Hormonal Therapies in the Management of Acne Vulgaris

Acne vulgaris (AV) is a common disorder that mostly affects the young population, ie, adolescents with around 80-90 % prevalence which usually subsides by 30 years of age. However, it may persist longer in some cases. A study by Perkins et al involving 2895 women reported that acne peaked in teenage years and in some cases extended through the fifth decade (adult acne).¹ In approximately 40-50% of the patients, AV may continue into adulthood, known as persistent adult acne instead of remitting within the third decade of life.² There is also a group of patients that develop the first episode of acne after 25 years of age. This is known as late onset adult acne/acne tarda.^3-5 AV severely impacts the quality of life of the affected individuals due to severity as well as easy visibility of the skin lesions. Also, it has a negative psychological impact with increasing incidences of social embarrassment, anxiety, and depression. Open or closed comedones, papules, pustules with associated seborrhoea are the most common manifestations of AV. In severe cases, nodules and cysts followed by scarring are observed. Conventional treatment modalities consist of topical therapies and oral medications. Topical therapies such as antibiotics and retinoids are currently recommended for mild acne whereas oral antibiotics and oral retinoids are used for the treatment of patients with moderate to severe AV.⁶ Some patients of acne have unpredictable course. Patients may have recurrent episodes of AV resistant to conventional therapy or due to hyperandrogenism.^7-9 These patients can have benefit from hormonal therapy. Moreover, with wider acceptance of acne as an inflammatory condition, there is a wider acceptance of non-antibiotic options for the treatment of AV. In this article, we discuss the role of hormonal therapies in treatment of AV.

We performed a literature search using the electronic database MEDLINE/PUBMED through June 2021. The search terms "anti-androgens", "acne", "hormonal acne", "adult acne", "adolescent acne", "hormonal therapy", "spironolactone", "oral contraceptive pills", "cyproterone acetate" were used to retrieve the articles from the database. Articles published in English language in peer review journals were used for qualitative analysis.

Role of Androgen in the Pathogenesis of AV
AV is an abnormality of the pilosebaceous unit (PSU) with multifactorial etiology. An androgen-mediated process plays a key role in the pathogenesis of acne.¹⁰ Androgens are mainly