Terapia antiandrogénica

Aporte del Dr. Jaime Piquero Martín 

Un grupo de pacientes femeninas que nos consultan por acné pueden ser controladas con terapia antiandrogenica

¿;A que pacientes le realizamos investigación de anormalidad endocrina?

– Repentino brote de acné  severo de inicio
– Acné refractario a tratamiento convencional
– Acné asociado a hirsutismo
– Períodos menstruales irregulares
– Otros signos de hiperandrogenismo

¿;Que exámenes hormonales solicitamos?

1. Testosterona total y libre  
2. Androstenediona 
3. Sulfato de DHEA
4. FSH/LH
5. Curva de tolerancia glucosada y de insulina 0, 60, 120 minutos con sobrecarga de 75 gramos

¿;En que momento debe hacerse la toma de la muestra?

En los primeros 5 días si es cíclica, en cualquier momento si no lo es

Anticonceptivos que pueden usarse como coadyuvante de la terapia del acné constitucional

– Ciproterone acetate 2 mg/ethinyl estradiol 35 mcg. (Diane-35)
– Drosperinona 3 mg + etinilestradiol 0.03 mg:  (Yasmin)
– Ethinyl estradiol/chlormadinone acetate (Belara)
– Ethinyl estradiol/levonorgestrel (Alese)
– Norethindrone acetate 1,000 mcg/ethinyl estradiol 20-30-35 mcg 
– Norgestimate 180-215-250 mcg/ethinyl estradiol 35 mcg 

Otros antiandrógenos que pueden utilizarse cuando el acné coexiste con androgenización

1.-Los antiandrógenos que realizan su acción bloqueando los receptores nucleares son: Espironolactona, Acetato de Ciproterona, Flutamida
2.-Otros bloqueadores de  receptores nucleares de diferenciacion del sebocito: Metformina, Bromocriptina, Inhibidores de la hormona tiroidea
3.- Frenadores de los andrógenos producidos por el ovario: Estrógenos, Anticonceptivos orales, Acetato de Ciproterona
4.-Bloqueadores de los andrógenos producidos por la suprarrenal: Anticonceptivos orales plus baja dosis de glucocorticoides
5.- Inhibidores de las enzimas citoplasmáticas del sebocito: Inhibidores de la 5 alfa reductasa: Finasteride

Harper JC. Antiandrogen therapy for skin and hair disease.Dermatol Clin. 2006 Apr;24(2):137-43.

Androgen hormones play an important role in common skin and hair conditions including acne vulgaris, hirsutism, and androgenetic alopecia. Blocking this androgen effect may lead to significant improvements in these conditions. Several medications that work through a variety of different mechanisms may be prescribed safely and effectively as antiandrogen therapies in the dermatology arena.

Zouboulis CC. [Treatment of acne with antiandrogens–an evidence-based review] J Dtsch Dermatol Ges. 2003 Jul;1(7):535-46

Increased sebaceous gland activity with seborrhea is one of the major pathogenetic factors in acne. Antiandrogen treatment targets the androgen-metabolizing follicular keratinocytes and the sebaceous gland leading to sebostasis, with a reduction of the sebum secretion rate of 12.5-65%. Antiandrogens can be classified based on their mechanism of action as androgen receptor blockers, inhibitors of circulating androgens by affecting ovarian function (oral contraceptives), inhibitors of circulating androgens by affecting the pituitary (gonadotropin-releasing hormone agonists and dopamine agonists in hyperprolactinemia), inhibitors of adrenal function, and inhibitors of peripheral androgen metabolism (5alpha-reductase inhibitors, inhibitors of other enzymes). METHODS: All original and review publications on antiandrogen treatment of acne as monotherapy or in combination included in the MedLine system were extracted by using the terms "acne", "seborrhea", "polycystic ovary syndrome", "hyperandrog", and "treatment" and classified according to their level of evidence. RESULTS: The combinations of cyproterone acetate (2 mg)/ethinyl estradiol (35 microg), drospirenone (3 mg)/ethinyl estradiol (30 microg), and desogestrel (25 microg)/ ethinyl estradiol (40 microg) for 1 week followed by desogestrel (125 microg)/ethinyl estradiol (30 microg) for 2 weeks showed the strongest anti-acne activity. Gestagens or estrogens as monotherapy, spironolactone, flutamide, gonadotropin-releasing hormone agonists, and inhibitors of peripheral androgen metabolism cannot be endorsed based on current knowledge. Low dose prednisolone is only effective in late-onset congenital adrenal hyperplasia and dopamine agonists only in hyperprolactinemia. Treatment with antiandrogens should only be considered if none of the contraindications exist. CONCLUSION: Antiandrogen treatment should be limited to female patients with additional signs of peripheral hyperandrogenism or hyperandrogenemia. In addition, women with late-onset or recalcitrant acne who also desire contraception can be treated with antiandrogens as can those being treated with systemic isotretinoin. Antiandrogen treatment is not appropriate primary monotherapy for noninflammatory and mild inflammatory acne.