Hilary Baldwin, MD 

Medscape Dermatology.  2008; ©2008 Medscape

Posted 07/31/2008

Question
When prescribing oral contraceptives in women with acne, what issues need to be considered?

Response from Hilary Baldwin, MD Associate Professor, Department of Dermatology, SUNY-Brooklyn, Brooklyn, New York

Oral contraceptives can be highly effective in the treatment of acne. In a review of all randomized and controlled trials evaluating the effectiveness of oral contraceptives in acne, Arowojolu and colleagues^[1] concluded that oral contraceptive pills (OCP) are effective in reducing both inflammatory and noninflammatory lesions. All OCPs that contain estrogen (combination pills) seem to be effective, and there does not appear to be significant differences between different formulations compared in clinical trials.^[1,2]

OCPs act by decreasing levels of ovarian androgens and free testosterone in the blood, partially through their effect of increasing sex hormone-blinding globulin.^[3]

OCPs are particularly effective for adult women with acne, women with pronounced menstrual flares, and those in whom OCPs are also indicated for gynecologic reasons.^[4] Although OCPs are an important part of polytherapy for women with hormonal imbalances, OCPs are also effective in women with no evidence of endocrine problems.

Combination OCPs contain both estrogen (generally ethinyl estradiol) and a progestin. Older progestins had stronger androgenic effects and have the potential to exacerbate acne. Newer combinations containing drospirenone, desogestrel, or norgestimate are less androgenic and, as a result, may be more beneficial for the treatment of acne.

Most of the side effects of OCPs are mild and include weight change, breast tenderness, mood changes, and breakthrough bleeding. Serious side effects are uncommon and include a small but significant increased risk for stroke, myocardial infarction, and thromboembolism.^[4] The relative risk for breast cancer in patients on OCPs is controversial. There is no evidence of concern in women with family history of breast cancer, and there seems to be a small protective effect with ovarian and endometrial cancers.^[4] Until further studies are conducted, it is perhaps prudent to limit use in patients with personal history of breast cancer.^[4]

This activity is supported by an independent educational grant from Medicis.

1. Arowojolu AO, Gallo MF, Grimes DA, Garner SE. Combined oral contraceptive pills for treatment of acne. Cochrane Database Syst Rev. 2004;(3):CD004425.
2. James WD. Clinical practice. Acne. N Engl J Med. 2005;352:1463-1472. Abstract
3. Harper JC. Antiandrogen therapy for skin disease and hair disease. Dermatol Clin. 2006;24:137-143. Abstract
4. Lynde CW. Hormonal approach to the treatment of acne: a Canadian perspective. J Cutan Med Surg. 2004;8(Suppl 4):1-2. Abstract

Hilary Baldwin, MD, Associate Professor, Department of Dermatology, SUNY-Brooklyn, Brooklyn, New York

Disclosure: Hilary Baldwin, MD, has disclosed that she has served as an advisor or consultant to, and on the speaker’s bureau of, Allergan, OrthoNeutrogena, Galderma, Medicis, Stiefel, Barrier, SkinMedica and Coria.