PCOS and Acne

Journal Watch:

Polycystic Ovary Syndrome and Acne
Sandy S. Chuan, MD and R. Jeffrey Chang, MD
Skin Therapy Letter. 2010;15(10):1-4.

Highlights:

• Women with PCOS have an excess of androgens due to which they may develop dermatological concerns such as hirsutism, acne vulgaris, and androgenic alopecia. 
• Acne occurs in 10 to 34% of women with PCOS. Most women with PCOS have facial acne lesions, while 50% have additional acne on the chest, upper back and neck.
• Women with PCOS with acne usually have elevated levels of circulating androgens. However, the severity of acne does not directly correlate to the levels of these androgens in the blood.
• However, some studies show that the severity of acne in PCOS patients may be directly correlated to the levels of DHEA-S in blood and inversely related to the level of SHBG produced in the liver.
• Many women with PCOS who have hirsutism do not have acne and vice versa. This may be due to the differential activity of the two isoforms of the ezyme 5alpha reductase and local androgen levels.
• For women with PCOS and acne, OCPs (oral contraceptive pills) are the mainstay of treatment.
• A Cochrane review noted that treatment of acne with OCPs effectively lowered the lesion count of acne, severity of acne as well as improved the self assessment by the patient.
• In women with PCOS who have acne, OCPs are the first line of treatment unless otherwise indicated.
• If there is no improvement or insufficient improvement, one may add oral Antiandrogens to OCPs.
• Insulin sensitizing drugs like Metformin are known to benefit patients with PCOS by reducing insulin levels. However, they are not recommended for treating either acne or hirsutism alone in such patients.
• The combination of OCPs and Flutamide works better than Flutamide alone for PCOS with acne.
• Finasteride is more effective as a treatment for hirsutism in PCOS than for PCOS with acne alone.
• Spironolactone works as an antiandrogen and also reduces sebum production, thereby improving acne. Spironolactone in PCOS is used at a lower dose for treating acne than for hirsutism. It may be added to the treatment plan of women on OCPs showing inadequate improvement with OCPs alone.
• For patients with PCOS, hirsutism and acne, being treated with OCPs showing inadequate improvement, it might be better to add Flutamide than Spironolactone to ongoing OCP treatment.
• Spironolactone is teratogenic thus is always given in conjunction with OCPs to avoid unplanned pregnancy. The patient must also stop Spironolactone three months before trying to conceive.