Journal of Clinical and Aesthetic Dermatology

OCT 2017

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

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19 JCAD JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY October 2017 • Volume 10 • Number 10 O R I G I N A L R E S E A R C H recruited for this study, which followed the Declaration of Helsinki Ethical Principles of Medical Research. Patients gave informed consent to participate in the study, and patients whose photographs are used in this article provided written consent for the same. Inclusion criteria was the presence of acne (irrespective of grade) with one or more of the following characteristics: hirsutism, acanthosis nigricans/acrochordons, patterned hair loss, weight gain, menstrual disturbances, and/or poor response to topical therapies or isotretinoin. Exclusion criteria were pregnancy and lactation, oral contraceptive use, any systemic illness including known hypothyroidism, current use of oral systemic medication, and/ or infertility treatment. The typical age of the study participants ranged from 16 to 39 years. All patients belonged to the middle socioeconomic class. The clinical characteristics of the patients are described in Table 1. Because follicle-stimulating hormone (FSH) and luteinizing hormone (LH) were being measured, the investigations were carried out within the first five days of onset of menses. An oral glucose tolerance test (OGTT) was performed in which blood sugar and insulin were measured after at least eight hours of fasting and two hours post-75g glucose. As some hormones have peak levels in the morning, FSH, LH, serum testosterone (total), anti-Müllerian hormone (AMH), thyroid stimulating hormone (TSH), serum prolactin, and serum vitamin D were measured from the morning fasting sample. Homeostatic Model of Assessment of Insulin Resistance (HOMA IR) score was calculated. Based on the method used by the laboratory and the references available, the following cut-off levels for "normal" were used: fasting blood sugar lower than 100mg/dL; two hours post-load blood sugar lower than 140mg/dL; fasting insulin lower than 17IU/ mL; two hours post-glucose insulin lower than 41IU/mL; HOMA IR lower than 2.5; LH lower than FSH (as the test was done in follicular phase); Serum AMH lower than 6.8ng/mL; and vitamin D higher than 20ng/ mL. Abdominopelvic ultrasound was done within 2 to 3 days of the blood tests and was checked for the presence of polycystic ovary syndrome (PCOS). RESULTS Of the 33 study participants who consented to receive a pelvic ultrasound, 14 (45%) showed the presence of PCOS. Two patients were detected as having a single large (<5cm) cyst in their ovaries and were referred to a gynecologist for appropriate treatment. Prevalence rates of raised biochemical markers for insulin resistance and hormone dysfunction are shown in Table 2. Thirty-five out of the 36 patients (97.22%) showed at least one altered marker. Twenty-one (58.3%) patients had at least one biochemical marker of insulin resistance. Mean fasting insulin in our study was 10.3 versus 7.7 from a healthy adult Indian cohort. 45 Two patients were newly detected as having hypothyroidism. Prolactin levels were high, but were under 100ng/mL in 11 patients (30.5%). DISCUSSION Serum testosterone. It has been shown that the development of acne can be a cutaneous symptom of hyperandrogenism, a medical condition characterized by excessive levels of male sex hormones (e.g., testosterone) in the female body. 8 Other cutaneous clinical signs of hyperandrogenism include hirsutism, patterned hair loss, acanthosis nigricans, and acrochordons. Serum testosterone level estimation is a simple and cost-effective laboratory test used to determine the presence of hyperandrogenism. As serum testosterone has been associated with acne vulgaris, testosterone levels should be measured in patients presenting with acne vulgaris, especially in those cases that are treatment-resistant. In female cases of elevated testosterone levels, anti-androgen treatment should be considered. 8 The total testosterone screening test, a marker of overall androgen production, has some advantages over free testosterone screening in that it is less expensive and might be considered easier to interpret. However, measuring free testosterone, which represents the biologically active testosterone, might be a more sensitive indicator of hormonal abnormality. If total testosterone is elevated, the clinician should consider further testing for free testosterone, sex hormone binding globulin (SHBG), and other androgens. However, not all women with clinical signs of hyperandrogenism have elevated circulating androgen levels. 5 Cutaneous signs of hyperandrogenism with a normal androgen level in the blood can be either due to increased responsiveness of the pilosebaceous unit to the normal androgen level (end-organ hypersensitivity) or increased activity of FIGURE 1. A women with polycystic ovaries, acne, hirsutism, and acanthosis nigricans on the chin FIGURE 2. A woman with irregular menstrual cycle, acne, and hirsutism TABLE 1. Clinical profile of cases CLINICAL CHARACTERISTIC n (%) Hirsutism 29 (80.5%) Weight gain 18 (50%) Acanthosis nigricans/acrocordons 12 (33.3%) Patterned hair loss 4 (11.1%) Menstrual disturbances (current or previous) 9 (25%) Poor response to topicals 19 (27.8%) Poor response to isotretinoin 2 (5.5%)

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