How do oral contraceptive pills affect rosacea?

Effect of Oral Contraceptive Pills on Rosacea

Oral contraceptive pills (OCPs) can improve rosacea in women, particularly those with papulopustular rosacea, through their anti-androgenic properties that reduce sebum production and inflammation. 1

Mechanism of Action

OCPs affect rosacea through several anti-androgenic mechanisms:

• Decrease free testosterone by 40-50% on average by increasing sex hormone-binding globulin 2, 3
• Reduce conversion of testosterone to dihydrotestosterone in the pilosebaceous unit, decreasing sebum production 2, 3
• Reduce 5-alpha-reductase activity, further limiting androgen effects on skin 3
• Block androgen receptor activation in the skin 3

Evidence for Effectiveness in Rosacea

• A study of women with papulopustular rosacea treated with cyproterone acetate-containing oral contraceptives showed complete resolution of papules and pustules after three months of treatment 1
• Hormonal factors are recognized as potential triggers for rosacea, particularly rosacea fulminans, which has been observed in women taking OCPs and during pregnancy 4
• The anti-inflammatory properties of OCPs may help control the inflammatory component of papulopustular rosacea 2, 1

Specific OCP Options for Rosacea

While there are no FDA-approved OCPs specifically for rosacea (unlike acne), the following options may be beneficial:

• Drospirenone-containing OCPs may be particularly effective due to their strong anti-androgenic properties 2, 3
• Other OCPs with anti-androgenic effects include those containing:
  • Norgestimate 3
  • Norethindrone acetate 3
  • Cyproterone acetate (not available in the US) 1

Treatment Considerations

• Full benefits of OCPs for skin conditions typically require 3-6 months of therapy 2
• OCPs should only be used in women who also desire contraception, as per FDA guidelines 2, 3
• Progestin-only contraceptives should be avoided as they may worsen skin conditions 2

Safety Considerations

• Venous thromboembolism (VTE) risk:

  • Baseline risk in non-OCP users: 1-5 per 10,000 woman-years 2
  • Risk with standard OCPs: 3-9 per 10,000 woman-years 2
  • Risk with drospirenone-containing OCPs: approximately 10 per 10,000 woman-years 2
  • For context, pregnancy VTE risk is 5-20 per 10,000 woman-years 2

• Contraindications include:

  • History of deep vein thrombosis or pulmonary embolism 3
  • Ischemic heart disease 3
  • Severe liver disease 3
  • Migraine with aura at any age or without aura if ≥35 years 3
  • Current breast cancer 3
  • Smoking in women over 35 2, 3

Combination Therapy Approach

• OCPs may be used as part of a comprehensive rosacea treatment regimen 5
• Can be combined with:
  • Topical agents (azelaic acid, metronidazole, ivermectin) 5
  • Low-dose oral antibiotics (doxycycline 40mg modified-release) 5, 6
  • Spironolactone (which has shown effectiveness in male rosacea patients, suggesting hormonal mechanisms) 7

Monitoring and Follow-up

• Obtain thorough medical history and blood pressure measurement before prescribing OCPs 2
• Educate patients that improvement may not be appreciated for the first few months of treatment 2
• Regular follow-up to assess efficacy and monitor for side effects 2
• Common side effects include breakthrough bleeding, nausea, and breast tenderness, which typically resolve within 2-3 cycles 2