Updated Guidance: Management of Hirsutism and Acne in Adolescents

SUMMARY:

ACOG provides guidance on the diagnosis and management of adolescents with hirsutism and acne, the most common manifestation of hyperandrogenism. While PCOS is the most common cause, making the diagnosis in this age group can be challenging. Furthermore, there are other diagnoses to consider and, while less frequent, may have significant clinical implications.

Diagnosis of Hyperandrogenism

Role of Lab Testing

Hirsutism Treatment – Multimodal Approach

Acne Treatment – Multimodal Approach

Additional Notes

CLINICAL ACTIONS:

Diagnosis of Hyperandrogenism

History

• Ask about the following
  • Menses: Regular vs irregular
  • Age of thelarche, adrenarche, and menarche
  • Hirsutism: Hair removal and/or shaving
  • Acne: Use of treatments
  • Medications, including possible use of anabolic steroids or testosterone
  • Family history of acne, hirsutism and possible PCOS

Physical exam

• Key elements include the following
  • BP
  • BMI
  • Derm exam
    • Hyperandrogenism: Acne | Hirsutism
    • Hyperinsulinism: Acanthosis | Skin tags
  • Pelvic exam
    • External examination “may be helpful” to assess presence or absence of clitoromegaly
    • Clitoromegaly definition: Glans >8 mm | Hood length >27.4 mm
    • “Internal vaginal examination is rarely indicated”
• Hirsutism grading system: Modified Ferriman–Gallwey score (see ‘Learn More – Primary Sources’ for the chart)
  • 9 body areas
  • Scored from 0 to 4 based on extent of hair growth and location
  • Hirsutism: Score >8
• Acne grading system: No universally agreed upon scoring system or scale
  • Overall severity (related to lesion quality, quantity and location)
    • Mild (only a few lesions)
    • Moderate (higher number of inflammatory papules and pustules on face and trunk)
    • Severe (may include nodules with extensive involvement of face and trunk)
  • Location: Face and/or trunk
  • Quality: Comedonal | Inflammatory (e.g, erythematous papules/nodules) | Mixed
• Need for Pelvic exam
  • External examination “may be helpful” to assess presence or absence of clitoromegaly
    • Clitoromegaly: Glans >8 mm | Length of the hood >27.4 mm
    • If clitoromegaly present, additional androgen studies warranted
  • “Internal vaginal examination is rarely indicated”
• Need for pelvic ultrasound
  • Usually not indicated on a routine basis but consider androgen producing tumor if the following are present
    • High laboratory androgen levels | Significant virilization
    • Adrenal ultrasound and CT scan may be used as well, especially if DHEAS is suggestive of adrenal tumor
  • Polycystic ovarian morphology
    • Present in up to 40% of adolescent girls
    • Does not generate a diagnosis of PCOS nor predict future risk

KEY POINTS:

Role of Lab Testing

Regular Menses

• Free/Total testosterone
  • >200 ng/dL: Consider ovarian tumor
• DHEAS
  • >700 micrograms/dL: Consider adrenal tumor
• 17OHP (first thing in the morning)
  • >200 ng/dL: Consider nonclassical congenital adrenal hyperplasia (CAH)

Note: If labwork is normal, consider idiopathic hirsutism and/or acne

Irregular Menses

• Testosterone, DHEAS and 17OHP (as above) plus
• LH/FSH
• Prolactin
• TSH

Note: If patient meets diagnostic criteria for PCOS (see ‘Related ObG Topics’ below), screen for diabetes and elevated lipids

Hirsutism Treatment – Multimodal Approach

Lifestyle modifications

• Weight loss for obese patients is effective with multiple other long term benefits aside from addressing hyperandrogenism

Medication

• Combined hormonal contraceptives (not currently FDA approved for this indication)
  • Effective regardless of route
  • Third-generation progestins (desogestrel, gestodene, and norgestimate): Less androgenic activity vs levonorgestrel
  • Drospirenone (spironolactone derivative): Antiandrogen activity
• Antiandrogens
  • Spironolactone (approved indication): 50 to 200 mg/day
    • May be used to enhance hormonal contraceptive
  • Less data available on other antiandrogens
• Other medications
  • Metformin: Used in adolescents with PCOS and insulin resistance

Hair removal

• Temporary removal
  • Bleaching | Shaving | Waxing Chemical depilatories | Eflornithine cream (approved for facial hirsutism)
• Permanent removal affecting follicle
  • Electrolysis | Laser

Acne Treatment – Multimodal Approach

• Consider working with dermatologist for moderate to severe acne and referral for more severe/complex cases (see American Academy of Dermatology guidelines in ‘Learn More – Primary Sources, below)
• Multiple topical agents are available
  • Benzoyl Peroxide (BP) | Salicylic acid | Antibiotics | Combination antibiotics with BP | Retinoids | Retinoid with BP | Retinoid with antibiotic | Azelaic acid | Sulfone agent
• Hormonal therapy
  • ACOG considers hormonal therapy (e.g., OCP) “acceptable first-line” therapy in postmenarchal adolescents
  • Additional benefits: Cycle control and contraception
  • May be especially effective for adolescents with flares prior to menses
  • Any OCP with estrogen component should be effective
  • Consider higher generation progestin (see above) if patient not responding to current OCP
• Spironolactone
  • Start at 25 mg/day and can go up to 100 to 200 mg/day
• Oral antibiotics
  • Used for moderate to severe with inflammatory lesions following failure of topical therapy
  • Tetracycline | Doxycycline | Minocycline |TMP/SMX | Trimethoprim | Erythromycin| Azithromycin | Amoxicillin | Cephalexin
  • Doxycycline and minocycline are more effective than tetracycline
  • Erythromycin and azithromycin can be effective in treating acne, its use should be limited to those who cannot use the tetracyclines (e.g., pregnancy)
  • Use limited to shortest duration possible
• Isotretinoin
  • For severe acne
  • Teratogenic in pregnancy
  • Requires compliance with iPLEDGE program (FDA mandated program) to mitigate pregnancy risk (see ‘Primary Sources – Learn More’ below) and use of dual contraception to avoid pregnancy

Additional Notes

• Hormonal therapy slows growth but does not remove hair | Due to lifespan of terminal hair, counsel patient that it may take 6 months to see an effect
• Elicit whether the adolescent is troubled by symptoms and address psychosocial issues
• ACOG suggests that in the setting of severe acne, a discussion regarding risk of scarring if acne left untreated should be considered
• Insufficient evidence currently to advise regarding diet and acne

Learn More – Primary Sources:

ACOG Committee Opinion 789: Screening and Management of the Hyperandrogenic Adolescent

Modified Ferriman–Gallwey scoring chart  

Visually scoring hirsutism

Guidelines of care for the management of acne vulgaris – Journal of the American Academy of Dermatology

iPLEDGE PROGRAM

Polycystic Ovary Syndrome: Pathophysiology, Presentation, and Treatment With Emphasis on Adolescent Girls