Treatment for acne in a women with acne and menstrual disturbances: (AIIMS May 2009)
a. Minocycline is a tetracycline group of antibiotic with good deal of anti-inflammatory activity. It is therefore considered to be the drug of choice for inflamed acne.
b. It is given orally; food does not interefere with its absorption unlike other terracyclins.
c. It is lipid soluble hence enters blood brain barrier. Elimination is via bile, hence it is safe in renal failure.
d. The drug is also active against nesseria, MRSA and has mild activity as disease modifying antirhematic drug (DMARD).
e. Side effects include vertigo and skin pigmentation. Like other tetracyclins, it is never used in pregnancy.
f. Cyproterone is an androgen receptor blocker, a derivative of 17-hydroxyprosgesterone. It has glucocoritcoid activity.
g. Acetate salt of cyperterone has more efficacy as an antiandrogen.
h. Main pharmacological action of cyproterone is to LH levels which in turn reduce testosterone levels.
i. It is used in prostate cancer, BPH and hypersexuality.
j. Till GnRH analogues have been introduced, it was used to treat precocious puberty. It has weak progestesnal activity and is used in acne.
k. Due to its antiandrogenic activity; it could be used in hirsutism also. Side effects include hepatotoxicity, adrenal suppression and antiandronic effects.
l. The drug should not be stopped abruptly due to risk of adrenal suppression. Per se, the risk of deep vein thrombosis posed by cyproterone is small; but along with estrogens, the risk is significant.
m. Clinical manifestations of androgen excess-hirsutism, acne and alopecia-are very common and distressing symptoms in women of reproductive age.
n. These symptoms are frequently associated with polycystic ovary syndrome, in which condition menstrual disturbances are also common.
o. Cyproterone acetate along with estrogens is used for treatment of hirsutism. It is important to know that spirinolactone, an anti aldosterone with anti androgenic activity is also equally effective in hirsutism (BG Katzung, Basic & Clinical Pharmacology’ 11th Edition’ 2010; pp-724).
p. The combination of the anti-androgen cyproterone acetate (2 mg) and ethinyl estradiol (35 microg) (co-cypridiol) is of proven efficacy in management of symptoms of both hyperandrogenism and menstrual abnormalities but its long-term use has been discouraged because of concern about increased risk of venous thromboembolism. (ref: Hum ReproD. 2008 Feb;23(2):231-2.)
q. Isotretinoin is a vitamin A analogue used in severe acne and cancers. It is also used to treat a plaque like skin condition named ichthyosis.
r. It is supposed to be antibacterial to propionibacterium acne. The drug is often given orally and is best absorbed with a fatty meal.
s. Cheilitis, ocular sicca, and decreased dark adaptation are usual side effect. The drug is a proven teratogen and never given in pregnancy.
t. Acitretin is a 2nd generation retoind given orally for treatment of psoriasis. It is a metabolite of etretinate which was used earlier. Problem with etretinate is its unusually long half life.