Keywords: acne, endocrine, endocrinology, hormones, testosterone, androgen, skin, disease, adrenal, ovary, treatment, diagnosis, complication, zits

In the past decade, research conducted by the staff of the Institute for Endocrinology and Reproductive Medicine, in conjunction with medical experts around the world, has clearly established the important role androgens (or male sex hormones) play in the development of acne in both males and females. Now there are precise and sensitive assays which determines male hormone levels in the blood, and these assays have led to the development of safe and reliable methods to diagnose and treat patients with acne.

The basic cause of acne is a plugged oil gland, an inherited condition affected by changing hormone levels within the body. Both sexes and various age groups can be affected by this unsightly and painful condition, but advanced research and new treatments offer positive results.

In most instances, acne results from the overactivity of sebaceous (oil) glands with accompanying complications such as infection, healing and scar formation. This overactivity of the sebaceous glands usually results from either the presence of excessive amounts of male sex hormones (androgens) or an increased response (sensitivity) of the sebaceous glands to normal levels of male sex hormones. It should be noted that male sex hormones are present in both males and females. One approach to the treatment of male hormone-dependent acne is to lower the levels of male hormone production. For this diagnosis, it is important to establish the presence of excessive male sex hormone production, the cause of its excess and the site of its production.  This is done by simple blood tests for testosterone, free testosterone, and adrenal hormones such as DHEAS (dihydroepiandrostene sulfate) and perhaps 17-OHP (17 hydroxyprogesterone).  There is also a form of excess male hormones associated with insulin resistance-- a new disorder currently under intense investigation.

The facts are that ten percent of all visits to physicians' offices are related to skin disorders. One third of visits to dermatologists are related to acne. These figures translate to as many as 30 million office visits a year related to acne. In addition, there are probably as many individuals who suffer from acne, purchase over-the-counter lotions for self-treatment and never visit a physician. These numbers place acne into perspective in relation to its magnitude as a health care problem. It should also be pointed out that excessive production of male sex hormones by a female not only causes acne, but also can result in hirsuitism (excessive hair growth), menstrual disorders and subsequent lessened fertility. Therefore, the presence of acne in females may be an important sign of an underlying endocrine (hormonal) problem. This underlying problem, if caused by ovarian or adrenal gland disease and left undiagnosed and untreated, could lead to disorders of the menstrual cycle, PMS, polycystic ovarian disease and other disorders of the reproductive system.

The most efficient way to manage this health care problem is to combine a dermatological and endocrinological approach in order to establish a specific diagnosis, determine the site of male hormone production (the adrenal glands or the ovaries) and develop a proper therapeutic plan to treat the underlying disease and counteract the effects of the male hormones. Appropriate monitoring of the hormone levels by a laboratory specializing in hormone analysis and evaluation is essential for determining the type of medication, its dosage and its effectiveness during therapy. Treating the underlying abnormality of male hormone production may improve not only the acne, but also help control excess hair growth and disorders of the menstrual cycle such as PMS, infertility and menstrual irregularity.

Among the endocrine treatments for acne are:

• Birth Control pills
  • In theory, birth control pills shut down the ovary which is producing inappropriate male hormones and than substiututes a more balanced hormone mixture. Although all birth control pills are probably the same, Demulen (ethinyl estradiol and  ) has been the standard for many years.  Ortho Tricyclen (estinyl estradiol and norgestimate) had an FDA indication for acne and is heavy marketed in the USA for that indication.
• Diane/Dianette
  • This birth control pill is avilable in Europe and contains ethinyl estradiol and cyproterone acetate.  It is very effective for excess hair growth and perhaps acne.   It probably will never be approved by the US FDA because of the theoretical risk of cyproterone acetate caused birth defects (feminization of male fetuses).  Obviously, used in combination as a birth control pill markedly cuts that risk.

• Drugs used in the management of insulin resistance 
  •    Recently, physicians have become aware that there is a disorder called insulin resistance which underlies dysfunctions of many endocrine systems including the ovaries, adrenals, and pancreas.  Certain people with insulin resistance can have polycystic ovaries which result in inappropriate secretion of male directed hormones resulting in irregular cycles, obesity, increase body hair, acne, and infertility.   This is a highly unlikely cause of typical adolescent acne but may need to be investigated in women with adult onset acne, particularly if they have other components of this syndrome.  A simple glucose challenge test measuring insulin and glucose levels can make the diagnosis.  Prelimary data suggests that medications such as Glucophage (metiformin)  may help with these conditions in certain women even if they do not have diabetes.
•               ( ) is used to treat cystic acne.  It is very effective for that purpose but dangerous to use in women of child bearing age without strict controls because it can cause birth defects in male children.

We stress, "A proper hormone balance is key to normal growth and development. Hormone imbalances can trigger cases of acne, cause problems related to sexuality, puberty and reproduction and are significant factors in the health of every major organ of the body. That's why keeping hormone levels properly balanced is crucial to feeling and looking your best."

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