PCOS and Dermatology

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Barbara Nesbitt: “I’m Barbara Nesbitt, and I’m in San Diego at the PCOS Conference with Dr. Armand Newman, who’s a dermatologist and who did a wonderful presentation yesterday for women with PCOS. I found it very interesting, and I learned a lot. I don’t have PCOS but after listening to Dr. Newman, I have great empathy for women that have it. Tell me how you got into this, Dr. Newman.”

Dr. Armand Newman: “PCOS basically has three components to it; one is the irregular menstrual cycles and the problems in ovulation and they generally would go ahead and see their gynecologist, endocrinologist, or reproductive endocrinologist for that. But the main one is metabolic abnormalities and weight gain, and the other component would be acne, excessive hair growth, and hair loss that they present with and the skin changes which consists of skin tags, darkening of the skin behind the neck or in the thigh area and those would be signs of polycystic ovarian syndrome and because of those, I would see a lot of patients who have this condition. So if somebody would come in with acne, you would ask them about their periods and if they have irregular periods, you run up some blood tests and you can make a diagnosis of them having PCOS. Once you make a diagnosis of PCOS, then you go ahead and treat those symptoms that are important or show in the patient. For example, if they have acne, then we need to treat the acne. How do we treat the acne - there are topical medications like Retin-A, benzol peroxide, topical antibiotics, and special anti-acne peels that can be performed on the patient. Then we have the oral medications, and in the oral medications you can use special birth control pills like Demulen 1/35, Mircette, Demulen, Ortho Tri-Cyclin, Ortho-Cyclin, and Desogen and those are the birth controls that are very friendly to somebody who has PCOS. Because PCOS is the oldest manifestations of acne, hirsutism, and hair loss which is due to excessive amounts of male hormones, you block the excessive male hormones with a medication called spirolactone or Aldactone.”

Barbara Nesbitt: “So somebody comes to you if they have what you call male-type hair loss.”

Dr. Armand Newman: “Right, if they have hair loss, there are two patterns that are hormonally derived hair loss which is androgenic hair loss. Now you can have either male pattern hair loss or you can have female pattern hair loss. If it’s female pattern hair loss, it means that they just have thinning over the top of their hair over all the scalp while the male pattern is if they have thinning just on the top but at the very back of the hair they still have no thinning down there and that’s why there’s a possibility of doing transplants because you can take that hair and…” 

Barbara Nesbitt: “Okay, and just move it to the area like you would for a man. Is there any topical medication?”

Dr. Armand Newman: “In the topical medications there is minoxidil 5% solution, and there’s also canrenone solution that can be given. Now canrenone is a derivative of spirolactone, when it goes through the liver it changes into canrenone. On the side of the medications that are oral that you can take for this is Proscar, which is finasteride at 5 mg and you can take spirolactone or Aldactone to a dosage of 200 mg.”

Barbara Nesbitt: “While I’m sitting here talking to you I’m thinking that, say, I’m a person that has some of these symptoms - when should someone say, “I think I should be going to a dermatologist, I think I have some condition and somebody should be treating and doing something about it?”

Dr. Armand Newman: “The first thing actually is the woman herself, she would notice that she’s having more hair loss. Either her parting in the hair is getting wider or she is noticing more hairs in the shower, but she notices it. By the time the doctor actually looks at her hair and goes ahead and says – yes, you are and everybody notices that you’ve already lost over 50% of your scalp so you want to treat these things early so the best thing to do is actually to listen to the patient. If they tell you they’re losing their hair, they should be taken seriously and a good history and physical should be performed.”

Barbara Nesbitt: “So what I’m hearing you say is if a woman comes in and she doesn’t have all the symptoms, signs, or insulin problems but you see that she has facial hair or she’s losing hair on her head or she has acne at 38 years of age like a teenager, what you and I are trying to say to a doctor or a nurse practitioner is to send that person to a dermatologist. Is that not a good thing? Let them check it out, there’s something somebody can do for them.”

Dr. Armand Newman: “Yes, I think you should be sent to somebody who’s knowledgeable in treating of the hormonal aspects of it and finding a cause of why she’s having hair loss. There are dermatologists who have an interest in this field and they will be the ideal doctors. Any doctor who has an interest in this field would be the ideal doctor to go ahead and to do a work up on her to find out why she’s having hair loss.”

Barbara Nesbitt: “So don’t say to somebody – well, you’re just losing some hair and there’s nothing anybody can do about it - there are things that can be done.”

Dr. Armand Newman: “Yes, of course, things can be done about it and most things we’re finding out are obviously much easier to do something about if it’s picked up early rather than when it’s really at the most full blown.”

Barbara Nesbitt: “Till it’s gone to a point where a person’s life is saddened by it.”

Dr. Armand Newman: “Right, so if somebody comes in totally bald and he comes to you and says - listen I’ve got hair loss, everybody in the street knows he’s got hair loss then.”

Barbara Nesbitt: “I’m going to share something with you because everybody at OBGYN.net knows it anyway because I talk about it a lot. I had breast cancer after my husband died, and I had CMF and you’re not suppose to lose your hair but I was one of those people, I lost 99% of my hair. Obviously it grew back in but when that hair was falling out, I have to tell you, it was the most devastating thing to just put your hands through your head and see your hair is gone. I was talking to somebody the other day here, and I knew deep down inside it was going to come back, I just thought I’m not going to be bald forever but boy while that was coming out and when it was out it’s a horrible thing. There’s nowhere you can go where people aren’t looking at you. Now what are the treatment options for excessive hair growth?”

Dr. Armand Newman: “Doctors should see the patient, do a history and physical exam, grade the amount of hair growth, find out how much hair growth a person has, do a blood test, find out where the source of the excess amounts of male hormones are coming from, and then go ahead and treat the source. Now generally we use antiandrogens, which are male hormone blocking agents, and one of them is called spirolactone and the other one is called Proscar. They act on different pathways in blocking the excessive amounts of male hormones. There’s another medication called flutamide Eulexin. They work very well in preventing the excessive amounts of hair growth and sometimes birth control is given” 

Barbara Nesbitt: “What can lasers do for excessive hair growth?”

Dr. Armand Newman: “There are a number of lasers available, the old lasers don’t work as well as the new ones that are out. The best lasers, in my opinion, that are available right now are the alexandrite and the diode lasers. They work by cooling the skin and delivering a high dose of energy to the skin, and it can cover a large area in a short amount of time. You do need to repeat the hair laser maybe after doing it 3-4 times, once every 6-9 months, to 1 year in order to make sure that the hair is kept under control.” 

Barbara Nesbitt: “What about the treatment of acne?”

Dr. Armand Newman: “Acne is one of these androgenic disorders that can be treated 100%, I mean to the fact it is completely gone. We have a number of medications for it, again, you have the antiandrogens as we discussed for the other conditions, birth control pills, Aldactone, but there’s also a medication called Accutane that can be added. The acne scars that are left can be treated with either special lasers or filling materials like collagen injections or newer forms of collagen that have come out now. Neo-fitting materials such as fascia can be used or Dermalogen in order to make the skin smooth. All the discoloration that was left from the previous scarring can be removed using chemical peels.” 

Barbara Nesbitt: “What are the other skin manifestations of PCOS?”

Dr. Armand Newman: “One is darkening of the skin under the back of the neck and under the arms or between the thighs and that’s called acanthosis nigricans, that plus the skin tags which are like fleshy moles around the neck and around the breast and under the arms, those are signs of insulin resistance. A two-hour glucose test should be done plus insulin to find out if the person has insulin resistance. A lot of times if they do, a medication called metformin or Glucophage as well as Actos or Avandia can be given in order to decrease the insulin resistance. The skin tags can actually be surgically removed; it’s a very simple procedure. The acanthosis nigricans can sometimes be helped a lot by reducing weight.” 

Barbara Nesbitt: “What are the treatment options for people with increased weight?”

Dr. Armand Newman: “Treatment for people who are insulin resistant and have PCOS and increased weight, of course, is a diet and exercise. The diet should be high in fiber and in vegetables, lower amounts of carbohydrates, and increased amounts of protein with eight glasses of water a day. The medical treatment for the weight loss would be medications that decrease the appetite and those would be Tenuate and phentermine, for example. Sometimes people add other medications, which are what we call the SSRI’s like Paxil, Zoloft, and Meridia so those are the ones that act on the brain to decrease the appetite. Then there are medications that actually decrease the fat absorption, and one called Xenical can be given. These medications plus the right diet and exercise program would help in order to reduce the weight, and reducing the weight would decrease the acanthosis nigricans. In some patients, after they’ve lost some weight, you can do liposuction in some areas where they have what is called cellulite where they cannot lose the fat. Also, with abdominal fat there might be some benefit in doing a liposuction to decrease the insulin resistance because most of the fat that is in the abdomen is the bad fat that causes insulin resistance. In summarizing, we can treat a person with PCO with acne, hirsutism, hair loss, acanthosis nigricans, skin tags, and insulin resistance. The weight loss problem also can be treated and that would have not only the short term benefits of treating the actual problems that we have right now but also in the long term problems of the complications of the PCOS which would be heart disease or problems that…” 

Barbara Nesbitt: “Psychological problems too.”

Dr. Armand Newman: “Of course, psychological problems happen here because we decrease the stress level once they know that these particular problems can be treated. Acne and the skin tags are actually one of those things that can be really treated up to the point where they can have basically completely clear skin. The other things just take longer for it to work but you do get good results. Also, the hirsutism with the lasers and together with the antiandrogens, I think that you can also expect to get very good results.”

Barbara Nesbitt: “We heard some people talking and it might not be this year or next year but if they come up with something that can help treat these people, maybe it will keep them from getting all these things or getting them to such an advanced stage. So I see some hope for these people, do you?”

Dr. Armand Newman: “There is a lot of hope, and there is a lot of research going on. Actually, there’s more research going on on antiandrogens that are more specific and will work better than the antiandrogens that we have right now for hair loss and hirsutism. But already we have come a long way to treat a lot of these conditions.”

Barbara Nesbitt: “I have to tell you in closing that when we first started our forum four years ago for women, women would write in and they would talk about this, and I had no idea what they were talking about. Nobody I knew had any idea what they were talking about but in four years I sure know what they’re talking about now.”

Dr. Armand Newman: “I think a lot of people make the mistake and I think they’ve also heard it even in medical school, they only look at the full blown and most excessive thing which is the Stein-Leventhal aspect of polycystic ovarian syndrome which is they come in, they have the obesity, they have the infertility, and they have the hirsutism. But you will also have the milder versions and you’ll have variations of it where they may just come in with acne as opposed to the hirsutism. They may come in and not be so obese, 20% of women with PCOS are not obese so the doctor needs to be astute about it and to pick these things up and needs to work with the patient. Everybody’s different and you need to find out what the priorities are and what other problems are and to zoom in on that problem and to go ahead and to treat that particular patient for that particular problem.”

Barbara Nesbitt: “I like finding out that a dermatologist can step in and help some of these things that are very, very visible and maybe we’re not curing this thing in the next year or two but we can certainly help women get a better look when they look in the mirror or they walk down the street.”

Dr. Armand Newman: “Dermatology is by definition the study of the skin care and the fat so the skin part of it is there, the hair is there, and the fat is there and those are the parts of dermatology that are involved. So I think that dermatologists should be involved and they should work closely with patients in order to try to help them out and work with their gynecologists and endocrinologists too.”

Barbara Nesbitt: “So the message is women should be ask their physicians or primary care physicians about referrals to dermatologists. Physicians that are treating women that have this should be maybe forming a good referral basis with a dermatologist so that they have overall choices.”

Dr. Armand Newman: “As I said, knowledgeable dermatologists should be able to take care of most of the stuff that we talked about except the infertility. With infertility, of course, they should be referred to a reproductive endocrinologist because they’re the expert at that and they would be the best people to go ahead and do that but the aspects that are involved with acne, the hair loss, and the hirsutism - that’s a job of the dermatologist to get in there and to treat it.”

Barbara Nesbitt: “I was really happy to hear all of this, and I will spread the word with our obstetricians and gynecologists because that’s what I was saying to you - it’s part of education. I have this patient and maybe I don’t know exactly what to do with her but I now know that I can send her in another direction where somebody can help her.”

Dr. Armand Newman: “As I said, most of the patients will be picked up by the gynecologist and the gynecologist can help them a lot with their insulin resistance, with their infertility, and with their diet and exercise but I still think that the acne, hair loss, and hirsutism is just better treated with a dermatologist in this thing.”

Barbara Nesbitt: “I am fully convinced. I thank you doctor.”

Dr. Armand Newman: “You’re welcome.”