Managing Acne and Other Skin Concerns in Women with PCOS

Monique Kumar, MD, MPhil Emory University SOM Department of Dermatology

PCOS Awareness Symposium September 19, 2015

External Industry Relationships * Company Name Role

Equity, stock, or options in biomedical industry companies or publishers

None

Board of Directors or officer None

Royalties from Emory or from external entity

None

Industry funds to Emory for my research

None

Other None

Monique G. Kumar, M.D., MPhil

Personal/Professional Financial Relationships with Industry

I will be discussing off label use of medications

Objectives

• Identify skin findings in women with PCOS

• Discuss how hormones influence the skin

• Discuss therapy options for women with PCOS skin findings

• “Acne has been a huge source of frustration in my life for a long time. It’s been a never-ending battle.”

• “I thought acne was for teenagers!”

• “I had beautiful skin as a teenager, and now all of a sudden as an adult, I have acne. It is very frustrating.”

• “ I have spent a lot of money of over the counter products, but still have acne.”

Things I hear in clinic…

What skin concerns do you have?

• Increased hair where you don’t want it (Hirsutism)

• Acne

• Hair loss where you do want it (Alopecia)

• Discoloration and skin thickening (Acanthosis nigricans)

Skin Findings in PCOS result from

• Hormone Imbalance- hyperandrogenism – Unwanted hair growth

– Acne

– Oily skin/seborrhea

– Hair loss

• Insulin Resistance – Discoloration and skin thickening

– Stretch Marks

– Skin tags

Causes of Acne and Hair Growth in PCOS

• Similar hormonal cause

• Androgens trigger the hair-oil-gland (pilosebacous) unit

– Sebaceous gland increased oil acne

– Hair root grows hairs that is longer, thicker, darker

Is this because I have too much hormones?

My hormone levels were checked and were normal but I still have skin issues.

• Blood levels of androgens DO NOT correlate to the degree of hirsutism or acne

• The sensitivity of androgen receptors and the local levels of androgens in the skin play a more significant role

Hirsutism

• Increased thick hair: – Upper lip

– Chin

– Breast

– Chest

– Back

– Lower abdomen

• 60-70% of women with PCOS

• Degree of hair growth depends on ethnicity

Hirsutism Treatment Pearls

• Multi-step approach is most effective!

• Because terminal hair turnover occurs slowly, at least 6 months of treatment is generally considered the minimal interval to see a response!

Hirsutism Treatment

– Hair Removal • Wax, laser, electrolysis

– Topical treatment eflornithine hydrochloride (vaniqa)

– Oral contraceptive pills • At least 3 months (>18 months is best)

– Metformin (+/-)

– Anti- androgens (USE WITH CONTRACEPTIVE) • Spironolactone- blocks androgen action at the hair

follicle

NOT ALL ACNE IS THE SAME! ACNE

ACNE

TYPES

• Comedonal acne

• Papulopustular acne

• Nodulocystic/ cystic acne

Acne in PCOS

• Differs from normal pubertal acne:

– Characteristic locations:

• Lower face

• Neck

• Chest

• Upper back

– Characteristic lesions:

• Inflammatory lesions (red bumps, pus bumps)

Acne in PCOS

• Differs from normal pubertal acne:

– Timing:

• Starts in adulthood

• Persists into adulthood

– Treatment:

• Often refractory to conventional acne treatments alone

Multifactorial Cause of Acne

• Stimulation of the sebaceous glands (oil making glands) by testosterone

• Increased sebum (oil) leads to bacterial overgrowth (P. acnes)

• Immune response

• Abnormal keratinization in hair follicle

Standard Acne Therapy

• Comedones-topical

– Retinoids (Tretinoin, RetinA, Differin, Tazorac)

– Topical antibiotics (clindamycin)

– Benzoyl peroxide (2.5-5%)

• Papulopustular lesions

– Add oral antibiotic

(tetracycline, doxycycline, minocycline)

• Cystic acne

– Isotretinoin (Accutane)

Chuan, Sandy and Chang Jeffrey. Polycystic Ovary Syndrome and Acne. Skin Therapy Letter. Nov 2010

Additional Acne Therapy In PCOS

General Principles for Acne Therapy in PCOS

• Hormonal therapy is key!

• Can be used in combination with all standard acne therapy

• OCPs are safe and effective even in females with normal hormone levels

• May need long term systemic therapy

Oral Contraceptive Pills (OCP)

• Estrogen provides the most benefit

• There are FDA approved OCP for acne

• NO SIGNIFICANT difference in the efficacy between formulations

• Spironolactone – Diuretic with antiandrogenic properties

– Blocks androgen receptor in skin

– Used to treat acne and increased hair growth

– Decreases sebum production and improves acne

– Adding to OCP has benefit!

– May require higher doses in PCOS

• Not recommended to be used alone!

Anti- Androgen Therapy

Alopecia

• Hair loss in areas you want hair

• Infrequent in women with PCOS

• Must looks for other causes of hair loss

– Thyroid abnormalities

– Iron deficiency

– Autoimmune

– Stress related

• Cosmetic Aids

– Hairstyling

– Camaflauge hair replacement

• Minoxidil (Rogaine)

– 5% once daily

– Effective, but minimally so 6-12 months of treatment

• Hormone Therapies*

Alopecia Treatment

Acanthosis Nigricans

• Velvety dark thickened plaques

– Nape and sides of neck

– Underarms

– Groin

• Up to 50% women with PCOS

• If you have signs, have your doctor evaluate for impaired glucose tolerance

Acanthosis Nigricans Treatment

• Topical:

– Lactic acid cream

– Urea cream

• Oral metformin

• Laser therapy

Summary

• PCOS can commonly affect the skin

• Blood levels of hormones do not correlate to the degree of hirsutism or acne

• Hormonal therapy is key (OCP, spironolactone) and can be used in combination with all standard acne therapy