Drug update: systemic acne treatments for women. (Clinical Rounds).

The road to clear skin is getting shorter. Recent Food and Drug Administration approval of several oral contraceptives for the treatment of mild to moderate acne has expanded the systemic treatment options for women. In addition, a flurry of direct-to-consumer advertising may send more women to their primary care physicians or gynecologists seeking prescriptions for acne medications.

As dermatologists know and primary care physicians are learning, acne is prevalent among adults, especially women. Women are becoming increasingly aware of their treatment options and are actively seeking them rather than hoping that the condition will resolve on its own. Physicians can treat adult acne with oral or topical agents, or a combination of both, but it's important 5 tailor treatment to the patient's type of acne. Oral contraceptives and antibiotics are good for inflammatory acne. Oral or topical retinoids, such as isotretinoin, are best for treating severe nodular acne. Treatment should also be dictated by severity; no treatment protocol is best for everyone.

All drugs listed should be avoided during pregnancy and by women who are breast-feeding. Women aged 35 or older who smoke should not take oral contraceptives.

ORAL CONTRACEPTIVES

This class treats inflammatory acne on a hormonal level by reducing androgen production and circulating androgens. Some study results have shown increased levels of androgens in women with acne, but the exact relationship between acne and the menstrual cycle remains elusive. Many women with acne also have hyperandrogenic symptoms, such as irregular periods, oily skin, and mild hirsutism.

OCs can be effective for mild to moderate acne but are often ineffective for more severe cases. They're a good choice for women with mild to moderate acne who also want contraception. Daily use is necessary. Some OCs have been specifically tested and approved for treating acne, while others have not. Some oral contraceptives, those with larger androgen doses, are bad for acne. All three OCs listed are equally safe and have not been tested head-to-head. Hormonal manipulation helps resolve the acne but also causes many side effects, so an element of trial and error is involved. Limit side effects by cutting the estrogen dose. A patient with bloating or nausea may find a lower dose more tolerable; a patient with breakthrough bleeding may need a higher dose. Other oral contraceptives probably have similar safety and efficacy, but physicians may feel more comfortable prescribing one with FDA approval for acne. If used with one of the antibiotics listed below, advise a second method of birth control because of concern that antibiotics may negate estrogen's contraceptive effect.

 
Drug                      Daily Dosage         Cost/Day * 
 
norgestimate and ethinyl  180-250 [micro]g     $1.11 
 estradiol                norgestimate and 35 
 (Ortho Tri-Cyclen)       [micro]g ethinyl 
                          estradiol 
 
norethindrone acetate     1 mg norethindrone   $1.18 
 and ethinyl estradiol    acetate and 20-35 
 (Estrostep)              [micro]g ethinyl 
                          estradiol 
 
 
 
 
 
 
 
 
levonorgestrel and        100 [micro]g         $1.13 
 ethinyl estradiol        levonorgestrel and 
 (Alesse)                 20 [micro]g ethinyl 
                          estradiol 
 
 
 
 
 
 
Drug                      Comment ** 
 
norgestimate and ethinyl  First birth control pill with FDA 
 estradiol                approval for acne. Contains 35 [micro]g 
 (Ortho Tri-Cyclen)       of estrogen. Generally well tolerated. 
 
 
norethindrone acetate     Approved by the FDA for treating 
 and ethinyl estradiol    moderate acne. Formulated so that 
 (Estrostep)              ethinyl estradiol dose rise as pills 
                          are used during a cycle, starting at 20 
                          [micro]g/day early in cylce and 
                          increasing to 30 [micro]g/day and then 
                          to 35 [micro]g/day. May be better 
                          tolerated in some women than 
                          alternative formulations. Currently 
                          the lowest estrogen does with FDA 
                          approval for acne. 
 
levonorgestrel and        Application for acne indication 
 ethinyl estradiol        submitted to FDA in January 2001; 
 (Alesse)                 approval expected this year. Delivers 
                          20 [micro]g of ehtinyl estradiol daily 
                          throughout cycle, making it the 
                          lowest-estrogen formulation. May be 
                          better tolerated in women with 
                          bloating or nausea on higher-dose 
                          formulations. 
 
OTHER SYSTEMIC AGENTS 
 
Drug                      Daily Dosage         Cost/Day * 
 
tetracycline              1 g                  $0.22 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
doxycycline               150 mg               $0.87 
                                               (doxycycline 
                                               hyclate); 
                                               $3.72 
                                               (doxycycline 
                                               monohydrate) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
minocycline               75-100 mg            $4.66 
                                               (100 mg b.i.d.) 
 
 
 
 
 
 
 
 
 
isotretinoin              1-2 mg/kg            419.50 
(Accutane)                                     (40 mg b.i.d.) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  ...