PCOS Cosmetic Concerns: Acne and Hirsutism

1. PCOSCosmetic Concerns:Acne and Hirsutism

2. Some Facts and Figures • Youth has been defined by the WHO as being between 15 and 24 years and Adolescence as being between the ages of 10 and 19 years • An estimated 25% of India's population of 138 million is aged 15-25 years. • Girls aged 10-19 years comprise about 22% of the female population • 78% of adolescents had evidence of hyperandrogenism [ hirsutism and / or acne ] - personal series Duru Shah 1996-2003

3. Hirsutism • Defined as the growth of pigmented coarse hair in androgen-dependent areas such as the face, chest, back, and lower abdomen • The most common manifestations of hyperandrogenism and PCOS

4. Hirsutism or Hypertrichosis? Hirsutism indicates the presence of excess terminal hair growth in areas of the body that are androgen-sensitive such as the face, chest, areola, lower back, buttock, inner thigh and external genitalia. Hypertrichosis indicates excess terminal hair growth in areas of the body that are not androgen- sensitive such as forehead, forearms, tops of the hands.

5. The Ferriman-Gallwey (FG) scale • To assess the degree of hirsutism in patients • Measure the degree of hirsutism in 11 areas of the body • The FG scale ranges from 0 – 44 • The higher the score, the more severe the hirsutism. • A typical score for someone with hirsutism is between 8 and 29. While this scale is somewhat subjective, it allows the physician to monitor the improvement in hair growth.

6. Investigations for Excess Androgens • Free testosterone • Total testosterone • Dihydroepiandrostenedione sulphate (DHEAS) • Androstenedione

7. Treatment of Hirsutism • Goals of hirsutism therapy are to control current hair growth and to prevent growth of new hair • Drug therapy • Mechanical hair removal techniques • Counselling

8. Drug Therapy • Combination oral contraceptives • Anti-androgen therapy • Gonadotropin-releasing hormone agonists

9. OC Pill  SHBG  FSH, LH Free Circulating Androgen Ovarian Androgen Combination Oral Contraceptives Mechanism of action • Regulates menstruation • Used in treatment of • acne • hirsutism

10. Androgen Antiandrogen therapy Androgen Receptor Testosterone 5α-reductase Dihydrotestosterone Anti-Androgen Therapy

11. Cyproterone Acetate Cyproterone Acetate ( CPA ) . . . 2mg Ethinyl Estradiol ( EE ). . .35μg • Available in combination with ethinyl estradiol as an oral contraceptive pill • The combination Effectively inhibits ovulation even in 1st cycle of use Cycle control : excellentPre-treatment :Inter-menstrual bleeding – 13%Post treatment : 12 cycles – 2.9% 24 cycles – 1.1% 36 cycles – 0.5% - Aydinlik S et at Clin Trials J 1990

12. CPA + EE Combination • Effectively controls excessive androgen levels - by binding to androgen receptors and reducing plasma testosterone - increases SHBG • Brings about definite healing of facial acne in • 1/3rd women by first 3 cycles • 3/4 women by first 6 cycles Aydinlik S et at Clin Trials J 1990

13. CPA + EE Combination • At least 12 months treatment is required to achieve a 50% reduction in the hirsutism scoreRef: Keller PJ diagnostics & therapy of androgenization 1992 • In severe cases of hirsutism, a higher dose of CPA (20-100mg) is recommended in first 10 days of treatment along with the combination i.e. reverse sequential regimen.Ref: Prelevic GM et al Ann New York Acad Sci 1993

14. Anti-Androgen Therapy Spironolactone: 25 to 100 mg twice daily Side effects are mild and can include • menstrual irregularity • hypotension • lethargy • urinary frequency • hyperkalemia

15. Anti-Androgen Therapy • Flutamide: • 250 to 500 mg/day • Finasteride: • 5 mg daily. The drug is well tolerated with few side effects in women.

16. Gonadotropin - Releasing Hormone Agonists • Complete suppression of the ovary resulting in decreased androgen levels. • Concomitant therapy with oral contraceptives has been shown to be more effective than GnRH agonist treatment alone. • A GnRH agonist combined with estrogen is more effective than an oral contraceptive alone in the treatment of hirsutism

17. Other Remedies for Hair Removal • Bleaching • Shaving • Plucking • Depilatory creams • Waxing • Electrolysis • Laser Treatment

18. Acne It is the term for • Plugged pores (blackheads and whiteheads) • pimples • Deep lumps (cysts or nodules) • That occur on the face, neck, chest, back, shoulders and even the upper arms

19. Acne Treatment The goals of treatment are . . . • To heal existing lesions • Stop new lesions from forming • Prevent scarring • Minimize the psychological stress and embarrassment caused by this disease Treatment Options • Over-the-counter (OTC) medicines • Prescription topical medicines applied to the skin • Prescription systemic medicines taken by mouth • Single or in combination

20. Treatment for Blackheads, Whiteheads, and Mild Inflammatory Acne • A topical medication without prescription, available over the counter • Benzoyl peroxide, resorcinol, salicylic acid, and sulfur are the most common • Available in many forms, such as gel, lotion, cream, soap, or pads • May cause side effects such as skin irritation, burning, or redness

21.  Treatment for Moderate to Severe Inflammatory Acne Treated with topical or oral medicines, alone or in combination • Prescription Topical Medicines – • Antibiotics • Benzoyl peroxide • Tretinoin • Adapalene • Azelaic acid • Common side effects include • Stinging Burning • Redness  Peeling • Scaling  Discoloration

22. Treatment for Moderate to Severe Inflammatory Acne • Treated with topical or oral medicines, alone or in combination • Prescription Oral Medicines – • Clindamycin • Erythromycin • Other common antibiotics used to treat acne are tetracycline, minocycline, and doxycycline • Side effects such as an increased tendency to • Sunburn • Upset stomach  Dizziness / light headedness  Changes in skin colour

23. Treatment for Severe Nodular or Cystic Acne A retinoid-Isotretinoin is a very effective medicine that can help prevent scarring • Acne completely or almost completely controlled in up to 90% of patients Possible side effects include • Dry eyes, mouth, lips, nose, or skin; • Itching • Nosebleeds • Muscle aches • Sensitivity to the sun • Poor night vision • Depression

24. Treatments for Hormonally Influenced Acne When acne is seen with hirsutism, irregular menstrual cycles, and elevated blood levels of certain androgens • Low-dose estrogen pills help suppress the androgen produced by the ovaries • Low-dose corticosteroids, such as prednisone or dexamethasone, suppresses the androgen produced by the adrenal glands • An antiandrogen drug, (such as spironolactone, cyproterone acetate) reduces excessive oil production. Side effects of antiandrogen drugs may include irregular menstruation, tender breasts, headache, and fatigue

25. Other Treatments for Acne • Dermabrasion (or micro dermabrasion), which is a form of "sanding down" scars, is sometimes combined with the subsurface laser treatment • Cleanse skin gently with a mild cleanser • Avoid frequent handling of the skin • Choose cosmetics carefully

26. Take Home Messages • Acne and Hirsutism are important manifestatons of PCOS due to hyperandrogenemia • Diagnosis of PCOS is important to prevent long term sequelae due to hyperinsulinemia and anovulation • The management of cosmetic problems in PCOS requires a multidisciplinary approach. • Youth are concerned about their appearance and body image therefore multiple concomitant therapies are often necessary to address the variety of symptoms and achieve better results.

27. Concept – Dr. Duru Shah • Contributors Dr. Duru Shah Dr. Safala Shroff • Editors Dr. Sangeeta Agrawal Dr. Reena Wani

28. We acknowledge the efforts of our : Coordinators : • Dr. Sangeeta Agrawal - Central • Dr. Narendra Malhotra - North • Dr. Hema Divakar - South • Dr. P. C. Mahapatra - East • Dr. Uday Thanawala - West In bringing the FOGSI YOUTH EXPRESS to your city.

29. Charak Pharma Pvt. Ltd CIPLA Ltd. Emcure Pharmaceuticals Ltd GlaxoSmithKline Pharmaceuticals Limited Glenmark Pharmaceuticals Ltd. Metropolis Health Services (India) Pvt.Ltd. Organon India Ltd Roche Pharmaceuticals Ltd. Sandoz Private Limited USV Limited Wyeth Limited This Youth Express has been possible due to the educational grant from