Acne
BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.38987.606701.80 (Published 02 November 2006) Cite this as: BMJ 2006;333:949
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I would like to underline and remind colleagues about the extremely powerful broad spectrum fungicidal and bactericidal activity, of carvacrol rich essential oil of oregano that has proved to be active, even against antibiotic and antimycotic resistant strains, without any side effects. [1][2]
Concomitant topical administration of carvacrol rich emulsions of essential oil of oregano, or other herbal monoterpenes, with current systemic pharmacologic therapies must be investigated and pursued, in order to achieve synergistic effects.
Carvacrol has also antinociceptive[5] and potent anti-inflammatory activity[3][4].
No bacterial resistance has ever been observed.
References
[1] http://www.bmj.com/content/352/bmj.i939/rr-1
[2] http://www.bmj.com/content/322/7281/288.1/rr
[3] http://www.ncbi.nlm.nih.gov/pubmed/22363615
[4] http://www.ncbi.nlm.nih.gov/pubmed/22892022
[5] http://www.ncbi.nlm.nih.gov/pubmed/23146035
Competing interests: No competing interests
It is perhaps unusual to disagree with both the respondent to an
article and
with the original authors, but I must do so here.
Drospirenone, the progestin/progestagen in Yasmin, is not merely a
component
of a non-norethisterone containing birth control pill / oral contraceptive
(BCP/
OC). It is the only non-androgenic progestin/progestagen other than
cyproterone acetate that is currently available in BCP / OC format. In the
USA,
where cyproterone acetate is not available, it is the sole choice if one
wishes to
both avoid additional androgenicity in managing acne and provide any
significant androgen-blocking effect to counteract androgens of adrenal,
ovarian, and peripheral sebaceous gland intracrine origin.
Were there a similar effective product on the market, I would be pleased
to
provide the same unpaid 'advertisement' for it. Scientific credit where
scientific
credit is due.
Competing interests:
I was the dermatologist on the
team that supported the successful
application for licensure in Canada
of Diane 35 in 1997 for the
indication of severe acne.
Competing interests: No competing interests
The comments made by Nasseri and Evans in their respective letters
concerning our review of Acne1 are interesting and valid. The issue of
background hyperandrogenism in adults with persistent acne has been
addressed in many settings, as cited by Nasseri as well as in the broader
arena of polycystic ovary syndrome and hirsutism associated with late
onset congenital adrenal hyperplasia. Where the excess is adrenal in
origin and can be suppressed by oral dexamethasone, the issue arises as to
whether this is in the patient’s long term interest in terms of side
effects of systemic steroid. It is common practice for Dermatologists to
use prednisolone for short periods in men and women with fulminant or
aggressive acne, usually in combination with isotretinoin during the most
inflammatory phase. However, this is a clinical judgement rather than one
based on metabolic profile. To provide a dose equivalent to 20mg
hydrocortisone daily for many years2 is likely to have long term
significance in terms of iatrogenic disease. It is for this reason that
anti-androgens rather than steroid suppression is the most commonly
advocated approach in women with hirsutism attributed to late onset
congenital adrenal hyperplasia3 and is equally a common treatment for
women with acne.
The point raised by Evans is one also made to us locally (by my wife who
is a GP) after publication. Why advocate Y****n above cheaper oral
contraceptives which do not contain norethisterone? Mea culpa – a mistake.
It is an example but there is no clear evidence indicating that it is the
best choice among similar oral contraceptives with a synthetic
progestagen. Although there is some evidence in favour of Dianette4. There
was no conflict of interest with this error and it was not intended as a
“free advert”.
References:
1. Purdy S, de Berker D. Acne. BMJ 2006;333(7575):949-53.
2. Marynick SP, Chakmakjian ZH, McCaffree DL, Herndon JH, Jr. Androgen
excess in cystic acne. N Engl J Med 1983;308(17):981-6.
3. Spritzer P, Billaud L, Thalabard JC, Birman P, Mowszowicz I, Raux-Demay
MC, Clair F, Kuttenn F, Mauvais-Jarvis P. Cyproterone acetate versus
hydrocortisone treatment in late-onset adrenalhyperplasia. J Clin
Endocrinol Metab. 1990;70(3):642-6.
4. Arowojolu AO, Gallo MF, Grimes DA, Garner SE. Combined oral
contraceptive pills for treatment of acne. Cochrane Database Syst Rev.
2004;(3):CD004425.
Competing interests:
authors of original article
Competing interests: No competing interests
The authors of this review[1] have been careful in the main text of
the article to avoid recommending any particular combined hormonal
contraceptive pills for acne, besides mentioning cyproterone acetate
(contained in Dianette) and making the comment that pills containing
norethisterone might be less suitable.
By contrast, in summary Box 4 just two pill brands that do "not
contain norethisterone" are listed. One is Dianette, which is reasonable
since it has a specific licence for acne. The other is Yasmin, an
ethinylestradiol/drospirenone combination.
Why has Yasmin been singled out?
The British National Formulary lists combined contraceptives with
five other non-norethisterone progestogens, sold under sixteen different
brand names[2]. The one reference in this review that concerns
contraception and acne does not mention Yasmin or drospirenone[3].
Yasmin may have been mentioned just as an example, but to the casual
reader it appears to have been recommended as the best choice besides
Dianette. I am not aware of any evidence to support this notion. It is
ironic that the manufacturer of Yasmin should receive this free
endorsement, when they have previously been admonished for making
unsupported claims in their advertising[4].
References:
1. Purdy S, de Berker D. Acne. Bmj 2006;333(7575):949-53.
2. http://www.bnf.org/bnf/bnf/current/4553.htm
3. Arowojolu AO, Gallo MF, Grimes DA, Garner SE. Combined oral
contraceptive pills for treatment of acne. Cochrane Database Syst Rev
2004;(3):CD004425.
4. Yasmin advert withdrawn - when and how. Drug & Therapeutics
Bulletin 2003: 41; no.3.
Competing interests:
None declared
Competing interests: No competing interests
Purdy and de Berker in their clinical review of "Acne" showed
different factors in the pathophysiology of acne in box 2 [1].
They mentioned increased androgen level as a possible ethiology of
acne in women. However androgen excess as a causative factor for acne is
not limited to women. It may also play a role in pathophysiology of acne
in men and indeed it could be the only clinical sign of androgen excess in
men[2, 3].
Suspicion and investigation for underlying endocrinological problem
in male acne patients, especially resistant cystic acne, may reveal
irregularities of androgen metabolism, such as congenital adrenal
hyperplasia [2-4]. In majority of these patients, lowering of elevated
androgen level is associated with an improvement in acne [2,4].
References:
1. Purdy S, de Berker D. Acne. Bmj 2006;333(7575):949-53.
2. Degitz K, Placzek M, Arnold B, Schmidt H, Plewig G. Congenital
adrenal hyperplasia and acne in male patients. Br J Dermatol
2003;148(6):1263-6.
3. Placzek M, Degitz K, Schmidt H, Plewig G. Acne fulminans in late-
onset congenital adrenal hyperplasia. Lancet 1999;354(9180):739-40.
4. Marynick SP, Chakmakjian ZH, McCaffree DL, Herndon JH, Jr.
Androgen excess in cystic acne. N Engl J Med 1983;308(17):981-6.
Competing interests:
None declared
Competing interests: No competing interests
Oestrogenic progestogens increase venous thrombosis Re: Acne
Giving oestrogenic progestogens for acne (.BMJ 2006;333:949 ) increases the risk of venous thrombosis.
In 2011 Lidegaard et al confirmed that OCs containing newer progestins (desogestrel, gestodene, or drospirenone) caused at least twice the risk of venous thromboembolism (VTE) than older progestins.1 Thomson et al found that desogestrel 150ug and drospirenone 3 mg increased endothelium-dependent vasodilation in large and small peripheral microvasculature, which further confirmed vasodilation in the aetiology of OC induced thrombosis.2 Acne-treating oestrogenic drospirenone and desogestrel caused more thrombosis than acne-causing androgenic levonorgestrel.
In 2015, Vinogradova et al collected 10,500 cases of VTE and 42,000 matched controls in UK general practice databases. 68% of cases and 57% of controls were analysed following exclusions mostly for pregnancy or hysterectomy. Any current use of combined OCs gave a 3-fold increased risk of idiopathic venous thromboembolism compared with no use in the past year. Newer third generation progestins doubled the risk compared with older progestins. Risks for desogestrel (x4.28), gestodene (x4.27), drospirenone (4.12) and cyproterone (4.27) were compared with levonorgestrel (2.38), norethisterone (2.56) and norgestimate (2.53).3
1. Lidegaard O, Nielson LH, Skovlund CW, Skjeldestad FE, Lokkegaard E. Risk of venous thromboembolism from use of oral contraceptives containing different progestogens and oestrogen doses: Danish cohort study 2001-9. BMJ 2011;343:d6423.
2. Thomson AK, Przemska A, Vasiloupou D, Newens KJ, Williams CM. Combined oral contraceptive pills containing desogestrel or drospirenone enhance large vessel and microvasculature vasodilation in healthy premenopausal women. Microcirculation. 2011 Mar 7. doi: 10.1111/j.1549-8719.2011.00094.x.
3. Vinogradova Y, Coupland C, Hippisley-Cox J. Use of combined oral contraceptives and risk of venous thromboembolism: nested case-control studies using the QResearch and CPRD databases. BMJ 2015;350:h2135
Competing interests: No competing interests