A study comparing the clinical and hormonal profile of late onset and persistent acne in adult females

The cutaneous effects of androgens and androgen-mediated sebum production and their pathophysiologic and therapeutic importance in acne vulgaris

Background: The recognition of an association between the development of acne vulgaris (AV) and pubertal hormonal changes during adolescence dates back almost 100 years. Since these formative observations, a significant role of circulating hormones in the pathophysiology of AV and other cutaneous disorders has been established.Aims: This review article aims to provide an overview of clinical and preclinical evidence supporting the influences of androgens on the skin and their therapeutic importance in AV pathophysiology.Results: The cutaneous effects of hormones are attributable, to a large extent, to the influence of steroid hormones, particularly androgens, on sebocyte development and sebum production in both sexes. Androgen-mediated excess sebum production is implicated as a necessary early step in AV pathophysiology and is therefore considered an important therapeutic target in AV treatment. Although the local production and/or activity of androgens within the skin is believed to be important in AV pathophysiology, it has received limited therapeutic attention.Conclusions: We have summarized the current evidence in support of the therapeutic benefits of targeted hormonal treatment to decrease androgen-stimulated sebum production for the effective and safe treatment of AV in both male and female patients.

Prolactin: A Mammalian Stress Hormone and Its Role in Cutaneous Pathophysiology

The hormone prolactin (PRL) is best recognised for its indispensable role in mammalian biology, specifically the regulation of lactation. Bearing in mind that the mammary gland is a modified sweat gland, it is perhaps unsurprising to discover that PRL also plays a significant role in cutaneous biology and is implicated in the pathogenesis of a range of skin diseases, often those reportedly triggered and/or exacerbated by psychological stress. Given that PRL has been implicated in over 300 biological processes, spanning reproduction and hair growth and thermo- to immunoregulation, a comprehensive understanding of the relationship between PRL and the skin remains frustratingly elusive. In an historical curiosity, the first hint that PRL could affect skin biology came from the observation of seborrhoea in patients with post-encephalitic Parkinsonism as a result of another global pandemic, encephalitis lethargica, at the beginning of the last century. As PRL is now being postulated as a potential immunomodulator for COVID-19 infection, it is perhaps timeous to re-examine this pluripotent hormone with cytokine-like properties in the cutaneous context, drawing together our understanding of the role of PRL in skin disease to illustrate how targeting PRL-mediated signalling may represent a novel strategy to treat a range of skin diseases and hair disorders.

An updated clinico-investigative approach to diagnosis of cutaneous hyperandrogenism in relation to adult female acne, female pattern alopecia & hirsutism a primer for dermatologists

INTRODUCTION

Hyperandrogenism is a clinical state consequent to excess androgen production by the ovary, adrenals, or increased peripheral conversion of androgens. The varied manifestations of hyperandrogenism include seborrhea, acne, infertility, hirsutism, or overt virilization of which adult female acne, hirsutism, and female pattern hair loss are of clinical relevance to dermatologists.

AREAS COVERED

We limited our narrative review to literature published during period from 1 January 1985 to Dec 2022 and searched PubMed/MEDLINE, Web of Science (WOS), Scopus, and Embase databases with main search keywords were 'Hyperandrogenism,' 'Female,' 'Biochemical,' 'Dermatological', and 'Dermatology.' We detail the common etiological causes, nuances in interpretation of biochemical tests and imaging tools, followed by an algorithmic approach which can help avoid extensive tests and diagnose the common causes of hyperandrogenism.

EXPERT OPINION

Based on current data, total testosterone, sex hormone binding globulin, DHEAS, prolactin, free androgen index, and peripheral androgenic metabolites like 3-alpha diol and androsterone glucuronide are ideal tests though not all are required in all patients. Abnormalities in these biochemical investigations may require radiological examination for further clarification. Total testosterone levels can help delineate broadly the varied causes of hyperandrogenism. Serum AMH could be used for defining PCOM in adults.

The Question of Adolescent and Postadolescent Acne: The Nigerian Experience

Introduction

Differences between adolescent and postadolescent acne are increasingly being recognized. This study aimed to document the clinical profile of facial acne vulgaris and, additionally, to compare adolescent to postadolescent acne and any gender-based differences.

Methods

Cross-sectional descriptive study of 261 facial acne vulgaris patients was conducted from February 2021 to March 2022 at three dermatology clinics. Patients had their anthropometric measurements, type of acne lesions, and severity and scarring assessed.

Results

A total of 261 patients (75.5% females) with a mean age of 24.5 (±7.4) years were diagnosed to have facial acne vulgaris. The severity of acne was mild in 44.8%, moderate in 48.3%, and severe in 6.9%. Acne was noninflammatory in 69.7%, inflammatory in 13.0%, and mixed in 17.2%. Adolescent and postadolescent acne significantly differed in the type of acne, BMI, type of acne lesions, and acne scarring. Gender-based differences included BMI, lesions of acne, and severity.

Conclusion

There is an increasing prevalence of postadolescent acne with persistent being the most common category. There are significant differences between adolescent and postadolescent acne: type of acne, BMI, type of acne lesions, and acne scarring. Gender-based differences exist in both adolescent and postadolescent acne.

Biochemical and hormonal abnormalities in adult female acne

BACKGROUND

Prevalence of adult patients with acne is increasing and women comprise majority of the cases. There is lack of data on biochemical and hormonal abnormalities in adult female acne (AFA).

AIMS

To evaluate biochemical and hormonal parameters in 60 patients of AFA.

METHODS

A cross-sectional observational study conducted from November 2018 to March 2020 in Dermatology outpatient department of a tertiary care hospital in North India. Adult females (age > 25 years) with a clinical diagnosis of acne were included in the study.

RESULTS

60 cases of AFA were included. The age ranged between 26-41 years with mean age at presentation being 29.45 years. 53.3% patients had persistent acne while 46.7% had late-onset acne. 50% patients had history of premenstrual flare-up of their acne. Raised FBG was found in 25% patients. 10% had raised serum insulin levels. HOMA-IR index was deranged in 55% patients. At least one lipid alteration was reported in 91.6% of patients. In hormonal parameters, raised TT was present in 6.7%, LH in 3.3%, FSH in 18.3%, prolactin in 3.3%, and TSH in 15%. No association was found between acne severity and biochemical and hormonal parameters.

CONCLUSIONS

Our study highlighted the importance of measuring lipid profile in AFA and calculating HOMA-IR index for measuring insulin resistance rather than simply measuring serum insulin levels. In our study, additional parameter deranged in significant number of patients was FBG. Hence, we recommend routine screening of lipid profile, FBG and calculation of HOMA-IR index in AFA.

Evaluation of Hormonal Factors in Acne Vulgaris and the Course of Acne Vulgaris Treatment with Contraceptive-Based Therapies in Young Adult Women

Acne vulgaris is a common chronic inflammatory skin disease, which is considered one of the diseases of civilization due to the significant influence of environmental factors on the severity and frequency of these lesions. The aim of this study was to evaluate the hormonal profile of patients before treatment and to assess selected hormonal parameters after treatment. Our first objective was to examine the correlation between the selected hormonal parameters and the severity of acne before treatment. Our second objective was to evaluate the impact of treatment with three therapies, as measured by the selected hormonal parameters and acne severity. Statistical calculations were performed using the R v.4.1.1 statistical calculation environment (IDE RStudio v. 1.4.1717) with a significance level for the statistical tests set at α = 0.05. The results showed that the women in the pre-treatment (T1) and control (C) groups had significant differences in testosterone, androstendione, FAI, SHBG, prolactin, ACTH, and cortisol concentrations. After treatment, there were still significant differences in testosterone, androstendione, FAI, and SHBG concentrations between the post-treatment (T2) and control groups. We concluded that testosterone, androstendione, and cortisol concentrations correlate with acne severity. Acne in adult women may be an important clinical marker of androgen excess syndrome and cannot be considered a transient symptom of puberty. The mainstay of acne treatment is contraceptive therapy (ethonylestradiol and drospirenone). In this study, we confirmed the effectiveness of three contraceptive-based treatments using hormonal parameters and acne severity.

Acne, Microbiome, and Probiotics: The Gut–Skin Axis

The objective of this narrative review was to check the influence of the human microbiota in the pathogenesis of acne and how the treatment with probiotics as adjuvant or alternative therapy affects the evolution of acne vulgaris. Acne is a chronic inflammatory skin disease involving the pilosebaceous units. The pathogenesis of acne is complex and multifactorial involving genetic, metabolic, and hormonal factors in which both skin and gut microbiota are implicated. Numerous studies have shown the bidirectionality between the intestinal microbiota and skin homeostasis, a communication mainly established by modifying the immune system. Increased data on the mechanisms of action regarding the relevance of Cutibacterium acnes, as well as the importance of the gut–skin axis, are becoming known. Diverse and varied in vitro studies have shown the potential beneficial effects of probiotics in this context. Clinical trials with both topical and oral probiotics are scarce, although they have shown positive results, especially with oral probiotics through the modulation of the intestinal microbiota, generating an anti-inflammatory response and restoring intestinal integrity, or through metabolic pathways involving insulin-like growth factor I (IGF-1). Given the aggressiveness of some standard acne treatments, probiotics should continue to be investigated as an alternative or adjuvant therapy.

Female Adult Acne and Androgen Excess: A Report From the Multidisciplinary Androgen Excess and PCOS Committee

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.

Androgens and acne: perspectives on clascoterone, the first topical androgen receptor antagonist

Introduction: Increased circulating androgens are key to the multifactorial pathogenesis of acne. Clascoterone is the first topical androgen antagonist developed to treat acne in both male and female patients and the first such agent to receive U.S. Food and Drug Administration (FDA) approval for treatment of acne. Androgens directly stimulate sebaceous gland growth and increased sebum production, creating a nourishing medium in which anaerobic Cutibacterium acnes (C. acnes) bacteria flourish. Androgens may directly contribute to inflammation in the sebaceous gland.Areas covered: In this review, the author assesses clascoterone's potential role in the management of acne. With a 4-ring backbone identical to dihydrotestosterone (DHT) and spironolactone, topically applied clascoterone binds androgen receptors (ARs) in the sebaceous glands and hair follicles, interfering with the pathogenesis of acne and reducing acne lesions with no reported systemic effects.Expert opinion: Phase III study results confirmed the safety and efficacy of topical clascoterone for acne, with considerable reductions in absolute non-inflammatory and inflammatory lesion counts at week 12. The approval of a first-in-class topical androgen antagonist is indeed a 'game-changer' for acne management. This topical agent is expected to be quickly adopted in clinical practice, likely within combination regiments, yet to be formally evaluated.

Sex hormones and acne: State of the art

Acne is an androgen-dependent inflammatory disease of sebaceous follicles. Herein, we reviewed and discussed the underlying pathways of androgen biosynthesis and metabolism, non-genomic regulation of androgen receptor expression and function, posttranslational regulation of androgen excess in acne and acne-associated syndromes, such as polycystic ovary syndrome, and congenital adrenal hyperplasia. We provide insights into the involvement of sex hormones, particularly androgens, in skin homeostasis and acne pathogenesis, including comedogenesis, lipogenesis, microbiota, and inflammation. Advanced understanding of the action mechanisms of classical acne treatment and new development of antiandrogens, both topical and systemic, are also highlighted.

A prospective study of anti-mullerian hormone and other ovarian and adrenal hormones in adult female acne

Polycystic ovarian syndrome (PCOS) diagnosis in adult female acne (AFA) is tough owing to unreliable ultrasonography in virgins or obese females and inconsistent hyperandrogenemia. We analyzed hormones in AFA and established a diagnostic cut-off value of anti-mullerian hormone (AMH) for PCOS. Female acne patients aged ≥25 years were assessed with total testosterone (TT), sex hormone binding globulin (SHBG), free androgen index (FAI), AMH, 17-hydroxyprogesterone (17-OHP), dehydroepiandrosterone sulfate (DHEAS), follicle stimulating hormone (FSH), and luteinizing hormone (LH). Rotterdam's criteria defined PCOS. AMH was measured (Access AMH assay) to calculate the diagnostic cut off value using receiver operating characteristic (ROC) curve. Of 120 cases, 25.83% had PCOS. This group had significant clinical hyperandrogenism, truncal and adolescent acne, polycystic ovarian morphology (PCOM), and raised hormones (AMH, TT, FAI, LH, and LH/FSH). AMH levels were significantly higher in the PCOS group (6.91 ± 3.85 ng/mL) and positively correlated with TT, FAI, 17OHP, LH, and LH/FSH ratio. AMH at >5.1 ng/mL (sensitivity-70.97% and specificity-82.02%) predicted PCOS and correlated with PCOM. AMH (>5.1 ng/mL) is useful for diagnosing PCOS and surrogate for hyperandrogenemia and PCOM. Its correlation with hormones in non PCOS AFA highlights its sensitivity to diagnose endocrinological derangements.