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Dr Harper on Hormonal Treatment of Acne

At the GW Virtual Appraisal of Advances in Acne Conference, Julie Harper, MD, discussed the use of hormonal treatments for acne. Dr Harper is a clinical associate professor of dermatology at the University of Alabama, Birmingham.

Her presentation mainly focused on the use of oral contraceptives. Currently, only four oral contraceptives are approved by the FDA for the treatment of acne in female patients aged 15 years or older who have achieved menarche, are unresponsive to topical treatments, and desire contraception. However, most oral contraceptives are effective for acne, especially ones that are a combination of estrogens and ethinyl estradiol plus progesterone, excluding those that only contain progesterone, which can worsen acne.

Dr Harper reviewed the risk of venous thromboembolism (VTE) and breast cancer with oral contraceptives. The risk for both of these is still low among women of child-bearing potential, she noted.

In a Cochrane meta-analysis, which included 26 studies, the risk of VTE was increased with all oral contraceptive. “However, we have to put this in perspective,” she said. She recommended dermatologists remember the numbers 3, 6, 9, and 12. The baseline risk for VTE in women of childbearing potential is about 3 per 100,000 per year with no oral contraceptives. Any oral contraceptive increases this risk to 6 per 100,000 women, she explained. The risk of VTE triples with third or fourth generation oral contraceptives to 9 per 100,000 women per year, but if pregnant then the risk of VTE in women in this age group is 12 per 100,000 per year.

Another study that examined the risk of breast cancer among 1.8 million women between aged 15 and 49 years found hormonal contraception, not just oral contraceptives, increased the risk of breast cancer. The relative risk was 1.2, and this risk increased with duration of use and persisted after 5 years of discontinuation, noted Dr Harper. Similar to VTE, the risk of breast cancer is not high in this age group. To put this in perspective, the overall absolute increased risk with any hormonal therapy was 13 breast cancer cases per 100,000, which is one extra breast cancer for every 7690 women using hormonal contraception per year, explained Dr Harper.

While there was a slight increase in the risk of breast cancer, there were protective effects against ovarian, endometrial, and colorectal cancers. Overall, there appears to be a net reduction in cancer risk, she noted.

Other aspects dermatologists should keep in mind, according to Dr Harper, are that pap smears and pelvic exams are not necessary prior to initiating oral contraceptives and most antibiotics do not interfere with oral contraceptives, including tetracycline and doxycycline. In addition, she recommended all dermatologists obtain a thorough medical history and document blood pressure.

In addition, Dr Harper discussed the use of spironolactone. Patients treated with spironolactone do not need to take oral contraceptives, said Dr Harper, noting that most of the patients she treats with spironolactone usually have a contraindication to oral contraceptives. However, spironolactone is classified as Category C for pregnancy due to a theoretical risk of improver genitalia development if the fetus is male. While there is a black box warning for breast cancer, the risk is based on data from rat studies. Two large studies did not find a higher risk of breast cancer with spironolactone use among women, said Dr Harper. In addition, she noted that checking potassium levels in healthy women under 45 years of age is not necessary. Women who are older, have a history of renal disease, cardiac disease, or medications known to affect potassium may need their levels checked, she added.


Harper J. Use of hormonal therapies in acne. Presented virtually at: The GW Virtual Appraisal of Advances in Acne Conference; July 30, 2020.


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