone) “works extremely well,” she said, describing the case of one patient with moderate but persistent acne with some hirsutism that improved following approximately 18 months of low- dose therapy.
“I find that low doses of 25 mg b.i.d. up to 75 mg a day often will work very well for that once-a-month outbreak,” she added.
Prevalence of adult onset acne has not been definitively quantified, but in a large epidemiologic study of the hundreds of thousands of patients in the National Ambulatory Medical Care Survey database from 1990 to 1994, investigators found 36 percent of patients who had sought medical care for acne were more than 25 years of age, with 20 percent between 25 and 34, 10 percent between 35 and 44 and 5 percent more than 45 (McConnell RC, et. al. J Am Acad Dermatol. 1998 Feb;38:221-6).
Several rare conditions may also be the cause of adult onset acne in women. Dr. Lucky described one patient with no history of acne who at the end of pregnancy began to get large nodules, especially on the back, and exhibited hirsutism. The patient refused isotretinoin postpartum, and within a year both the acne and hirsutism disappeared. The case was described as a transient phenomenon probably related to a luteoma – a small collection of androgen producing cells of the ovary.
Dr. Lucky also described another adult woman with acne who had been treated by a dermatologist for rosacea, a hair transplant surgeon for hair thinning, an internist for hypertension, and a nutritionist for obesity. The patient was subsequently accurately diagnosed with Cushing’s syndrome.
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