Female Adult Acne and Androgen Excess

Abstract and Introduction

Abstract

In endocrine and reproductive endocrine literature, adult female acne is considered as a possible clinical expression of hyperandrogenism, with most polycystic ovary syndrome (PCOS) guidelines considering acne as a condition of androgen excess. Adult female acne, however, in the dermatological literature is considered as an inflammatory skin disease and new guidelines on adult female acne have been produced by dermatological societies, with little perspective from any endocrine or reproductive endocrine points of view. An expert task force was appointed by the AE-PCOS society to determine the current state of knowledge and provide evidence-based recommendations that could be valid for all specialists taking care of female adult acne. The following are the recommendations (level of evidence A or B): (1) diagnosis of female adult acne is mainly clinical, but a grading tool is needed for optimizing the treatment; (2) measurement of serum androgen values (total testosterone, free testosterone, and dehydroepiandrosterone sulfate) by high-quality assays is recommended in all women with adult acne; (3) in women with adult acne and proven hyperandrogenism, oral combined estroprogestins should be added to the topical or systemic treatment of acne, independently of severity of acne; (4) all second- and third-generation estroprogestins may be used, independently of the estrogen dose and progestin component; (5) spironolactone may be added to estroprogestins in women with moderate or severe hyperandrogenic adult acne, not responding to usual treatments; (6) estroprogestins may be used in nonhyperandrogenic patients with adult acne as second-line therapy.

Introduction

In endocrine and reproductive endocrine literature, adult female acne is considered as a possible clinical expression of hyperandrogenism (androgen excess), with most polycystic ovary syndrome (PCOS) guidelines considering acne as a condition of androgen excess.^[1–4] Adult female acne, however, in the dermatological literature is considered as an inflammatory skin disease determined by several factors that may or may not include hyperandrogenism. Recently, new guidelines on diagnosing and treating adult female acne have been produced by dermatological societies^[5,6] with little perspective from any endocrine or reproductive endocrine points-of-view.

Therefore, the Androgen Excess and PCOS (AE-PCOS) Society appointed an expert task force not only to evaluate the current state of knowledge regarding the relationship of hyperandrogenism with adult female acne, but also to propose consistent strategies to evaluate and treat these patients. This publication provides evidence-based and expert opinion–based recommendations for the evaluation, diagnosis, and treatment of adult female acne, and its association with hyperandrogenism, for use by healthcare providers of different specialties who care for these women.

Authors and Disclosures

Enrico Carmina¹, Brigitte Dreno², W. Anne Lucky³, W. George Agak⁴, Anuja Dokras⁵, Jin Ju Kim⁶, Rogerio A. Lobo⁷, Fahimeh Ramezani Tehrani⁸ and Daniel Dumesic⁹

¹Endocrinology Unit, University of Palermo Medical School, Palermo, 90139, Italy
²Department of Dermatology, University of Nantes Medical School, Nantes, 44093, France
³Department of Dermatology, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
⁴Department of Medicine, Division of Dermatology, University of California (UCLA), Los Angeles, CA 90035, USA
⁵Department of Obstetrics and Gynecology, The Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA 19104, USA
⁶Department of Obstetrics and Gynecology, Healthcare System Gangnam Center, Seoul National University Hospital and The Institute of Reproductive Medicine and Population, Medical Research Center, Seoul National University College of Medicine, Seoul 03080, Korea
⁷Department of Obstetrics and Gynecology, Columbia University, New York, NY 10032, USA
⁸Reproductive Endocrinology Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, IR 1985717413, Iran
⁹Department of Obstetrics and Gynecology, University of California at Los Angeles, Los Angeles, CA 90095, USA

Correspondence
Enrico Carmina, MD, Endocrinology Unit, University of Palermo Medical School, via delle Croci 47, Palermo, 90139, Italy. Email: enricocarmina@libero.it.

Author contributions
E.C. organized the study and participated in the collection of literature data, manuscript writing and critical discussion. He read and approved the final manuscript. B.D. participated in the collection of literature data, manuscript writing and critical discussion. He read and approved the final manuscript. W.A.L. participated in the collection of literature data, manuscript writing and critical discussion. She read and approved the final manuscript. W.G.A. participated in the collection of literature data, manuscript writing and critical discussion. He read and approved the final manuscript. A.D. participated in the collection of literature data, manuscript writing and critical discussion. She read and approved the final manuscript. J.J.K. participated in the collection of literature data, manuscript writing and critical discussion. She read and approved the final manuscript. A.R.L. participated in the collection of literature data, manuscript writing and critical discussion. He read and approved the final manuscript. F.R.T. participated in the collection of literature data, manuscript writing and critical discussion. He read and approved the final manuscript. D.D. participated in the collection of literature data, manuscript writing and critical discussion. He read and approved the final manuscript.

Disclosure Summary
The authors have no competing interests to declare.