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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22 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 PCOS diagnosis. Girls with severe acne or acne resistant to oral and topical agents, including isotretinoin, have a 40-percent likelihood of developing PCOS. 53 Twenty to 40 percent of female patients with acne suffer from PCOS. 54 The performance of transvaginal ultrasound is not possible in women who are not yet sexually active. While FSH and LH testing is dependent on the menstrual cycle, the menstrual cycle has little influence on AMH. AMH testing is useful for diagnosing PCOS in patients with persistent acne. 55 Serum AMH level is also correlated with the severity of PCOS, and thus a raised AMH should prompt the clinician to do an ultrasound for PCOS. LH/FSH. In healthy women, LH/FSH ratio is approximately 1:1 during the follicular phase. 57 LH hypersecretion is a characteristic hallmark of PCOS. 58 High LH levels in the follicular phase indicate hypersecretion and probably an absence of LH surge, which causes anovulation in PCOS. Thus, in the present study we used the principle of LH/FSH ratio greater than 1 to indicate an abnormality in LH secretion. For PCOS, the ratio of greater than 2 is accepted as abnormal. Prolactin. Women with hyperprolactinemia might present with signs of chronic hyperandrogenism, such as hirsutism and acne (possibly due to increased dehydroepiandrosterone sulfate secretion from the adrenals) and reduced SHBG, leading to high free testosterone levels. Normal serum prolactin levels range from 5 to 25ng/mL in female subjects, although physiological and diurnal variations occur. 59 Hyperprolactinemia is usually defined as fasting levels of above 25ng/mL in women. 60 Many common medications can cause hyperprolactinemia with prolactin levels 100ng/mL or less. Other common conditions that must be excluded when considering raised prolactin levels include samples taken from a non-fasting individual or from individuals who excessively exercise, have had chest wall surgery or trauma, have renal disease or cirrhosis, or have had a seizure within 1 to 2 hours of testing. Certain medications can also affect prolactin levels. All of these conditions can cause prolactin elevation over 50ng/mL. 61 Study limitations. We found an almost universal prevalence of altered biochemical and hormone markers in our study. One reason for this might be the socioeconomic bias, as all patients in our study belonged to the middle class. Also, since only those patients who had some objective indication of insulin resistance or hyperandrogensim were included in our study, the prevalence rates do not reflect the real-world prevalence in female individuals with acne. CONCLUSION Rather than a transient pubertal cutaneous condition, acne is now recognized as a chronic systemic disease. There is a very high prevalence of altered metabolic and hormonal status in female individuals with acne. Although this study focused on women in India, there is no reason to believe that similar findings would not be seen in insulin-resistant men or in other countries. 34 It has been suggested that PCOS should be renamed "female metabolic syndrome" or "syndrome XX." 62 Dermatologists frequently evaluate and manage the cutaneous manifestations of PCOS, and therefore can play a key role in PCOS diagnosis and management. 63 Knowing the markers that indicate abnormalities can guide us to the correct acne treatment approach (Table 3). A patient with insulin resistance should be counseled about weight loss, exercise, and the consumption of a diet with low glycemic index. These patients can also be treated with metformin. Myoinositol supplements improve insulin sensitivity in PCOS patients. 64 Oral contraceptives with antiandrogenic progesterone can be used in women with PCOS who are experiencing irregular menstrual cycles. Vitamin D supplementation can help treat acne directly or indirectly by improving insulin sensitivity and hormone dysfunction. 20 Since the prevalence of vitamin D deficiency is ubiquitous, a study should be conducted to assess whether all acne patients should be given vitamin D supplements. Insulin resistance is also highly prevalent in patients with acne, so diet modification should be prescribed universally. The skin reflects the internal health of the body. Dermatologists should keep a high index of suspicion for other disorders, including PCOS, in their patients with acne, and evaluate them appropriately. Dermatologists are in a unique position to introduce lifestyle modifications at an early age to their patients with acne in order to prevent or delay the onset of serious systemic disorders. REFERENCES 1. Jansen T, Jansen OE, Plewig G. [Acne tarda. Acne in adults]. Der Hautarzt. 2013;64(4):241–51. 2. Lynn DD, Umari T, Dunnick CA, Dellavalle RP. The epidemiology of acne vulgaris in late adolescence. Adolesc Health Med Ther. 2016;7:13–25. 3. Balaji A, Thappa DD. Profile of acne vulgaris— a hospital based study from south India. Indian J Dermatol Venereol Leprol. 2009;75(3):272–278. 4. Cunliffe W, Gollnick H. Clinical features of acne Acne Diagnosis and Management. London: Martin Dunitz. 2000;49–67. 5. Khunger N, Kumar C. A clinico-epidemiological study of adult acne: is it different from adolescent acne?. Indian J Dermatol Venereol Leprol. 2012;78(3):335–341. 6. Dréno B, Layton A, Zouboulis CC, et al. Adult female acne: a new paradigm. J Eur Acad Dermatol Venereol. 2013;27(9):1063–1070. 7. Kellett SC, Gawkrodger DJ. The psychological and emotional effect of acne and the effect of treatment with isotretinoin. Br J Dermatol. 1999;140(2):273–282. TABLE 3. Treatment recommendations based on evaluation of female patients with acne CLINICAL/ LABORATORY FINDING RECOMMENDED INTERVENTION Weight gain, acanthosis nigricans/acrochordons, insulin resistance Exercise, diet with low glycemic index, weight loss, myoinositol and dietary supplements, metformin Irregular menses, patterned hair loss, hirsutism, high testosterone, high AMH level, altered LH/FSH, PCOS Oral contraceptive pills with antiandrogenic progesterone Hyperprolactinemia (<100ng/mL) Cabergoline AMH: anti-Müllerian hormone ; LH/FSH: leutinizing hormone/follicle stimulating hormone; PCOS: polycystic ovary syndrome

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