Desogen

Dr. Brand: Hormones are an important category for a population that we often see--adult women with a lot of cyclic flares of their acne. Oral contraceptives can play a vital role for adult women who have not responded to topicals. It's a logical choice. I think that a higher percentage of women who tend to have very irregular cycles will have significant improvement when put on oral contraceptives than women who are of regular cycle. OCPs also take a few months to improve acne in these women.

Dr. Shalita: Do you think there are any differences among the oral contraceptives?

Dr. White: Yes, I think there are.

Dr. Shalita: Yet from a theoretical point of view, there shouldn't be. Because if you get enough estrogen to prevent ovulation, you decrease antigen-binding globulin and DHEA-S, etc. But I still think there's a difference clinically.

Dr. Shupack: The one that has the first labeling for it is Ortho Tri-Cyclen[R].

Dr. Shalita: Right, and all the gynecologists are writing for it. Everybody comes in saying they're on birth control pills; it doesn't work for their acne.

Dr. White: For those people, which progestins do you look for?

Dr. Berson: Traditionally we talk about norgestimate and desogestrel as being the least androgenic progestins.

Dr. Robins: Norgestimate gets converted to norgestrel.

Dr. Berson: I'm not sure if the good progestin vs. bad progestin issue is relevant; the estrogen moiety is really responsible for the improvement that we see. Having said that, I do find that patients who are on the pills which contain norgestimate or desogestrel, such as Mircette[R], Ortho-Cept[R], and Desogen[R], tend to do better with respect to acne. And Yasmin[R], recently introduced, seems to be very helpful, possibly because its progestin has some anti-androgenic properties similar to Diane-35[R].

Dr. Shalita: It's a spironolactone derivative.

Dr. Berson: Right, it's a low-dose drospirenone that someone can take and get the benefit of the closest thing to Diane-35 that we might have in the United States.

Dr. Shalita: And also get DVT--deep vein thrombosis. I saw recently in a medical letter that there is some concern about whether DVT is going to be a problem.

Dr. Berson: One thing we should always remember is that while the patient is coming to us strictly for acne, if we prescribe an oral antibiotic, they also may need back-up birth control. Whether oral antibiotics can counteract the ovulatory properties of OCP is a controversial topic.

Dr. Shalita: ACOG (The American College of Obstetricians and Gynecologists) is supposed to have come out with a position paper saying that that's nonsense. It occurs only with a couple of antibiotics, not ones that we use. The original paper about those few antibiotics was published in the British Medical Journal, and then it got extrapolated to other antibiotics to the point where it actually was added to package inserts. The FDA wanted to take it out of the package insert, and now says that you have to do both pharmacodynamic and pharmacokinetic studies to prove it. As you know, that's very difficult to do when taking the two drugs, so nobody is willing to spend the money to do it.

Dr. Berson: But it is still on the package insert. If you want to be a purist, use back-up the first month.

Dr. Shupack: So, what is the current status of Diane-35? Are we ever going to see it in the United States?

Dr. Shalita: No, we'll never see it in this country. The patent has expired.

Dr. White: But they have Yasmin.

Dr. Shalita: Yes, they got one. But we'll never get Diane-35. Patients have to go to Mexico or Canada for it. The FDA can bother us if we get it for them, but when patients bring it in, the FDA can't do anything to them. If all else fails, I'll prescribe Accutane.

Dr. Brand: Accutane is the topic of a whole seminar by itself.

Dr. White: If you have severe acne and it's not responding to the orals and all your topicals, you go to Accutane.

Dr. Shalita: They also used to use the combination of acetone and [CO.sub.2]. You'd put them together in a big piece of cheesecloth to do the treatment. Then the patients' faces would swell up so they'd look terrific for Saturday night. It didn't do anything for their acne otherwise.

Dr. Berson: A lot of people use a Q-tip with liquid nitrogen.

Dr. Shalita: We tested all of the freezing methods, including liquid [CO.sub.2] and liquid nitrous oxide. The results were similar to intralesional steroids.

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