Hormonal therapy is indicated in those females who are not responding well to conventional therapy. Occasionally hormonal therapy has been given to males but now that isotretinoin is available there is no clinical justification for this.

 

  There are three major types of hormonal therapy to be considered: oestrogen plus prednisolone, oestrogen plus cyproterone acetate (Diane, Dianette) and  spironolactone.  Because  of the availability  of Diane and spironolactone this author no longer uses the oestrogen plus prednisolone combination.  Hormonal regimens should  be given for 6-12 months and  the patient must be continued on topical therapy as well. As with oral antibiotics the rate of response is slow; there will be  no  response within the first  month and sometimes very little until six weeks, but thereafter there is a considerable  improvement.  The rate of improvement with Diane is similar to that with tetracycline 1 g/day.

  One  of  the commonest  hormonal regimens  used in the UK is Diane although in the UK and many other countries Diane is gradually being replaced by Dianette. Diane is a  combination of 50 |xg ethinyloestradiol and 2mg  cyproterone acetate.  Although  incidentally  an excellent contraceptive, it cannot be prescribed primarily for this purpose but is used in the female whose acne is not responding well to conventional therapy or whose contraceptive control is jeopardized as a result of antibiotic-induced diarrhoea.

Many late teenage adolescent females are on the contraceptive pill so, if the patient's acne is not responding well to conventional therapy, a further alternative is to change the oestrogen content of the contraceptive pill from 30 to 50.

  Until Diane and isotretinoin were available this author's department treated about ten patients a year with the combination of a 50 jxg oestrogen contraceptive pill with prednisolone 5 mg at night. Given at night prednisolone suppresses  adrenal androgens.55  However, Diane is more convenient for the patient to take and is now a  well-established  treatment  for acne  in  the  UK. Although most patients respond well to Diane,  8 per cent do not; the reasons for this lack of response are not clear. In  1987 Dianette  (30|xg ethinyloestradiol plus 2mg cyproterone  acetate) was made available in the UK. It is probably as effective as Diane;58'39 this author has limited  personal experience.

  In older patients, especially those over the age  of 30, with various absolute or relative contraindications to the contraceptive pill (such as varicose veins, breast lumps or a history  of smoking), there is a virtue in the use of spironolactone. In males spironolactone may produce anti-androgenic  effects such  as  enlargement of the breasts and  loss  of libido. In females 100-200 mg will have a reasonable  effect  on  acne, which is  associated with a concomitant reduction in seborrhoea, .60'61 As with all hormonal regimens, spironolactone should be  given for 6-12  months  plus topical therapy.

 

  Another useful indication for spironolactone is the hirsute  female since   100-200 mg/day  spironolactone slowly reduces  the  hirsuties.  Diane will not  affect hirsuties but Diane plus lOOmg cyproterone acetate (CPA) given from  the fifth to the fifteenth day of the cycle will, after several months, have a beneficial effect on any concomitant hirsuties.

 

  The mechanism  of action  of all  these  hormonal regimens  is not entirely clear but  effects  on both systemic and local modulations of hormones are likely. All the regimens have a systemic  effect and reduce plasma levels of testosterone, dehydroepiandrosterone (DHA) and  influence other hormones.

  Unfortunately there has been no  single comparative study to relate the clinical  efficacy of the individual therapies  with  the  reduction in  sebum  excretion. However, it is unlikely that the reduction of 30 per cent seen in patients receiving Diane or Dianette is the entire explanation of its effect.  This author's department has a cohort of patients who have shown a good clinical response with little or no reduction in sebum excretion rate. Lesion counting shows a reduction of noninflamed lesions in these  patients,  (Cunliffe WJ,  Forster  RA, data presented at 17th International Congress of Dermatology, Berlin 1987) which would support the view (which this department  has maintained for some time) that comedogenesis is under androgenic control. There is also evidence  that oestrogens modulate lymphocyte function.  Therefore,  hormones may  modulate acne inflammation.