Acne vulgaris is hormone-related (adult acne). Hormone therapy does work for female patients (not for men), but usually requires continued medication to maintain control. Isotretinoin is also effective for some women with adult acne, but usually relapses shortly after discontinuation. Isotretinoin has a teratogenic risk and is therefore contraindicated in pregnant women. Hormonal acne is associated with hormonal disorders and has a different presentation than adolescent acne (with nasal and forehead acne). Female patients with hormonal acne usually do not have acne during their adolescence (teenage years) and only break out in their twenties or thirties (mostly before menstruation, which may not be allowed); in addition, their skin is greasier and acne is mostly distributed in the lower part (jaw line, chin, behind the ears, etc.) and sometimes may be accompanied by hirsutism. If the acne outbreak is sudden, it is best to test hormone levels to determine if there is an endocrine disorder. Oral contraceptives Usually, dermatologists first treat with oral antibiotics or topical retinoids, topical antibiotics and topical antibacterial agents, but the results are usually less than satisfactory. At this point, it makes sense to switch to hormonal therapy — starting with oral contraceptives. Oral contraceptives stabilize hormone levels (without the monthly cyclical fluctuations), and the estrogen component in them elevates sex hormone-binding globule levels (which promotes androgen cycling and thus diminishes its effects). The low dose of progesterone in oral contraceptives may have little effect on acne control (although some products claim this effect). Most second and third generation birth control pills are effective for adult acne, and some of them are even specifically designed for this purpose. Spironolactone In addition to oral contraceptives, the anti-androgen spironolactone (antiandrogen
spironolactone) is one of the safest, most effective (and most neglected) treatments. The mechanism is that spironolactone blocks testosterone and dihydrotestosterone from stimulating oil production and androgen-sensitive hair growth. The typical dose of spironolactone is 50-100 mg per day and is contraindicated in men (can reduce libido and cause breast enlargement). Spironolactone can be used alone or in combination with birth control pills (for better results). Spironolactone may cause irregular menstrual cycles if not used in combination with birth control pills. When using birth control pills and spironolactone for adult acne, patients should avoid smoking and it is contraindicated in people with high blood pressure and severe migraines; in addition, spironolactone should also be discontinued in people who are planning to become pregnant and have stopped taking oral contraceptives.