Acne treatment options now extend beyond antibiotics, and hormonal therapy, particularly birth control pills (BCPs), may provide clearance of acne in women who may not respond to other therapies. "Challenge [yourselves] to learn how to safely use BCPs," said Dr. Julie Harper, Clinical Associate Professor of Dermatology at the University of Alabama in Birmingham, in the presentation, "Use of Hormonal Therapy for Acne," at the Summer Meeting of the American Academy of Dermatology. The use of BCPs for acne has a strength-of-recommendation grade of A (consistent, good-quality patient-oriented evidence).
According to Dr. Harper, all combination BCPs should work for acne, except progestin-only BCPs, which will make acne worse. Currently, there are 4 BCPs approved by the US Food and Drug Administration for acne: norgestimate-ethinyl estradiol (Ortho Tri-Cyclen); norethindrone acetate-ethinyl estradiol (Estrostep Fe); drospirenone-ethinyl estradiol (Yaz); and drospirenone-ethinyl estradiol-levomefolate calcium (Beyaz). Birth control pills are known to carry risks for venous thromboembolism (VTE), stroke, hypertension, and myocardial infarction; however, they are generally well tolerated in acne patients. "The risk of venous thromboembolism in women who take BCPs is doubled or tripled compared to women who do not take these pills. This sounds scary until you put it into context," said Dr. Harper. She explains the risks to patients using the following 3-6-9-12 model: A woman's baseline risk of having a VTE if she is not on a BCP is approximately 3 in 10,000 women in one year. When she takes a BCP, her risk doubles to 6 per 10,000 women in one year. If she takes a BCP that contains drospirenone, her risk is 9 per 10,000 women in one year. If she gets pregnant, her risk is 12 per 10,000 women in one year.
Dermatologists may be apprehensive to prescribe BCPs, but Dr. Harper provided several important tips on managing patient expectations and monitoring patients. Dr. Harper emphasized that BCPs should be used patiently for acne. "It frequently takes at least 3 cycles of BCPs to see a meaningful change in acne reduction," she advised. She recommended obtaining a thorough medical history and blood pressure measurement prior to prescribing BCPs. However, a Papanicolaou test and bimanual pelvic examination are no longer deemed mandatory prior to initiating a BCP, according to the World Health Organization and the American Congress of Obstetricians and Gynecologists. "While these exams may help to detect cervical cancer and other pelvic diseases, BCPs help to prevent unwanted pregnancies and the risks that accompany those pregnancies," said Dr. Harper. "Remember that BCPs reduce the risk of ovarian, uterine and colorectal cancer and also lessen ovarian cysts and pelvic inflammatory disease." Dermatologists also should inform patients that rifampin and griseofulvin, both anti-infectives, will interact with BCPs, lessening their effectiveness.
A March 2017 study published in Cutis (2017;99:195-201) of US dermatologists' knowledge, comfort, and prescribing practices (N=116) revealed that most dermatologists (95.4%) believe BCPs effectively treat acne; however, only 54% reported prescribing them. The American Academy of Dermatology's guidelines of care for the management of acne vulgaris published in February 2016 (J Am Acad Dermatol. 2016;74:945-973) stated that "estrogen-containing combined oral contraceptives are effective and recommended in the treatment of inflammatory acne in females."
Overall, Dr. Harper's take-home message was that dermatologists should not be afraid to prescribe BCPs, even in teenaged girls (following the onset of menarche). "Birth control pills can be used in younger patients but it is not my first line of treatment," said Dr. Harper. "It is recommended that BCPs not be prescribed for acne until 2 years after the young woman has achieved menarche. When considering whether or not to use a BCP in the early teenage years, keep in mind that these are not short-term treatments. If a BCP does help acne, it will likely need to be maintained for many years." When discussing this treatment in front of parents/guardians, consider referring to it as hormonal therapy and use the term birth control pills only initially.