Journal of Clinical and Aesthetic Dermatology

AUG 2017

An evidence-based, peer-reviewed journal for practicing clinicians in the field of dermatology

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52 JCAD JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY august 2017 • volume 10 • number 8 r e v i e w of sebaceous glands. 2 3,24 sebum production decreases by 90 percent during oral isotretinoin t herapy and osers some much needed optimism for patients with severe seborrhea. 38 One year after the completion of isotretinoin therapy, sebum excretion rates have been found to remain significantly suppressed for most individuals. 39 a lower dose of isotretinoin (<0.5mg/kg/day) is often employed when treating oily skin alone without nodulocystic acne, but this lower dose is clearly associated with a higher relapse rate. 40 Overall, up to 17 percent of patients will require a second course of oral isotretinoin despite achieving the recommended cumulative dose of 120 to 150mg/kg. 4 1,42 regardless of the severity of their oily skin, all patients should be reminded that this sizeable reduction in sebum production does not go without adverse esects. most commonly, patients will experience generalized dry skin, chapped lips, xerophthalmia, and secondary skin infections. 38 clinicians should educate their patients and provide tips to minimize these common side esects. One major consideration to discuss with patients prior to starting oral isotretinoin is teratogenicity. this very concern dictates the use of the iPledge system, a computer-based risk management program designed to help eliminate fetal exposure to isotretinoin, even if low doses are being used to treat oily skin. to help prevent this severe adverse risk, sexually active women must use two forms of contraception, and pregnancy testing is required for all female patients of childbearing potential at baseline and monthly until completion of therapy. Spironolactone. while this potassium- sparing diuretic has classically been utilized in medicine as an antihypertensive agent, it has become increasingly employed by dermatologists for the treatment of oily skin, acne, hirsutism, and androgenic alopecia in women. 43,44 spironolactone has been shown to directly reduce sebum production when dosed 50 to 200mg daily. 4 5 in addition to being an alderosterone antagonist, spironolactone also f unctions as an androgen receptor blocker and an inhibitor of 5α-reductase. 3 8 Human sebocytes contain type 1 5α-reductase, which converts testosterone to the potent androgen 5α-dihydrotestosterone (dHt). 46 this androgen plays an important role in inducing sebocyte proliferation. thus, by inhibiting production of dHt and blocking testosterone and dHt from binding to sebocytes, spironolactone has been proven to inhibit sebocyte proliferation in a dose- dependent manner. 47 Prior to starting a female patient on spironolactone for oily skin, several potential side esects need to be addressed. in an eight- year follow-up study, no serious immediate or long-term complications attributable to spironolactone for treatment of acne were reported. 48 still, mild side esects were present in 59 percent of the subjects, with menstrual irregularity being among the most common. 48 Hyperkalemia is often discussed as a potential concern; however, a retrospective study of 974 healthy women taking spironolactone for acne found only 0.72 percent of serum potassium measurements were abnormal compared to the 0.76 percent baseline rate of hyperkalemia. 49 considering these results and other similar reports, many dermatologists deem routine potassium monitoring as unnecessary for healthy women on spironolactone, but ultimately, lab monitoring is left to each provider's discretion. given spironolactone has endocrine esects, it is plausible that it could increase the risk of hormonally dependent cancers, such as breast, ovarian, or endometrial cancers. contrary to this notion, a large cohort of more than 74,000 patients treated with spironolactone found no evidence of an increased risk of breast, ovarian, or endometrial cancer. 50 these results have been supported by several other recent studies that investigated the potential relationship between spironolactone and risk of hormonally dependent cancers. 5 1,52 all in all, spironolactone is a safe systemic medication to consider for h ealthy women seeking treatment for oily skin. Oral contraceptives. Oral contraceptives are beneficial for oily skin in that they result in a decrease in ovarian and adrenal androgens and increase sex hormone-binding globulin, which limits free testosterone. as described above, androgens stimulate sebocyte proliferation and contribute to seborrhea. estrogens, all in all, have been found to exhibit an inhibitory esect on excessive sebaceous gland activity in vivo. 53 in order to avoid the risk of endometrial hyperplasia, or even cancer, that can result from unopposed estrogen, it must be used in combination with a progestin. it is important to consider which progestin is in the combination oral contraceptive, as some progestins have intrinsic androgenic activity. levonorgestrel, desogestrel, norgestimate, and norethindrone notably have the lowest androgenic activity. 5 4 some newer progestins, such as drospirenone or cyproterone acetate, even antagonize the androgen receptors and display antiandrogenic properties. 55,56 several studies have shown that oral contraceptives do indeed reduce facial oiliness. in a double-blind, randomized study of 128 women receiving either an ethinyl estradiol/drospirenone combination or an ethinyl estradiol/cyproterone acetate combination, both preparations significantly reduced sebum production. 55 katz et al 57 found a 60-percent relative reduction in sebum output on the cheeks and a 30-percent relative reduction in sebum output on the forehead of 41 women after six cycles of a combination ethinyl estradiol/desogestrel pill. the use of this same combination oral contraceptive was also proven to improve oily skin after just one cycle of treatment. 58 an important consideration prior to starting an oral contraceptive is the potential increased risk of venous thromboembolism. the newer oral contraceptives have lowered the estrogen doses in an esort to eliminate this risk. 38 some

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