Although
acne is seldom associated with high serum levels of
androgens, it has been shown that female
acne patients have definite increases in ovarian and adrenal
androgen levels when compared to appropriate controls. As shown in several pilot and in multiple open and comparative studies,
oral contraceptives (OCs) are effective in causing a significant regression of mild to moderate
acne. These results have been confirmed by multicentre randomized trials where low-dose OCs did not cause side effects different from those of the placebo-controlled group. The beneficial effect of OCs is related to a decrease in ovarian and adrenal
androgen precursors; to an increase in
sex hormone-binding globulin (SHBG), which limits free
testosterone; and to a decrease in 3a-androstenediol
glucuronide conjugate, the catabolite of
dihydrotestosterone (DHT) formed in peripheral tissues. The
estrogen-
progestin combination containing
cyproterone acetate (CPA) is particularly effective in treating
acne, since this
progestin also has a direct peripheral anti-androgenic action in blocking the
androgen receptor. Only two open studies and one randomized study on small numbers of patients have reported some efficacy of
spironolactone used alone or in combination with an OC in the treatment of
acne. The new non-steroidal anti-
androgens flutamide and
finasteride are being evaluated for the treatment of
hirsutism. Oral
antibiotics are prescribed to patients with inflammatory lesions, where they are effective in decreasing the activity of microbes, the activity of microbial
enzymes, and leukocyte chemotaxis. Concomitant intake of an OC and an
antibiotic usually prescribed for
acne does not impair the
contraceptive efficacy of the OC. A second effective
contraceptive method should be used whenever there would be decreased absorption or efficacy of the OC (digestive problems,
breakthrough bleeding), lack of compliance and use of a type or dose of
antibiotic different from that usually prescribed for
acne.Overall, the various approaches for the treatment of
acne depend on the needs of the patient and on the therapeutic objectives. Low-dose OCs are effective in improving
acne and have side effects similar to placebo. They can be used alone or in combination with other anti-
acne agents. The physician prescribing an OC as an anti-
androgen intervention should take into account the multiple factors involved in
acne and be familiar with current non-hormonal agents for treating mild to moderate
acne. Individuals presenting with moderate to severe
acne, or not responding to an
estrogen-
progestin combination, should be referred to a dermatologist.