Hormonal Contraceptives and Dermatology

Natalie M. Williams; Michael Randolph; Ali Rajabi-Estarabadi; Jonette Keri; Antonella Tosti


Am J Clin Dermatol. 2021;22(1):69-80. 

In This Article

Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a chronic skin condition affecting apocrine gland-bearing sites, such as the axillary, inframammary, and anogenital regions. The disease is characterized by recurrent, inflamed nodules with sterile abscesses, followed by draining sinus tracts with subsequent scarring.[109] While the role of hormones is not clearly defined for HS, the fact that there is a female predominance, propensity for premenstrual flares, and improvement during pregnancy suggests that hormones are part of the pathogenesis.[110] In addition, antiandrogen medications such as spironolactone, finasteride, and COCs may improve the disease in women.[111,112]

There is limited, anecdotal evidence of HS occurring in patients taking COCs (Table 5). Stellon and Wakeling identified seven females who developed HS after starting COCs, with the time of onset after initiating the pill ranging from 1 to 24 months.[113] The most common COC used was the combination of EE 30 μg and levonorgestrel 150 μg. Two patients achieved complete remission after discontinuation of the COC, while three patients benefited from a change to a pill with a higher estrogen–progesterone ratio. One patient who stayed on a progesterone-only pill continued to have HS flares. The last patient who experienced HS flares on the EE–levonorgestrel combination was switched to a pill containing desogestrel, a compound thought to have low androgenicity, but the patient experienced another HS flare within 1 month. As there is no stronger evidence available, a relationship between HS development and COCs seems unlikely.

Furthermore, several case–control studies have not found an association between HS and COC use. When comparing 58 cases of females with HS and 268 female controls, Jemec et al. found that both groups used COCs at similar rates (74% and 73% for estrogen-based, and 19% and 19% for progestogen-based pills, respectively).[114] Furthermore, a separate case–control study found that the use of hormonal contraceptives was significantly less common in women with HS than controls.[115] This not only countered the idea that COCs may cause HS but also suggested the potential use of hormonal contraceptives in its treatment.

One of the earliest reports on the utility of COCs in HS was a randomized, double-blind, crossover trial of 24 females with HS that compared the reverse sequential combination of EE and CPA with EE with norgestrel.[116] While two patients dropped out due to disease exacerbation, the remaining patients demonstrated clinical improvement, with no difference in efficacy between the two arms. Of note, seven patients in the study achieved complete clearance of their disease. Similarly, a case series that used a reverse sequential regimen of CPA (100 mg/day for 10 days) and EE (50 mg/day for 21 days) in four patients with longstanding HS demonstrated clinical improvement after only one to two cycles of treatment;[117] however, when CPA was decreased to 50 mg/day, three of the patients exhibited worsening of their symptoms. Other researchers have suggested that hormonal manipulation, including COCs, may be equivalent or superior to antibiotic therapy in HS patients. Kraft and Searles found that antiandrogenic hormonal manipulation, most commonly with the combination of CPA and EE, resulted in a higher response rate (55%) compared with oral antibiotic therapy (26%, p < 0.04) in female HS patients.[118]

Overall, there is limited evidence to support or refute the effects COCs in HS, or which form would be most ideal for these patients. It is believed that COCs containing drospirenone might be preferred due to the effects being similar to spironolactone.[119] While a Cochrane review in 2013 suggested a relationship between drospirenone-containing COCs and venous thromboembolism, various large trials since have not identified an association.[120–123] In addition, it is important to note that the effect of COCs is reduced if the patient is also taking rifampin due to its induction of the P450 enzyme.[124] Recently, the North American clinical management guidelines for HS were published, which recommended antiandrogen contraceptives at a grade C recommendation strength and a recommendation level of II.[125] Ultimately, higher-quality patient-oriented data on the use of hormonal contraception in HS are needed.