Treatment of Acne in Men with Congenital Adrenal Hyperplasia
Men with congenital adrenal hyperplasia (CAH) presenting with acne require dual treatment: low-dose glucocorticoid therapy to suppress excess adrenal androgen production combined with standard severity-based topical acne therapy. 1
Addressing the Underlying Hormonal Disorder
Initiate low-dose glucocorticoid therapy as the foundation of treatment to suppress ACTH-driven excess androgen production from the adrenal glands, which is the root cause of acne in CAH patients. 1
Men with CAH may present with acne as the only clinical manifestation of androgen excess, making hormonal evaluation critical when acne is severe or treatment-resistant. 2, 1
The American Academy of Dermatology recommends endocrinologic evaluation for patients with recalcitrant acne caused by androgen excess, which can occur in both men and women with nonclassical congenital adrenal hyperplasia. 3
Glucocorticoid treatment goals include normalizing androgen levels while avoiding iatrogenic hypercortisolism—this requires careful dose titration and monitoring of 17-hydroxyprogesterone and delta-4 androstenedione levels. 4, 5
Concurrent Standard Acne Treatment Based on Severity
For Mild Acne
Start with adapalene 0.1-0.3% gel once nightly combined with benzoyl peroxide 2.5-5% gel once daily in the morning as first-line topical therapy. 6, 7
Adapalene is preferred over tretinoin because it can be safely combined with benzoyl peroxide without oxidation concerns and lacks photolability restrictions. 6, 7
For Moderate Acne
Add a fixed-dose combination of clindamycin 1% with benzoyl peroxide 5% to the topical retinoid regimen for inflammatory lesions. 6
Never use topical antibiotics as monotherapy—always combine with benzoyl peroxide to prevent bacterial resistance development. 3, 6
For Moderate-to-Severe Inflammatory Acne
Implement triple therapy: oral doxycycline 100 mg once daily + topical retinoid + benzoyl peroxide for 3-4 months maximum. 6
The American Academy of Dermatology strongly recommends doxycycline with moderate evidence, or conditionally recommends minocycline 100 mg once daily as an alternative. 6
Limit systemic antibiotics to 3-4 months maximum to minimize bacterial resistance development, then transition to maintenance therapy. 6
For Severe or Recalcitrant Acne
Consider isotretinoin 0.5-1.0 mg/kg/day targeting cumulative dose of 120-150 mg/kg if acne is severe, treatment-resistant after 3-4 months of appropriate therapy, or causing scarring or significant psychosocial burden. 6
Isotretinoin is the only drug affecting all four pathogenic factors of acne and may be particularly valuable in CAH patients with severe androgen-driven acne. 6
Monitor only liver function tests and lipids during isotretinoin therapy—CBC monitoring is not needed in healthy patients. 6
Maintenance Therapy After Clearance
Continue topical retinoid monotherapy indefinitely after achieving clearance to prevent recurrence, as this is the most critical step to prevent relapse. 6, 7
Benzoyl peroxide can be continued as maintenance therapy to prevent new inflammatory lesions and bacterial resistance. 6
Critical Pitfalls to Avoid
Do not treat acne in CAH patients with standard acne therapy alone—failure to address the underlying hormonal disorder will result in treatment failure. 1
Never extend oral antibiotics beyond 3-4 months without re-evaluation, as this dramatically increases resistance risk. 6
Avoid using topical or oral antibiotics as monotherapy without concurrent benzoyl peroxide, as resistance develops rapidly. 6
In severe cases, particularly acne fulminans associated with CAH, do not use oral antibiotics as primary therapy—these patients require glucocorticoid therapy and potentially isotretinoin. 2
Monitoring and Follow-up
Monitor hormonal parameters (17-hydroxyprogesterone, delta-4 androstenedione) to ensure adequate suppression of adrenal androgen production with glucocorticoid therapy. 4, 5
Consider 11-ketotestosterone as a more specific biomarker for monitoring androgen excess in difficult cases. 5
Assess for testicular adrenal rest tumors (TARTs) in men with CAH, as these have been described even in nonclassical forms and may contribute to fertility issues. 8