Yves Poulin

Acne is an androgenic disorder. There is no acne without hormones. Acne starts with adrenarche and may be seen until menopause. Although many factors are involved in the pathogenesis of acne (dyskeratinisation of follicular infundibulum, bacterial overgrowth, triggering of an  inflammatory cascade), sebum production is essential and this is under hormonal control.

Many hormones play a role on the pilosebaceous unit. Dihydrotestosterone (DHT) is the main one. DHT is produced directly into the skin by conversion of  Testosterone (T).

How to inhibit the action of DHT without major side effects?

All combined oral contraceptives (OC) are able to decrease circulating  free T  by increasing the binding globulin SHBG.  DHT is decreased  as there is less available T. Moreover all OCs block the ovary secretion of androgens by inhibiting FSH-LH secretion.

Estrogens alone (Ethinyl estradiol of OCs ), given in adequate dosage, can diminish sebaceous secretion. The minimal dose has been suggested as being 35 mcg.

The progestins from all brands of OC’s, except Diane-35,  are all derivatives of  Testosterone , and still have some androgenic activity, norgestimate and desogestrel being the less androgenic ones.

The capacity of Alesse (EE 20 mcg + Levonorgestrel ) and Tri-Cyclen (EE 35 mcg + Norgestimate) to improve acne has been established  in excellent placebo-controlled trials.

The progestin of Diane-35 (EE 35 mcg + Cyproterone ) is an anti-androgen. This means that the progestin « Cyproterone Acetate » works by competitive inhibition of DHT directly at the level of the pilosebaceous unit, in addition to the standard effect of increased SHBG and  inhibition of FSH-LH secretion that is seen with all progestins. Diane-35 is the only OC containing an anti-androgen.

Diane-35 is precisely aimed at  suppressing DHT, the main hormone involved in the pathogenesis of acne.

A review of  the main data  on the use of OCs as acne treatment is presented.

Main reference:

Lemay A, Poulin Y. Oral contraceptives as anti-androgenic treatment of acne.

J.Obstet Gynaecol Can. 2002 Jul ; 24(7):559-67.