Androgen biology as a basis for the diagnosis and treatment of androgenic disorders in women. II

Second-to-fourth digit ratio and seborrheic dermatitis in males: a cross-sectional study

BACKGROUND

Seborrheic dermatitis is a common disease characterized by the erythematous plaques with oily-yellow desquamation. Increased sebaceous gland activity by androgenic hormones has played a role in the etiology of the disease. The second-to-fourth digit (2D:4D) ratio is thought to be a marker of prenatal androgen exposure.

OBJECTIVES

To investigate the association between 2D:4D ratios and seborrheic dermatitis in a male population.

METHODS

Healthy male controls and patients with seborrheic dermatitis were included in this study. One hundred seborrheic dermatitis patients and 120 healthy controls, aged 17-59, were enrolled. A digital Vernier caliper was used to measure the finger lengths. Seborrheic dermatitis severity was assessed using the Seborrheic Dermatitis Area and Severity Index (SDASI).

RESULTS

The 2D:4D ratios of the patients (x = 0.977) were significantly lower than those of the controls (x = 1.050) for right hands (t = 6.948; p = 0.000; > 0.05). No similar relationship was found between the 2D:4D ratio for left hands (t = 0.901; p = 0.368; > 0.05). Seborrheic dermatitis severity was negatively correlated with 2D:4D ratios of right hands (r = -0.391; p = 0.000-0.05).

STUDY LIMITATIONS

One of the main limitations of this study was the small sample, which got a head of us from acquiring certain findings about the 2D:4D ratio and seborrheic dermatitis. The other limitation is that the patient selection did not reflect the general population, as a single clinic was studied.

CONCLUSION

To the authors' knowledge, this is the first study examining the relationship between 2D:4D ratios and seborrheic dermatitis. The result of this study may indicate a line of investigation and can support the theory of prenatal androgen exposure.

Androgens in women: Androgen-mediated skin disease and patient evaluation

Androgens are produced throughout the body in steroid-producing organs, such as the adrenal glands and ovaries, and in other tissues, like the skin. Several androgens are found normally in women, including dehydroepiandrosterone, dehydroepiandrosterone-sulfate, testosterone, dihydrotestosterone, and androstenedione. These androgens are essential in the development of several common cutaneous conditions in women, including acne, hirsutism, and female pattern hair loss (FPHL)-androgen-mediated cutaneous disorders (AMCDs). However, the role of androgens in the pathophysiology of these diseases is complicated and incompletely understood. In the first article in this Continuing Medical Education series, we discuss the role of the skin in androgen production and the impact of androgens on the skin in women. Specifically, we review the necessary but insufficient role that androgens play in the development of acne, hirsutism, and FPHL in women. Dermatologists face the challenge of differentiating physiologic from pathologic presentations of AMCDs in women. There are currently no dermatology guidelines outlining the indications for endocrinologic evaluation in women presenting with acne, hirsutism, or FPHL. We review the available evidence regarding when to consider an endocrinologic workup in women presenting with AMCDs, including the appropriate type and timing of testing.

Female Offspring From Chronic Hyperandrogenemic Dams Exhibit Delayed Puberty and Impaired Ovarian Reserve

Female offspring of many species exposed to high doses of androgens in utero experience endocrine dysfunction during adulthood. The phenotype of offspring from females with prepregnancy hyperandrogenemia and impaired ovulation, however, has not been examined. We developed a mouse model of hyperandrogenemia by implanting a low-dose dihydrotestosterone (DHT) pellet 15 days before conception. Female offspring born to dams with hyperandrogenemia (DHT daughters) had delayed puberty (P < 0.05) with first estrus on postnatal day (PND) 41 compared with daughters from dams with physiological levels of DHT (non-DHT daughters, PND37.5). Serum follicle-stimulating hormone (FSH) levels in the DHT daughters were fourfold higher (P < 0.05) on PND21, and anti-Müllerian hormone levels were higher (P < 0.05) on PND26 than in non-DHT daughters (controls). DHT daughters showed an extended time in metestrus/diestrus and a shorter time in the proestrus/estrus phase compared with non-DHT daughters (P < 0.05). To examine ovarian response to gonadotropins, superovulation was induced and in vitro fertilization (IVF) was performed. Fewer numbers of oocytes were retrieved from the DHT daughters compared with non-DHT daughters (P < 0.05). At IVF, there was no difference in rates of fertilization or cleavage of oocytes from either group. There were fewer (P < 0.01) primordial follicles (6.5 ± 0.8 vs 14.5 ± 2.1 per ovary) in the ovaries of DHT daughters compared with non-DHT daughters. Daughters from hyperandrogenemic females exhibited elevated prepubertal FSH levels, diminished ovarian response to superovulation, impaired estrous cyclicity, delayed onset of puberty, and reduced ovarian reserve, suggesting that fetal androgen exposure had lasting effects on female reproductive function.

Gestational Hyperandrogenism in Developmental Programming

Androgen excess (hyperandrogenism) is a common endocrine disorder affecting women of reproductive age. The potential causes of androgen excess in women include polycystic ovary syndrome, congenital adrenal hyperplasia (CAH), adrenal tumors, and racial disparity among many others. During pregnancy, luteoma, placental aromatase deficiency, and fetal CAH are additional causes of gestational hyperandrogenism. The present report reviews the various phenotypes of hyperandrogenism during pregnancy and its origin, pathophysiology, and the effect of hyperandrogenism on the fetal developmental trajectory and offspring consequences.

Treatment of hirsutism with combined pill containing drospirenone

The aim of the present study was to evaluate the biochemical and clinical effects of the combined pill consisting of ethinyl estradiol (EE) and drospirenone (DRSP) in hirsute patients. Fifty-two adolescents or young women from Greece were treated with 30 mug EE and 3 mg DRSP for 1 year. Hirsutism was evaluated by the Ferriman-Gallway (FG) score in the initial visit and at 3, 6 and 12 months. Follicle-stimulating hormone, luteinizing hormone, etradiol, free and total testosterone (T), sex hormone-binding globulin (SHBG), androstenedione and dehydroepiandrosterone sulfate were determined at the same intervals. Hirsutism improved and FG scores reduced to 77.4%, 67.2% and 51.8% at 3, 6 and 12 months, respectively. Plasma SHBG levels rose, while free and total T levels reduced from the third month onwards. In conclusion, the EE/DRSP pill improves hirsutism in women via antiandrogenic and antimineralocorticoid action. The biochemical manifestations of hyperandrogenism are also improved.

Mulheres adultas com acne: aspectos comportamentais, perfis hormonal e ultra-sonográfico ovariano

OBJETIVOS: abordar os aspectos comportamentais, o perfil androgênico e as alterações ultra-sonográficas ovarianas de uma amostra de mulheres adultas com acne. MÉTODOS: estudo de série de casos envolvendo uma amostra de 60 mulheres, escolhidas por conveniência. As pacientes foram submetidas a exame clínico, dosagens hormonais e ultra-sonografia para avaliação da morfologia ovariana. Na análise estatística, foi aplicado o Teste de Fischer para análise de correlação entre as variáveis. RESULTADOS: a média de idade foi de 26,5 anos. Todas as pacientes referiram atitudes e sentimentos negativos em relação à acne, sendo os mais freqüentes ansiedade (88,3%) e manipulação constante das lesões (88,3%). O grau de acne mais observado foi o grau II (48,3%). Foram identificados níveis de androgênios fora da faixa de normalidade em 63,3%, com elevação mais freqüente do, dehidroepiandrosterona (57,6%). O padrão ultra-sonográfico mais observado foi o microcístico (74,6%). CONCLUSÕES: as formas clínicas leves de acne predominaram nas mulheres estudadas. Ainda assim, essas apresentaram, com grande freqüência, atitudes e sentimentos negativos em relação à doença. Foram identificados, ainda, modificação dos níveis séricos dos androgênios, bem como do padrão de normalidade do exame ultra-sonográfico.

Klinische Formen der Akne

Acne is a very common dermatosis with characteristic clinical features. It is a polymorphic disease. The clinical expression ranges from non-inflammatory closed and open comedones to inflammatory papules, pustules, and nodules. Most patients have a mixture of non-inflammatory and inflammatory lesions, although some have predominantly one or the other. Acne varies in severity from a very distressing, socially disabling disorder to a state that has been regarded as physiological by some authors. The most severe forms of acne are acne fulminans and acne inversa. Although acne may occur in all age groups, it is most prevalent during adolescence. It is not known why acne subsides in most patients but persists into adulthood in some. Certain medications may be associated with provocation, perpetuation, or exacerbation of pre-existing acne or with acneiform eruptions. Acne-like disorders include rosacea, pseudofolliculitis barbae, and other conditions that share clinical features with acne.

Retrospective evaluation of sex hormones and steroid hormone intermediates in dogs with alopecia

The purpose of this study was to determine if there are specific steroid hormone aberrations associated with suspect endocrine alopecias in dogs in whom hypothyroidism and hyperadrenocorticism have been excluded. Steroid hormone panels submitted to the UTCVM endocrinology laboratory over a 7.5-year period (783 samples) from dogs with alopecia were reviewed. During this period, 276 dogs met the criteria for inclusion and were comprised of 54 different breeds. Approximately 73% of dogs had at least one baseline or post-ACTH stimulation steroid hormone intermediate greater than the normal range. The most frequent hormone elevation noted was for progesterone (57.6% of samples). When compared with normal dogs, oestradiol was significantly greater in Keeshond dogs and progesterone was significantly greater in Pomeranian and Siberian Husky dogs. Not all individual dogs had hormone abnormalities. Chow Chow, Samoyed and Malamute dogs had the greatest percentage of normal steroid hormone intermediates of the dogs in this study. Baseline cortisol concentrations were significantly correlated with progesterone, 17-hydroxyprogesterone (17-OHP) and androstenedione. Results of this study suggest that the pathomechanism of the alopecia, at least for some breeds, may not relate to steroid hormone intermediates and emphasizes the need for breed specific normals.

Hair diseases

A few common causes of hair loss account for the vast majority of cases. A well-directed history and simple physical examination is often sufficient to make a diagnosis. Laboratory testing is often unnecessary. A scalp biopsy can be useful, but only if processed and interpreted correctly. Androgenetic alopecia, alopecia areata, senescent alopecia, telogen effluvium, traction alopecia, trichotillomania, and cosmetic hair damage are common causes of non-scarring alopecia. Discoid lupus erythematosus, lichen planopilaris, and central, centrifugal scarring alopecia are the most common forms of scarring hair loss.

Prepubertal acne: a cutaneous marker of androgen excess?

BACKGROUND

Early-onset acne before obvious signs of puberty is an uncommon phenomenon.

OBJECTIVE

The aim of this study was to determine if prepubertal acne is associated with an excess of androgens.

METHODS

Basal and adrenocorticotrophic hormone-stimulated plasma androgen levels were measured and bone age was determined in 15 children with early-onset acne.

RESULTS

A late-onset adrenogenital syndrome caused by 21-hydroxylase deficiency was diagnosed in two children. These children had early pubic hair development and advanced bone maturation. Heterozygosity for 21-hydroxylase deficiency was found in three other children.

CONCLUSION

We recommend hormonal evaluation in children with prepubertal acne, especially those with associated advanced bone maturation and early pubarche.

Re-examination of the effect of hCG on plasma levels and renal excretion of dehydroepiandrosterone sulfate in healthy males

To reinvestigate the effect of hCG on circulating and urinary dehydroepiandrosterone sulfate (DHEAS), a hCG stimulation test (5000 IU administered i.m. at 8.30 h on 3 consecutive days) was performed in 6 healthy males (aged 24 to 35 years). Blood specimens and 24-h urine samples were collected immediately before the first and directly after the last hCG administration. Contrary to previous findings in normal men, the present study revealed significant DHEAS responses after testicular stimulation with hCG: plasma DHEAS increased from 7.9 +/- 2.3 to 9.6 +/- 2.2 mumol/L (P < 0.05) and urinary DHEAS from 5.7 +/- 3.6 to 9.3 +/- 5.2 mumol/day (P < 0.05). There was also a marked rise (P < 0.05) in the urinary excretion of total 17-ketosteroid sulfates. Clear increases of unconjugated plasma dehydroepiandrosterone as well as of circulating and renally excreted androstenedione and testosterone definitely confirmed an adequate Leydig cell stimulation. Significant post-hCG changes were additionally observed for plasma and urinary 3 alpha-androstanediol glucuronide (149% and 79% increases, respectively) and for urinary cortisol (21% decrease). Significant correlations were found for the post-hCG percent increases of plasma androstenedione versus plasma DHEAS (r = 0.86) and for the percent increases of plasma testosterone versus urinary DHEAS (r = 0.98), indicating that the extent of gonadal androgen elevations in the circulation of normal men is a determinant of DHEAS increases in blood or urine. These findings provide an explanation for the frequently observed sex differences for DHEAS in adults.(ABSTRACT TRUNCATED AT 250 WORDS)

Androgenetic alopecia: an autosomal dominant disorder

A hereditary, androgen-driven disorder, androgenetic alopecia is the most common form of alopecia in humans: its prevalence is 23-87%. Central alopecia is more severe in men; women are more likely to experience diffuse thinning. The acute onset of alopecia in those with inflammatory diseases of the scalp suggests a variety of etiologies, including the impact of inflammatory cells, release of cytokines, presence of growth factors, and increased interaction of stromal cells. Therapeutic modalities, which are most effective when used in combinations, utilize hair growth promoters, antiandrogens, and androgen blockade agents.

Androgenic disorders of women: diagnostic and therapeutic decision making

Women with androgenic disorders usually seek medical attention to ameliorate the effects of androgens on appearance or on fertility, less commonly for oligomenorrhea or for prevention of metabolic complications. These conditions affect at least 5-10% of women and can be very disturbing to the affected woman. Careful attention to possible androgenic changes is necessary when performing physical examination because changes are often concealed. Treatment for skin and hair changes depends less on the nature of the changes than on the underlying endocrine causation. The two endocrine factors are androgen levels and receptor sensitivity. The latter is a factor in all androgenic changes, and therapy is rarely successful without use of medication to block androgen receptors. If androgen levels are even minimally elevated, suppression of the source gland--ovary or adrenal--is appropriate. Ovarian suppression is usually by means of an oral contraceptive; for adrenal suppression, a glucocorticoid is effective. Response to medical therapy of androgenic disorders is slow; physicians and patients must be willing to wait weeks, or months, for the beginning of improvement. Endocrine therapy does not seem to help associated diabetes or dyslipidemia. Overall, medical therapy of androgenic disorders is more effective than generally recognized. The principal pitfalls are failing to select medication based on the specific endocrine disturbance and failing to wait long enough for improvement to appear. Side effects do occur but are generally uncomfortable or inconvenient rather than dangerous. Treatment is highly rewarding, however, for there are few situations in medicine in which treatment is so appreciated by the patient.