Hormonal therapy is an important component in the treatment of women with acne who may or may not have elevated serum androgens. The mainstays of hormonal therapy include oral contraceptives and antiandrogens such as cyproterone acetate, flutamide or spironolac tone.
Recent research over the past several years has unraveled some of the details regarding the way that the skin and sebaceous glands synthesize and metabolize hormones. The knowledge gained from this work may provide an impetus for future drug discovery in the hormonal treatment of acne and lead to improvements in the care of our patients with acne.
Both clinical observation and experimental evidence confirm the importance of hormones in the pathophysiology of acne. Hormones are best known for their effects on sebum excretion.
It has also been suggested that hormones may play a role in the follicular hyperkeratinization seen in follicles affected by acne [1–3]. From a therapeutic standpoint, the importance of the role of hormones in acne is supported by the clinical efficacy of hormonal therapy in women with acne.
Although we know that hormones are important in the development of acne, many questions remain unanswered about the mechanism by which hormones exert their effects. For example, the specific hormones that are important in acne have not been definitively identified.
Androgens such as dihydrotestosterone (DHT) and testosterone (T), the adrenal precursor dehydroepiandrosterone sulfate (DHEAS), estrogens such as estradiol and other hormones such as growth hormone may each be important in acne.
It is not known if these hormones are taken up from the serum by the sebaceous gland or if they are made locally within the gland. Finally, the cellular and molecular mechanisms by which these hormones exert their influence on the sebaceous gland have not been fully elucidated.
As future research fills in these gaps, we will be able to design improved therapies that target the hormonal causes of acne.
Hormonal therapy is an option for treatment when acne is not responding to conventional therapy. If there are signs of hyperandrogenism, an endocrine evaluation is indicated, consisting of an assessment of DHEAS, total and free-testosterone levels and an LH/FSH ratio.
Although an indication for hormonal therapy is hyperandrogenism, women with normal serum androgen levels also respond well to treatment. Hormonal therapy choices consist of androgen-receptor blockers, androgen-production blockers, and, potential in the future, androgen metabolizing enzyme inhibitors. The mainstays of hormonal therapy include oral contraceptives and spironolactone. Other agents to choose from are cyproterone, flutamide, and glucocorticoids.
As more is learned about the hormones involved in acne, their source of production and the mechanisms by which they influence sebaceous gland growth and sebum production, new opportunities will arise for the development of novel therapies aimed at the hormonal aspects of acne.
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