Published on 18/03/2015 by admin
Filed under Dermatology
Last modified 22/04/2025
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Rachel V. Reynolds and Terry T. Farsani
Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
Polycystic ovary syndrome (PCOS) is an endocrinopathy characterized by hyperandrogenism, menstrual irregularities, polycystic ovaries, and metabolic derangement.
Diagnosis is currently based on the Rotterdam 2003 consensus, and must include at least two of the following: (1) oligomenorrhea or amenorrhea; (2) clinical and/or biochemical signs of hyperandrogenism; and (3) polycystic ovaries. It also requires exclusion of other potential etiologies.
Treatment of PCOS is targeted towards decreasing androgen excess, normalizing menses, and ameliorating metabolic syndrome and cardiovascular complications. While treatment of the reproductive and metabolic complications decreases the risk of endometrial cancer and cardiovascular issues, treatment of cutaneous disease is also integral to the care of these patients and their quality of life.
Cutaneous manifestations resulting from androgen excess may include acne in 25–35%, hirsutism in 40–92%, female pattern alopecia, seborrhea, and, in some, acanthosis nigricans, a sign of hyperinsulinemia. Therefore, as dermatologists, we are in a unique position to identify and treat patients early in the course of their disease.
Cutaneous manifestations, including acne and hirsutism, may be targeted using topical or oral retinoids, and/or topical or systemic antibiotics. If the response is inadequate, combined oral contraceptives (OCPs) and/or anti-androgen therapy may be beneficial. Mechanical hair removal methods may be utilized. In patients with PCOS, weight loss may correct all metabolic abnormalities. In those with inadequate response, insulin resistance may be treated with insulin-sensitizing agents, such as metformin.
PCOS is associated with several mental health problems, including depression and anxiety, body dissatisfaction and eating disorders, diminished sexual satisfaction, and lowered health-related quality of life. Patients should be evaluated for psychologic issues and referred for appropriate counseling as needed.
Ovary ultrasound imaging
Serum androgen levels (testosterone, DHEA-S, 17-hydroxyprogesterone)
Pregnancy (urine or serum hCG)
Other hormone tests (FSH, LH, TSH, prolactin, 24-hour urine free cortisol)
Metabolic factors, diabetes (BMI, fasting lipid panel, oral glucose-tolerance test)
Blood pressure
Moran LJ, Misso ML, Wild RA, Norman RJ. Hum Reprod Update 2010; 16: 347–63.
Women with PCOS have increased glucose levels, type 2 diabetes, and metabolic syndrome.
PCOS is strongly linked with insulin resistance and glucose intolerance. Screening for impaired glucose tolerance requires an oral glucose-tolerance test (75 g, 0- and 2-hour values), as HbA1c demonstrates lower sensitivity in comparison.
Toulis KA, Goulis DG, Mintziori G, Kintiraki E, Eukarpidis E, Mouratoglou SA, et al. Hum Reprod Update 2011; 17: 741–60.
A meta-analysis of 130 studies revealed that women with PCOS have more coronary artery calcification, vascular endothelial dysfunction, and elevated C-reactive protein and homocysteine levels. Although women with PCOS have increased serum concentrations of cardiovascular disease (CVD) risk markers, an association with increased incidence of CVD is unclear.
Periodic assessment of diabetes, blood pressure, fasting lipid panel, and BMI is recommended in women with PCOS.
Fearnley EJ, Marquart L, Spurdle AB, Weinstein P, Webb PM. Cancer Causes Control 2010; 21: 2303–8.
A case-control study of 156 women with PCOS, <50 years of age, revealed a fourfold increased risk of endometrial cancer. After adjusting for confounders, risk was increased twofold.
Most endometrial cancers are well differentiated and have a good prognosis. Symptoms of heavy frequent menstrual periods or intermenstrual bleeding should prompt the physician to refer to gynecology and/or imaging for further evaluation.
Himelein MJ, Thatcher SS. Obstet Gynecol Surv 2006; 61: 723–32.
Moran LJ, Hutchison SK, Norman RJ, Teede HJ. Cochrane Database Syst Rev 2001; 7: CD007506.
Lifestyle intervention improves hyperandrogenism (based on clinical hirsutism and total testosterone level), waist circumference, and fasting insulin. Weight management is proposed as an initial treatment strategy.
Harwood K, Vuguin P, DiMartino-Nardi J. Horm Res 2007; 68: 209–17.
Loss of only 2–7% of weight improves all parameters of PCOS.
These effects are related to reduction of insulin levels.
Moghetti P, Toscano V. Best Pract Res Clin Endocrinol Metab 2006; 20: 221–34.
Topical retinoids are the first-line therapy for comedonal acne and may be combined with a topical antibiotic. Azelaic acid demonstrates moderate antibacterial, anti-inflammatory, and keratolytic activity. Topical benzoyl peroxide is weakly comedolytic, but is a potent antibiotic. Concomitant use of benzoyl peroxide decreases incidence of antibiotic resistance.
Topical treatments are first-line therapy in acne. In the presence of scarring acne or treatment failure, oral therapy is indicated.
Balfour JA, McClellan K. Am J Clin Dermatol 2001; 2: 197–201.
Facial hair growth was reduced in the treatment group after 2 to 8 weeks of treatment. Hair growth returned to pretreatment rates within 8 weeks of stopping treatment
Mcgill DJ, Hutchison C, McKenzie E, McSherry E, Mackay IR. Lasers Surg Med 2007; 39: 767–72.
A split-face study comparing the GentleLase alexandrite laser with the Lumina IPL system in 38 women with PCOS. After six treatments, the alexandrite laser demonstrated longer hair-free intervals and decreased hair counts.
Arowojolu AO, Gallo MF, Lopez LM, Grimes DA. Cochrane Database Syst Rev 2012; 7: CD004425.
Combined oral contraceptives (COCs) reduced acne lesion counts, severity grades, and self-assessed acne. Those containing chlormadinone acetate or cyproterone acetate (CPA) were more effective than levonorgestrel. Overall, few differences in efficacy were found between the COC types in treatment of acne.
FDA-approved OCPs for acne: norgestimate/EE (ethinyl estradiol), norethindrone acetate/EE, drospirenone/EE.
Kelekci KH, Kelekci S, Yengel I, Gul S, Yilmaz B. J Dermatolog Treat 2012; 23: 177–83.
Total of 134 women treated with combination oral contraceptive and anti-androgen: (1) EE/dropspirenone (DRSP) plus CPA 100 mg; (2) EE/DRSP plus spironolactone 100 mg; and (3) EE/CPA plus CPA 100 mg, over a 6-month period. Although all three groups showed significant decrease in hirsutism, there was no significant difference among groups.
Brown J, Farquhar C, Lee O, Toomath R, Jepson RG. Cochrane Database of Systematic Reviews 2009; Issue 2: CD000194.
Spironolactone 100 mg daily resulted in subjective decrease in hair growth. There was no evidence for effectiveness in treating acne.
In general, spironolactone is considered first choice in anti-androgen drugs in the treatment of hirsutism. Lower grade evidence supports anecdotal efficacy in acne.
Moghetti P, Tosi F, Tosti A, Negri C, Misciali C, Perrone F, et al. J Clin Endocrinol Metab 2000; 85: 89–94.
Forty hirsute female subjects were randomized to receive either spironolactone 100 mg daily, flutamide 250 mg daily, finasteride 5 mg daily, or placebo. All treatment groups revealed similar reduction in hair diameter.
Due to high cost and potential adverse liver effects, flutamide is rarely used.
Anti-androgens should not be used without effective contraception given the potential risk for femininization of a male fetus.
Costello MF, Shrestha B, Eden J, Johnson N, Moran LJ. Cochrane Database of Systematic Reviews 2007; Issue 1: CD005552.
Combined OCPs are superior to metformin in improving menstrual pattern and reducing serum androgen levels. Metformin is more effective than OCPs in reducing fasting insulin levels and not increasing triglyceride levels.
Aruna J, Mittal S, Kumar S, Misra R, Dadhwal V, Vimala N. Int J Gynecol Obstet 2004; 87: 237–41.
There was significant improvement in BMI, waist circumference, menstrual regulation, and pregnancy rate in 41 of 50 women taking metformin 1 g daily in this 6-month prospective study.
Metformin is first-line therapy in the treatment of hyperinsulinemia.
Frank S. Clin Endocrinol (Oxf) 2011; 74: 148–51.
Metformin has been shown to be safer than other insulin sensitizing agents.
Treatment of Skin Disease Comprehensive Therapeutic Strategies 4e
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Weight loss
Topical and systemic therapy for acne
Topical eflornithine
IPL/laser hair removal
Oral contraceptives
Anti-androgens
Metformin
Pioglitazone
Rosiglitazone
