Hormonal and Steroid Acne

Hormonal Acne

Hormonal acne are acne associated with hormonal disorders or hormonal drugs.

In some women, acne can be associated with high levels of the hormone dehydroepiandrosterone sulfate (DHEAS), dihydrotestosterone (DHT), testosterone ^[9] or cortisol ^[10] and in men with high levels of cortisol ^[18,19], androstenedione, DHEAS ^[10,19] or estradiol ^[9]. Other common symptoms in women with high levels of androgen hormones include excessive hair growth on the skin (hirsutism), hair loss on the scalp (alopecia) and abnormal menstruation.

Picture 1. Severe hormonal acne on the forehead
(source: DermNetNZ, CC license)

Picture 2. Hormonal cystic acne on the chest
(source: DermNetNZ, CC license)

Picture 3. Severe hormonal acne on the back
(source: DermNetNZ, CC license)

Causes of Hormonal Acne

Conditions with increased levels of androgen and other hormones that can cause acne ^[11]:

• Obesity associated with insulin resistance and therefore increased blood levels of insulin; it is not clear if untreated diabetes type 2 is associated with acne, though ^[20]
• Acromegaly with increased levels of the growth hormone (GH), insulin-like growth factor (IGF-1) ^[12] and testosterone ^[17]
• Congenital adrenal hyperplasia (CAH) with increased secretion of androgen hormones in children or adults ^[15]
• Cushing syndrome, for example, due to adrenal gland tumors with increased secretion of cortisol and androgen hormones ^[3,13,16]
• Polycystic ovary syndrome (PCOS) with increased levels of dehydroepiandrosterone sulfate (DHEA-S) ^[23]
• Pituitary adenoma – a benign tumor with increased secretion of adrenocorticotropic hormone (ACTH) ^[14]
• Androgen-secreting tumors in the ovaries or adrenal glands in women ^[16]
• Hypothyroidism associated with an increased secretion of the hormone prolactin ^[16] and testosterone ^[17]

Steroid Acne

Steroid acne develop as a side effect of steroid drugs ^[4,17]:

• Oral steroids, such as prednisone
• Steroid creams
• Contraceptives: medroxyprogesterone injection, implanted or intrauterine progesterone and oral contraceptives which reduce circulating sex hormone binding globulin (SHBG)
• Progestin-containing contraceptives in the form of pills or intrauterine devices (desogestrel, levonorgestrel, norethindrone, norgestimate, norgestrel)
• Testosterone
• Dehydroepiandrosterone (DHEA)
• Anabolic steroids, such as danazol, stanozolol and nandrolone (used mainly by bodybuilders)

Picture 4. Cystic acne after use of steroid cream 
(source: SF da Silva, MD, Dermatology Atlas)

Picture 5. Mild steroid acne on the chest
(source: DermNetNZ, CC license)

Treatment of Hormonal and Steroid Acne

Antiandrogens such as cyproterone acetate ^[21], spironolactone ^[21], finasteride, flutamide ^[21] and corticosteroids (prednisone, dexamethasone) in low doses are used in women with signs of increased androgen production, such as excessive body hair; they may need 3-6 months to show effects ^[1,2,21].

• According to one 2012 review, spironolactone may help reduce hormone-related acne that appears in women before menstrual period ^[8].
• There is INSUFFICIENT EVIDENCE of the effectiveness of finasteride ^[21] and spironolactone ^[5,6] in reducing acne in women with diseases with increased androgen hormone levels.
• Prednisone by mouth can help in severe acne (acne fulminans) ^[22].

Side effects, such as breast tenderness, stomach upset and severe liver damage, limit the usability of antiandrogens in the treatment of acne in women ^[21]. Antiandrogens are not convenient for the treatment of acne in men, because of feminizing side effects, such as impotence and enlarged breasts ^[21].

• References

  1. Questions and answers about acne National Institute of Arthritis and Musculoskeletal and Skin Diseases
  2. Graber E, 2015, Patient Information: acne (beyond the basics) UpToDate
  3. What causes acne? DermNet NZ
  4. Acne due to medicines DermNet NZ
  5. Brown J et al, 2009, Spironolactone versus placebo or in combination with steroids for hirsutism and/or acne Cochrane
  6. Titus S et al, 2012, Diagnosis and Treatment of Acne American Family Physician
  7. Chen MJ et al, 2011, High serum dehydroepiandrosterone sulfate is associated with phenotypic acne and a reduced risk of abdominal obesity in women with polycystic ovary syndrome PubMed
  8. Kim GK et al, 2012, Oral Spironolactone in Post-teenage Female Patients with Acne Vulgaris
     Practical Considerations for the Clinician Based on Current Data and Clinical Experience PubMed Central
  9. Yang XQ et al, 1989, Testosterone and estradiol serum levels in acne PubMed
  10. Cappel M et al, 2005, Correlation between serum levels of insulin-like growth factor 1, dehydroepiandrosterone sulfate, and dihydrotestosterone and acne lesion counts in adult women PubMed
  11. Lolis MS et al, 2009, Acne and systemic disease PubMed
  12. Jain K et al, 2008, Late onset isotretinoin resistant acne conglobata in a patient with acromegaly PubMed
  13. Fudge EB et al, 2009, Cushing Syndrome in a 6-Month-Old Infant due to Adrenocortical Tumor PubMed Central
  14. Shaver D et al, 2015, Case report: Patient presenting with Cushing’s disease PubMed Central
  15. Dessinioti C et al, 2009, Congenital adrenal hyperplasia PubMed Central
  16. Abdel-Rahman MY, Androgen excess, clinical presentation Emedicine
  17. Abdel-Rahman MY, Androgen excess, overview Emedicine
  18. Schmidt JB et al, 1990, Endocrine parameters in acne vulgaris PubMed
  19. Ramsay B et al, 1995, Raised serum 11-deoxycortisol in men with persistent acne vulgaris PubMed
  20. Emiroglu N et al, 2015, Insulin resistance in severe acne vulgaris PubMed Central
  21. Ebede TL et al, 2009, Hormonal Treatment of Acne in Women PubMed Central
  22. Lages RB et al, 2012, Acne fulminans successfully treated with prednisone and dapsone PubMed
  23. PCOS and acne  PCOS.com