Dr Aileen McPhillips discusses polycystic ovarian syndrome, the common associated skin conditions, their management and relevance to aesthetic practice
Polycystic ovarian syndrome (PCOS) is one of the most common endocrine disorders in woman of reproductive age1 and is thought to affect one in five women in the UK.2 It impacts women of all races and ethnicities. PCOS tends to emerge at puberty and is characterised by hyperandrogenism, ovulation disorders and polycystic ovarian morphology.2 Clinically, PCOS may present with menstrual disturbance, anovulatory infertility and the manifestations of hyperandrogenism (possibly including hirsutism, acne, alopecia).3 Although not always present, an association between PCOS and obesity, impaired glucose tolerance, type II diabetes and sleep apnoea has been noted.1 Many woman with PCOS are obese and have a higher prevalence of impaired glucose tolerance, type II diabetes and sleep apnoea than is observed in the general population.1
In adults, PCOS can be diagnosed if two out of the three following criteria are present, provided other causes of menstrual disturbance and hyperandrogenism have been excluded:
PCOS should be considered for women with associated signs of hyperandrogenism, failure to respond to conventional therapy, menstrual irregularities, and insulin resistance.4 It is reported that 20-40% of those with PCOS suffer from acne.5 Androgens increase sebum production and cause abnormal desquamation of follicular epithelial cells, resulting in the formation of comedones, which in turn can lead to further inflammation and formation of pustules, cysts and scarring.4
Hirsutism, defined as excessive growth of terminal hair in women in a male-like pattern, is the most commonly-used clinical diagnostic criterion of hyperandrogenism.6 It can be very distressing for the patient. In PCOS, there is increasing activity of 5-alpha reductase in hair follicles, which is also stimulated by hyperandrogenism, insulin-like growth factors, and insulin.7 Testosterone and dihydrotestosterone (DHT) alter the hair cycle resulting in the transformation of vellus hair into terminal hairs that are thicker and darker, especially in the face, neck, chest, and pubic region which are androgen-sensitive sites.6
Alopecia is characterised by progressive hair loss or thinning. Alopecia associated with PCOS usually displays a pattern of thinning at the vertex with maintenance of frontal hairline, however, in some, it is similar to androgenic alopecia in which there is loss of hairs in the central region of scalp.4 Hyperandrogenism causes increased levels of 5-alpha reductase, along with increased androgen receptors and decreased levels of cytochrome P450 enzyme, resulting in short anagen phase and miniaturisation of terminal hairs with eventual transformation to vellus hairs and therefore hair loss or thinning.8
Acanthosis nigricans, which is associated with several endocrine and other conditions (obesity, insulin resistance, PCOS, diabetes, malignancy), is characterised by brown velvety moist, verrucous hyperpigmentation of skin, usually seen on the back of the neck and intertriginous areas like armpits and groins, underneath breasts and inside thighs. It is reported in approximately 5% of PCOS sufferers.9 The condition is due to excessive binding of serum insulin to IGF-1 receptors, which results in proliferation of keratinocytes and fibroblasts.4
Along with addressing the menstrual disturbance and potential fertility issues, common dermatological manifestations need attention, which is of relevance to aesthetic practitioners. It is estimated that 72-82% of women with PCOS are seen with classical associated cutaneous signs, such as acne, hirsutism and androgenic alopecia.10 Hyperandrogenism may also manifest as acanthosis nigricans or seborrheic dermatitis.10 Patients with PCOS are frequently first seen by a dermatologist.11 Reports of acne and hirsutism (the most common recognisable symptoms of androgen excess) should be taken seriously due to their potential association with medical disorders, their substantial effect of self-esteem and quality of life, and potential for psychosocial morbidity.12
Treatment choice for acne may be influenced by severity, affected area and patient choice. Topical options are usually used as first-line treatment, however hormonal therapy, such as the combined oral contraceptive pill (OCP), can also be considered an acceptable first-line treatment for patients who desire this method.12 The main ingredients that have been shown to be effective in topical treatments include salicylic acid, benzoyl peroxide, sulphur, alpha-hydroxyl acids and retinoids.14,15 There are many cosmeceutical ranges that provide treatments with the mentioned effective ingredients that would prove beneficial to those suffering from PCOS-associated acne.
Oral treatments (for example antibiotics, isotretinoin) are typically used for moderate-severe acne and more widespread acne affecting the back/chest.12 They are also appropriate when topical treatment has not been effective.
Effective management of hirsutism includes lifestyle measures, physical hair removal and androgen suppression.13 Lifestyle measures include a healthier lifestyle and weight loss in overweight patients. Weight management and glycemic control can be helpful interventions to address symptoms of androgen excess.13 Androgen suppression examples include the combined contraceptive pill, spironolactone, finasteride and metformin.
Physical hair removal methods, such as bleaching, shaving, waxing, chemical depilatories, electrolysis and laser and IPL therapy can be used safely and effectively.13 However, only electrolysis and laser therapy offer a long-lasting treatment aimed at permanent hair reduction,13 therefore aesthetic clinics may offer effective and long-term treatments options to patients suffering for hirsutism.
Research has shown that mild-moderate androgenic alopecia in women can be treated with anti-androgens and/or topical minoxidil with good results in many cases.16 While many women using oral anti-androgens and topical minoxidil will regrow some hair, early diagnosis and initiation of treatment is desirable, as these treatments are more effective at arresting progression of hair loss than stimulating regrowth.17
Platelet-rich plasma (PRP) is a treatment modality which is gaining popularity for androgenic alopecia. Activated platelets are understood to release numerous growth factors and cytokines from their alpha granules as part of the wound-healing process.18 The process involves collecting blood from the patient to be treated, which is then centrifuged, therefore separating the specimen and providing concentrated platelets.20 PRP is injected sub- or intradermally into the affected area.18 Platelets in PRP become activated when injected into the scalp and release multiple growth factors, which promote hair growth. Several studies have shown PRP is beneficial. Alves and Grimalt performed a randomised, blinded, half-head study of 25 patients with androgenic alopecia.19 Each patient received three treatments of PRP one month apart and were evaluated using phototrichogram and global photography. At six months a statistical improvement in hair density was recorded. Gentile et al. conducted a randomised, evaluator-blinded, placebo-controlled, half-head group study of 20 patients with androgenic alopecia.20 Three treatments of PRP were performed, 30 days apart. Improvement in mean hair count and total hair density was noted after the treatments, compared to the placebo group.
Microneedling has shown promising results as a treatment for androgenic alopecia. The minimally-invasive procedure uses fine needles on the skin to puncture the stratum corneum.21 Microneedling induces a wound-healing cascade with minimal damage to the epidermis that induces collagen formation, neovascularisation, and growth factor production of the treated areas. Although there is limited research in this area it has been shown that microneedling combined with other hair-growth promoting therapies is beneficial. Dhurat et al. conducted a 12-week randomised, comparative, evaluator blinded study, where 100 patients (with mild-moderate hair loss) were randomly allocated to treatment with microneedling plus minoxidil or minoxidil alone.22 Hair count was assessed at baseline and 12 weeks. The group treated with microneedling plus minoxidil showed statistically significant superior improvement in hair growth compared to minoxidil alone. Light therapy is a relatively new technique in the treatment of androgenic alopecia. It is thought that the cellular respiratory chain of mitochondria probably absorb the light energy, which results in increased electron transport and promotion of cellular signalling and, in turn, allows for hair regrowth.21 Leavitt et al. conducted a randomised double-blind sham-device controlled, multi-centre trial to evaluate the effect of low level laser therapy to the scalp.23 A total of 110 patients completed the study over a 26-week period and were randomly allocated to treatment with a laser light energy device called HairMax Laser Comb or a sham device. Results showed that subjects in the HairMax LaserComb group exhibited a significantly greater increase in mean terminal hair density and significant improvements in overall hair growth over the 26-week period.
Hair transplantation may be an option for patients who do not have success with other therapies. It involves the relocation or transfer of hairs from the occipital area to the bald area.21 To achieve a good result, the correct selection of the ideal candidate is important for this procedure. The adjunct use of PRP along with/prior to is becoming an increasingly popular trend.21 The growth factors and plasma components can be injected directly into the scalp before placement of the grafts.24
Although the studies mentioned above do not specifically look at a PCOS patient group, it can be concluded that treatment outcome should be similar in patients with PCOS-associated androgenic alopecia.
Whilst treating the underlying cause is the ultimate goal, cosmetic treatment of acanthosis nigricans can be important for patients. For topical options, retinoids are considered first-line treatment. In a study of 30 patients, clinical improvement of treatment-resistant acanthosis nigricans was seen in all patients after 14 days of using topical 0.05% tretinoin. 80% showed total clearance at 16 weeks, however intermittent tretinoin was needed to maintain improvement as relapse was noted.25
Chemical peels are a relatively safe and effective treatment for acanthosis nigricans. Trichloroacetic acid (TCA) is a chemical exfoliating agent that causes destruction of the epidermis with subsequent repair and rejuvenation.21 This destruction is followed by inflammation and the activation of wound repair, causing re-epithelialisation with smoother skin.21 A pilot study was carried out to look at the safety and efficacy of TCA as a chemical peel in the treatment of acanthosis nigircans.26 Treatments were carried out weekly for one month. All patients showed improvement in hyperpigmentation, thickening and overall appearance. Patient numbers were small (six), however the results do suggest TCA peels are a useful and safe treatment for the skin condition.
Laser therapy has also been suggested as an effective treatment for acanthosis nigricans. A case report reviewed the effectiveness and safety of a long-pulsed alexandrite laser in the treatment of acanthosis nigricans of the axillae.27 Results showed 95% clearance after seven sessions with no recurrence after two years. The untreated axilla was unchanged. Further research is required, however this would suggest long-pulsed alexandrite laser can effectively and safely treat the condition.
Although the studies mentioned above do not specifically look at a PCOS patient group, it can be concluded that treatment outcome should be similar in patients with acanthosis nigicans associated with PCOS.
Management of PCOS often requires a multidisciplinary approach. Skin manifestations associated with PCOS are very common and are often the first presenting features. It is critical that the commonality of these conditions does not lead the clinician to dismiss them as trivial, as many can have severe and long-standing consequences, both physically and psychologically. Aesthetic practitioners can provide valuable input into the management of these common skin manifestations.
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