Managing a request for an acne cure from a teenager
Dr Melanie Wynne-Jones discusses the issues
Dr Melanie Wynne-Jones discusses the issues
Rachel is 17 and 'fed up of being fat and spotty'. She asks if she can take Dianette as it's helped her friend who has had problems with her ovaries.
What does Rachel need?
Teenage acne can be very distressing in our looks-obsessed culture, and so can being overweight, so Rachel's request for a cure may be exactly what it seems. But it's worth exploring how these conditions make her feel – is this normal teenage self-consciousness or is she suffering from low self-esteem or depression?
Is she being teased or bullied about her looks, is she having problems with her periods? Or is this a thinly veiled request for contraception? If she has brought someone with her you will need to find a way to ask her this in private.
Does she want to get rid of her spots, lose weight, avoid pregnancy or all three? What has she tried already?
Most teenagers have tried over-the-counter products before going to the doctor about their spots; if not you could suggest Rachel tries these. She may already have been prescribed topical or systemic antibiotics. If these have failed, you'll need to check compliance and duration of use. If she hasn't, and does not require contraception, they are a possible option if acne is in fact the main problem.
Acne can be very disfiguring, so you may want to consider specialist referral if your treatment isn't effective or there are signs of scarring. Has she been using injectable contraception? This can trigger amenorrhoea, weight gain and, less commonly, acne.
Does she have a healthy lifestyle?
Some teenagers are very health conscious and have exemplary diet and exercise habits, others eat all the wrong things and take little or no exercise.
Asking Rachel about her eating patterns, alcohol intake (full of calories), smoking and exercise habits may reveal room for improvement, although it's very difficult to interest some teenagers in their future health, and easy to come across as parental, preachy or patronising. Many teenagers prefer to go to advice centres aimed at young people; you could suggest this if there is one locally.
Could she have polycystic ovaries?
Yes, as these are quite common – but only a third of women with polycystic ovaries actually have polycystic ovary syndrome (PCOS). PCOS causes metabolic abnormalities. The cause is unknown but there may be a genetic link. Women with PCOS have double the normal risk of developing diabetes and almost triple the risk of stroke.
They are more likely to be centrally obese, have high blood pressure and triglyceride levels, reduced HDL-cholesterol levels and impaired glucose tolerance which leads to increased androgen levels.
Other symptoms of PCOS include scanty or absent periods (ovulation may also stop, causing infertility); in teenagers, periods may become frequent or erratic. Excess androgens can result in acne or hirsutism with increased body or facial hair. Simply finding polycystic ovaries on an ultrasound scan does not make the diagnosis.
Blood tests should be taken in the week after a period. Luteinising hormone (LH) will be high with normal follicle stimulating hormone (FSH); the LH:FSH ratio is usually more than 3:1. The serum testosterone will be raised (levels above 4.8mmol/l suggest other causes such as Cushing's, or adrenal/ovarian tumours) and the sex hormone binding globulin level will be low.
It's also worth checking thyroid function.Measure her. If she does have PCOS, the best thing she can do to safeguard her health is to keep her weight down, so that her BMI is less than 30 and her waist circumference below 80cm.
Should Rachel take Dianette?
Any oestrogen-dominant contraceptive pill, including Yasmin and Marvelon, may improve acne.
Dianette is licensed for treatment of moderately severe hirsutism or severe acne which has not responded to antibiotics, and for contraception in women who have these problems (but not for contraception alone). If it is being prescribed for contraception in addition to acne/hirsutism, adding the female symbol will mean the prescription is free.
Dianette (co-cyprindiol) contains 35µg of ethinylestradiol and 2mg cyproterone. It increases the risk of venous thromboembolism and should not be used in women who have a personal or close family history of VTE. It should be prescribed with caution if Rachel's BMI is over 30, but not at all if her BMI exceeds 39.
She should be asked the usual questions about oral contraceptive pill (OCP) contraindications, including her family history, have her blood pressure checked, taught how to take the OCP correctly, advised about side-effects and, if she smokes, given smoking cessation advice. She should also be counselled about protecting herself against sexually transmitted infections.
Dianette should not be prescribed indefinitely as there have been links to liver damage and/or tumours, as well as depression. Twelve months may be long enough – it should be discontinued around three months after the acne has resolved. Repeat courses may be given if the acne later recurs.
Rachel should be advised that taking Dianette will not affect her long-term fertility prospects but PCOS might.
Dr Melanie Wynne-Jones is a GP and GP trainer in Marple, Cheshire
- A request for the OCP may or may not imply a need for contraception
- Acne, obesity and low self-esteem are common teenage problems
- Teenagers are not always receptive to lifestyle advice from GPs
- Polycystic ovary syndrome consists of polycystic ovaries plus metabolic abnormalities
- Dianette is an effective treatment for severe acne and hirsutism but carries a greater risk than standard oral contraceptive pills and should not be given for extended periods