The clinical predictors of biochemical hyperandrogenemia and its relation to treatment resistance in women with acne

Introduction:
The prevalence of biochemical hyperandrogenemia (BHA) in female acne varies across studies. While certain phenotypic features may suggest hormonal evaluation, clinical predictors of BHA are unclear. Furthermore, the predictors of treatment outcome remain inconclusive, and despite common belief, no strong evidence links BHA to treatment resistance.

Aim:
To identify determinants of BHA and treatment response in female acne.

Material and methods:
Female acne patients who underwent hormonal tests (androstenedione, DHEAS04, E2, FSH, LH, free testosterone, prolactin, SHBG, TSH, total testosterone, and 17-OHP) from January 2020 to September 2022 were analysed for associations of clinical parameters with BHA, PCOS, and treatment resistance.

Results:
Among 86 females (mean age: 24, range: 14–41), acne categories were as follows: persistent (46.5%), adult-onset (26.7%), recurrent (19.8%), and adolescent (7%). Clinical and BHA rates were 65.1% and 70.9%, respectively. The most common elevated hormones were 17-OHP (65%) and androstenedione (40%). Hirsutism and truncal acne were associated with BHA. High DHEAS04 and menstrual irregularity were linked to the persistent category, and 17-OHP elevation was related to a chronic course. PCOS prevalence (17.4%) was associated with high DHEAS04, Free Androgen Index, TT, low E2, and hirsutism. Persistent/recurrent acne and hirsutism were associated with treatment failure.

Conclusions:
The persistent course and prolonged duration of acne in females, combined with hirsutism and truncal location, are associated with BHA. Patients without androgenic signs may have BHA, and PCOS diagnosis can be established through appropriate referral. Treatment response does not correlate with hormone levels; however, prolonged duration/persistent course and hirsutism predict poorer outcomes.