INDIA

PCOS
TUTORIALS
A Post Graduate
Certificate Course in
PCOS Management

Module 3
PCOS and Cosmetic Issues

Brought to you by The PCOS Society (India)

 INDIA

Course Directors

Dr. Duru Shah Dr. Madhuri Patil

Founder President Chair, Scientific Committee
The PCOS Society, India The PCOS Society, India

Course Faculty for Module 3

Dr. Rekha Sheth

Vice President, The PCOS Society, India
 Module III
PCOS and Cosmetic Issues

1
Table of Contents
1. Module Overview 3
2. Learning Objectives 3
3. Pre-Test 4
4. Introduction
• PCOS and Skin: The Relationship 6
5. Prevalence of Cutaneous Manifestations in PCOS 7
6. Types of Cutaneous Manifestations in PCOS
• Skin Changes and Hormonal Levels: Correlation 8
• Hirsutism 9
• Acne 10
• Alopecia 11
• Acanthosis Nigricans 12
• Acrochordons (Skin tags) 13
7. Pathogenesis of Cutaneous Manifestations in PCOS
• Hyperandrogenaemia 14
• Hirsutism 15
• Acne 17
• Acanthosis Nigricans 18
• Alopecia 19
8. Grading the Severity of Cutaneous Manifestations
• Hirsutism 20
• Acne 22
• Acanthosis Nigricans 23
9. Management of Cutaneous Manifestations
• Hirsutism 24
• Acne and Alopecia 27
10. Conclusion 31
11. Key Points 31
12. Suggested Readings 32

2
Module Overview
• One in 10 women is affected by polycystic ovarian syndrome (PCOS)
• Hyperandrogenism and insulin resistance are found in PCOS
• They tend to cause dermatologic manifestations in the form of hirsutism, acne
vulgaris, androgenic alopecia (AGA), and acanthosis nigricans (AN). These are
among the cardinal manifestations of PCOS
• These have a profound effect on the health and quality of life of the women
suffering from the cutaneous manifestations
• This module is designed to provide in-depth understanding of the
pathophysiology of the cutaneous presentations in PCOS
• Further quantifying the severity of these malformations is important to delineate
the appropriate management plan; hence grading systems have been included
in this module along with the overview on management of cosmetic issues in
PCOS

Learning Objectives
At the completion of this module the participant is expected to be able to :
• Identify the cutaneous manifestations of PCOS
• Understand the pathophysiology of the development of these lesions
• Grade their severity, and
• Develop a management plan for satisfactory clinical outcomes

3
 PCOS and Cosmetic Issues

PRE-TEST
State whether the following statements are True or False.

1. PCOS has a minimal impact on the aesthetics of the patient.

True

False

2. Acne in PCOS patients indicates hyperandrogenism.

True

False

3. Acanthosis nigricans is a poor marker of insulin resistance.

True

False

4. Alopecia in PCOS occurs due to poor nutrition.

True

False

5. Weight reduction is an important management for all aspects in PCOS

patients.

True

False

6. Adrenal tumors may cause hirsutism.

True

False

7. Acne does not respond to conventional therapy if hormonal

dysregulation is present.

True

False

4
8. Skin tags are unusual in obese PCOS patients.

True

False

9. Contraceptive pills are the mainstay of PCOS management.

True

False

10. Lifestyle modification is of little benefit in the management of cosmetic

issues in PCOS patients.

True

False

Answers: 1. False; 2. True; 3. False; 4. False; 5. True; 6. True; 7. True; 8. False; 9. True; 10. False

5
 PCOS and Skin: The Relationship

• Almost 90% patients with PCOS present with skin disorders/ cutaneous
manifestations
• Main pathophysiological feature of PCOS: abnormal regulation of
steroidogenesis
• Excessive androgen secretion in PCOS results in: hirsutism, acne, seborrhoea
and AGA, AN etc.1

The philosebaceous unit

Follicle Hair shaft

Sebaceous gland
Arrector
Hair bulb Sweat gland
pilli muscle
Matrix Dermal papilla

• PCOS refers to a heterogeneous collection of signs and symptoms forming a

spectrum of disorders with the disturbance in reproductive, endocrine and
metabolic functions.
• It has been observed that PCOS has various skin manifestations and almost
90% of patients with PCOS present with cutaneous signs/symptoms.
• The main pathophysiological process in PCOS points to the ovary being the
source of excess androgens, resulting from an abnormal regulation of
steroidogenesis.
• Excessive secretion of androgens in PCOS patients results in a series of skin
changes including hirsutism, acne, seborrhoea and AGA, AN etc.1
• The pilosebaceous unit is the target of androgen stimulation, and is
responsive to local enzymes and the androgen receptors.2
References:
1. Gowri BV, Chandravathi PL, Sindhu PS, et al. Correlation of Skin Changes with Hormonal
Changes in Polycystic Ovarian Syndrome: A Cross-sectional Study Clinical Study. Indian J.
Dermatol. 2015;60(4): 419.
2. Fauser BCJM, Tarlatzis BC, Rebar RW, et al. Consensus on women’s health aspects of polycystic
ovary syndrome (PCOS): The Amsterdam ESHRE/ASRM-Sponsored 3rd PCOS Consensus
Workshop Group. Fertility and Sterility. 2012;97(1):28–38.

6
 Prevalence of Cutaneous Manifestations in PCOS
• Hirsutism; the most common skin manifestation of PCOS followed by
acne and alopecia.
• Patients with hirsutism were found to be younger 1
Cutaneous manifestations of PCOS1: Prevalence (%) Prevalence (%)
90
80 78

70

60
50 48

40
31 30 29
30
20
13
10 9

0
Hirsutism Acne Female pattern Acanthosis Seborrhea Striae Acrochordons
hair loss nigricans

• A recent Indian study published in Indian dermatology online studied the

incidence and prevalence of various skin manifestations in patients with
PCOS.
• This study also attempted to correlate these skin manifestations with
hormonal changes. The study results showed that hirsutism was the most
common skin manifestation of PCOS followed by acne and alopecia.
• The prevalence of skin manifestations of PCOS has been depicted in the
figure.
• Acne which is persistent and recurrent indicates hormonal irregularities in
women >25 years of age.
• Increased seborrhoea of the skin and pre-menstrual flares of acne in women
> 30 years of age depict hyperandrogenimea and end organ sensitivity.2,3,4
References:
1. Keen MA, Shah IH, and Sheikh G. Cutaneous Manifestations of Polycystic Ovary Syndrome: A
Cross-Sectional Clinical Study. Indian Dermatol. Online J. 2017; 8(2):104–110.
2. Lucky AW. Quantitative documentation of a premenstrual flare of facial acne in adult women.
Arch. Dermatol. 2004;140(4):423–4.
3. Collier CN, Harper JC, Cantrell WC, et al. The prevalence of acne in adults 20 years and older Am.
Acad. Dermatol. 2008;58(1):56–9.
4. Shaw JC, White LE . Persistent acne in adult women. Arch. Dermatol. 2001;137(9):1252–3.

7
 Skin Changes and Hormonal Levels: Correlation
• High fasting insulin levels was the most common hormonal abnormality seen
in both acne and hirsutism
• AGA was associated with high testosterone levels

Skin manifestation FSH (%) LH (%) TSH (%) Fasting insulin (%) PRL (%) Testosterone (%) DHEA-S (%) SHBG (%)
Hirsutism 7 9 4 30 4 21 21 4
Acne 5 15 5 28 3 23 18 3
AGA 4 15 0 23 4 31 19 4
Seborrhea 4 15 2 28 4 24 21 2
Acanthosis nigricans 5 14 0 33 5 24 19 0
Acrochordons 6 13 0 27 7 20 20 7

FSH: Follicle stimulating hormone; LH: Luteinizing hormone; TSH: Thyroid stimulating hormone; DHEA-S:
Dehydroepiandrostenidione; SHBG: Sex hormone binding globulin; AGA: Androgenetic alopecia; PRL:
Prolactin

• An Indian study by Gowri et al. aimed to understand the correlation of skin

manifestations with hormonal changes in patients with PCOS.
• It was seen that fasting insulin levels was the most common hormonal
abnormality seen in both acne and hirsutism.
• Acne was associated with increase in fasting insulin in 28% of patients,
testosterone in 23%, Dehydroepiandrostenidone (DHEA-S) in 18% and
Lueteinizing hormone (LH) in 15%.
• AGA was associated with high testosterone levels.
• AGA showed increase in testosterone by 31%, fasting insulin by 23%, DHEA-
S by 19%.
• Seborrhea showed increase in fasting insulin by 28%, testosterone by 24%
and DHEA-S in 21%.
• AN showed increased fasting insulin level in 33%, increased testosterone in
24% and DHEA-S in 19%.
• Acrochordons showed increased fasting insulin levels in 27% whereas 20%
showed rise in both testosterone and DHEA-S.1
Reference:
1. Gowri BV, Chandravathi PL, Sindhu PS, et al. Correlation of Skin Changes with Hormonal
Changes in Polycystic Ovarian Syndrome: A Cross-sectional Study Clinical Study. Indian J.
Dermatol. 2015;60(4):419.

8
 Cutaneous Manifestations of PCOS: Hirsutism

• Hirsutism is usually manifested by excessive facial and/or body hair.

• It is the most frequent clinical manifestation seen in 60% of the women with
PCOS.1

• Hirsutism is defined as excessive terminal hair growth in androgen-

dependent areas in women.
• It is the most frequent clinical manifestation seen in 60% of the women with
PCOS.1
• In PCOS patients, hirsutism may result from the combined influence of
increased androgen production, increased circulating free testosterone, or
greater androgen activity within the pilosebaceous unit.
• Systemic conditions such as hypothyroidism and growth hormone therapy
may also be associated with hirsutism.
• Ovary is the primary source of androgen overproduction; however, adrenal
androgens are increased in about 30% of cases.
• In addition, this increased androgen output is enhanced by elevated levels of
serum free testosterone due to decreased sex hormone–binding globulin
(SHBG) levels, particularly in obese women.
• Differential diagnosis of hirsutism includes: hyperthecosis, nonclassic
adrenal hyperplasia, Cushing syndrome, thyroid dysfunction, and ovarian
and adrenal androgen-secreting tumors.2
• Drugs causing hypertrichosis include acetazolamide, anabolic steroids (eg,
danazol, nandrolone, stanozolol), androgenic progestogens or oral
contraceptive pills (OCPs) containing progestogen (eg, norethindrone and
levonorgestrel found in first- and second-generation OCPs), cyclosporine,
diazoxide, glucocorticoids, drugs containing heavy metals, minoxidil,
penicillamine, phenytoin, tamoxifen, and thyroxine.
• Drug-induced hypertrichosis is reversible upon discontinuation of the drug.
In certain cases where the medication needs to be continued, use of laser
hair reduction methods can be beneficial. 3

9
References:
1. Marques AR, Silva C, Colmonero S, et al . Diabetes Mellitus and Polycystic Ovary Syndrome:
Beyond A Dermatological Problem. Diabetes Case Rep. 2016;1:113.
2. Fauser BCJM, Tarlatzis BC, Rebar RW, et al. Consensus on women’s health aspects of polycystic
ovary syndrome (PCOS): The Amsterdam ESHRE/ASRM-Sponsored 3rd PCOS Consensus
Workshop Group. Fertility and Sterility. 2012;97(1):28–38.
3. Rosenfield RL. Clinical practice. Hirsutism. N. Engl. J. Med. 2005; 353(24):2578–88.

Cutaneous Manifestations of PCOS: Acne

• Facial Acne is seen in most women with PCOS

• About 50% of women with PCOS demonstrate lesions on the neck, chest, and
upper back1

• Acne results from the formation of comedones, due to sebum accumulation

along with desquamated follicular epithelial cells, which allows colonization
by the bacterium Propionibacterium acnes.
• Inflammation of comedones may lead to the development of papules,
pustules, and nodules.
• Androgens may worsen acne formation by increasing sebum production
within the pilosebaceous unit .
• It has been observed that about 50% of women with acne do not have clinical
or biochemical evidence of hyperandrogenism.
• Conversely, in many women with PCOS hirsutism may not be associated
with acne.
• These differences may be due to local androgen bioactivity.
• It has been suggested that:
o Androgen levels within skin are more important mediators of acne than
circulating levels
o Androgen receptors may exhibit variable sensitivity to androgens.1

10
Reference:
1. Fauser BCJM, Tarlatzis BC, Rebar RW, et al. Consensus on women’s health aspects of polycystic
ovary syndrome (PCOS): The Amsterdam ESHRE/ASRM-Sponsored 3rd PCOS Consensus
Workshop Group. Fertility and Sterility. 2012;97(1):28–38.

Cutaneous Manifestations of PCOS: Alopecia

• Alopecia: Male-pattern (affecting the fronto–temporo–occipital scalp) or
female-pattern (Christmas tree pattern)1
• AGA shows a wide variation in prevalence range among PCOS patients,
ranging between 3.2%–34.8%2

• Alopecia can represent as male-pattern (affecting the fronto–temporo–

occipital scalp) or female-pattern (affecting the crown, typically manifesting
early as a midline part widened in a "Christmas tree" pattern).1
• AGA is a form of nonscarring hair loss characterized by miniaturization of
mature terminal scalp hairs into thin vellus hair follicles that do not reach full
length.
• In AGA androgen-responsive hair follicles shorten the anagen (growth)
phase, resulting in fewer and finer hairs.
• AGA is associated with variable degrees of biochemical androgenemia.
• AGA is associated with other cutaneous markers of androgen excess,
including hirsutism and acne.
• It is seen that there is decreased SHBG in subjects with AGA and PCOS than
in those with PCOS alone.
References:
1. Rosenfield RL. Definition, clinical features and differential diagnosis of polycystic ovary
syndrome in adolescents. UpToDate. Available at: https://www.uptodate.com/
contents/definition-clinical-features-and-differential-diagnosis-of-polycystic-ovary-syndrome-
in-adolescents?source=search_result&search= PCOS&selectedTitle=4~150. Last accessed:
19th June 2017.
2. Quinn M, Shinkai K, Pasch L, et al . Prevalence of androgenic alopecia in patients with polycystic
ovary syndrome and characterization of associated clinical and biochemical features. Fertility
and Sterility. 2014;101(4):1129–1134.

11
 Cutaneous manifestations of PCOS: Acanthosis Nigricans

• AN is a marker of insulin resistance2

• AN is seen in about 30% of hyperandrogenic women3

• AN refers to velvety, brown, thickened plaques with accentuated skin

markings in intertriginous areas such as the axillae, groin, anogenital region,
and inframammary region.
• It has been observed that obese patients with AN had markedly higher
fasting plasma insulin levels than obese patients without this condition.1
• AN is an indicator of insulin resistance and may be the presenting complaint
of patients with PCOS.
• Among women with PCOS, acanthosis nigricans may be a marker of
increased risk for endocrine and metabolic abnormalities.2
References:
1. Marques AR, Silva C, Colmonero S, et al. Diabetes Mellitus and Polycystic Ovary Syndrome:
Beyond A Dermatological Problem. Diabetes Case Rep.2016;1:113.
2. Sander I. Acanthosis nigricans. UpToDate. 2017. Available at: https://www.uptodate.com/
contents/acanthosis-nigricans?source=see_link. Last accessed: 19th June 2017
3. Pannil M. Polycystic Ovary Syndrome: An Overview. Advanced Practice Nursing eJournal.
2002;2(3)

12
 Cutaneous Manifestations of PCOS: Acrochordons (Skin tags)

• Multiple skin tags are frequently found in obese individuals and those with
diabetes1
• Acrochordons are associated with pregnancy, acromegaly, intestinal polyps,
dyslipidaemia and syndromes such as PCOS2

• Acrochordons (skin tags) appear as soft, pedunculated, flesh-colored to tan

papules, usually ranging from 1 to 5 mm in diameter.1
• They are commonly seen in areas that are exposed to a high degree of friction,
such as the sides of the neck and axillae.
• The proliferation of fibroblasts that occurs in skin tags is due to
hyperinsulinemia, via activation of the insulin-like growth factor (IGF-1)
receptors present on their surfaces.2
• A sudden increase in the number of skin tags serves as a marker of
developing insulin resistance.
References:
1. Azziz R, Nestler JE and Dewailliy D. Androgen excess disorders in women with polycystic ovary
syndrome and other disorders. Second edition. Chapter 14. Clinical Features of the Polycystic
Ovary Syndrome. 155–169. Humana Press. Totowa. New Jersey
2. Barbato MT, Criado PR, Silva AK, et al. Association of acanthosis nigricans and skin tags with
insulin resistance. An. Bras. Dermatol. 2012;87(1):97–104.

13
 Hyperandrogenaemia in PCOS
Hyperinsulinemia and hyperandrogenemia

Insulin receptor dysfunction Hypothalamus

LHRH

Pancreas Pituitary

LH­ FSH
Hyperinsulinemia

Stroma Follicle
Liver
Stimulate theca cells ¯
Granulosa cells
Reduced SHBG Adrenals with increase production to aromatize
of androgens androgens

­
Free androgens Elevated DHEAS Elevated androgens

LHRH: Luteinizing hormone-releasing hormone; DHEAS: Dehydroepiandrosterone; LH: luteinizing hormone; FSH: Follicle-stimulating hormone

• Hyperandrogenaemia inhibits production of hepatic SHBG.

• Due to decreased SHBG in circulation, more androgens are left unbound and
therefore produce a greater clinical response in terms of hirsutism, acne, and
other manifestations of androgen excess.
• Hyperandrogenism can result in glucose intolerance and elevated levels of
insulin.
• It is a well known fact that hyperinsulinaemia begets hyperandrogenism.
• Insulin may increase androgen synthesis by various mechanisms:
o Increasing ovarian androgen synthesis by interacting with its own
receptor or with the receptor for IGF–1, thereby increasing cytochrome
P450c17-alpha enzyme activity.
o Insulin amplifies the LH response of granulosa cells, thereby causing an
abnormal differentiation of these cells with premature arrest of follicular
growth thus causing an ovulation. It may also change the ovarian response
to LH.
o It also suppresses hepatic production of SHBG, which increases free
testosterone levels.
o Insulin alters normal folliculogenesis by increasing intra-ovarian
androgens.

14
• Obesity is known to increase androgen, insulin & leptin levels, insulin
resistance and risk of early pregnancy loss. Adipose tissue dysfunction may
be the central factor in the pathogenesis of PCOS. There is a complex
interaction between the pituitary gland, pancreas and ovary that results in
the changed hormonal secretion pattern.1
References:
1. Patil M. Pathophysiology of PCOS. The PCOS Society of India Newsletter. PANDORA. 2016;1: 6–8.

1,2
Pathogenesis of Hirsutism
• The development of hirsutism is based on a conversion of weak light vellus hair
into strong dark terminal hair in androgen-sensitive areas of the body

Develpoment of terminal hair

Androgens

Vellus hair Terminal hair

prepubertal stage adult stage

• Vellus hair is the type of hair that is soft, non-pigmented and with a diameter
<0.03 mm covering much of the body in men and women.
• Terminal hair is longer, pigmented, and coarser in texture. Women have
terminal hair only in the eyebrows, eyelashes, scalp, pubis, and axillae.
• Hirsutism occurs due to the alteration in the hair follicle cycle with a
prolongation of the anagen phase with a consequent transformation of vellus
into terminal hair.
• These changes occur under the effect of androgens that are triggered and
involved in the regulation of sexual hair growth.
• Androgens involved in the regulation of hair follicles are testosterone and
dihydrotestosterone (DHT).1,2.
References:
1. Kopera D, Wehr E, Obermayer-Pietsch B. Endocrinology of Hirsutism. Int. J. Trichology. 2010;
2(1):30–35.
2. Pasquali R, Gambineri A. Treatment of hirsutism in the polycystic ovary syndrome. European
Journal of Endocrinology. 2014;170: R75–R90.

15
 Aetiology of Hirsutism

Gonadal hyperandrogenism Peripheral androgen overproduction

• Ovarian hyperandrogenism • Obesity
• PCOS/functional ovarian • Idiopathic
hyperandroganism Pregnancy-related hyperandrogenism
• Ovarian steroidogenic blocks • Hyperreactio luteinalis
• Syndromes of extreme insulin • Thecoma of pregnancy
resistance (e.g, lipodystrophy)
Drugs
• Ovarian neoplasms
• Androgens
Adrenal hyperandrogenism
• Oral contraceptives containing
• Premature adrenarche androgenic progestins
• Functional adrenal • Minoxidil
hyperandrogenism
• Phenytoin
• Congenital adrenal hyperplasia
• Diazoxide
(nonclassic and classic)
• Cyclosporine
• Abnormal cortisol
action/metabolism True hermaphroditism
• Adrenal neoplasms
Other endocrine disorders
• Cushing's syndrome
• Hyperprolactinemia
• Acromegaly

• This slide enumerates the causes of hirsutism1 other than PCOS

• These causes should be considered in the differential diagnosis of hirsutism
Reference:
1. Ehrmann DA. Alterations In Sexual Function and Reproduction. Chapter 68. 331–335. Harrison’s
Principles of Internal Medicine. 19th Edition. McGraw Hill Education.

16
 1,2
Pathogenesis of Acne in PCOS
Genetic factors
Androgen excess + PPAR ligands

Hyperseborrhoea with Regulatory

pro-inflammatory lipids neuropeptides

Epithelial hyperproliferation (ductus P. acnes

Inflammation
seboglandularis, acroinfundibulum)
Dietary lipids?

Smoking?

Other?

PPAR: Peroxisome proliferator-activated receptor

• Androgens cause worsening of acne formation by increasing sebum

production within the pilosebaceous unit.
• It is important to note that androgen levels within the skin are more
important mediators of acne than circulating levels.
o The different stages of acne that may be clinically encountered are:
o The primary lesion of acne is a comedone - these can also be invisible to
the naked eye and can be visualised after stretching, palpating the skin.
o Comedones can remain as they are open - blackhead, closed - whitehead
or they can become inflamed and appear as papules, pustules, nodules
and cysts.
• Immune response of the host plays an important role in the development of
acne.
• Following steps result in the different stages of acne :
o Altered follicular keratinisation
o Hyperplasia of sebaceous glands
o Colonization of Propionibacterium acnes, a bacterium which is
responsible for the inflammation that occurs in acne.3
• Within the hair follicle, the androgen bioactivity is regulated, partly by 5-a-
reductase, which acts to convert free testosterone to the more potent DHT.
• This enzyme has two isoforms: type 1 is found in the sebaceous glands and
pubic skin and type 2 is located primarily in the hair follicle, genital skin, and
adult scalp.

17
.• The relative activities of these isoenzymes within the hair follicle may be
responsible for the variable clinical presentation seen in hyperandrogenic
women.
• 5-a-reductase expression is also stimulated by excess androgen, insulin, and
insulin-like growth factor, which is likely to contribute to the increased local
androgen bioactivity, resulting in the hirsutism and acne seen in PCOS.1
• Androgens, peroxisome pro-liferator activating receptor (PPAR) ligands,
regulatory neuropeptides along with hormonal and non-hormonal activity
and environmental factors cause cascade of processes resulting in the
formation of inflammatory acne.2
References:
1. Chuan SS, Chang JR. Polycystic Ovary Syndrome and Acne. Skin Therapy Letter.
2010;15(10):1–4.
2. Zouboulis CC, Eady A, Philpott M, et al. What is the pathogenesis of acne? Experimental
Dermatology. 2005;14(2).
3. Kubba R, Bajaj AK, Thappa et al. Pathogenesis of acne. Indian J. Dermatol. Venereol. Leprol.
2009;75 Suppl S1 :5–9

Pathogenesis of Acanthosis Nigricans

Obesity

Insulin resistance

Hyperinsulinemia

¯
IGF BP-1, BP-2

­
Free IGF-1

EGFR activation ­
IGF-1R activation
FGFR activation Other factors

Acanthosis nigricans
EGFR: Epidermal growth factor receptor; FGFR: Fibroblast growth factor receptors; IGF: Insulin-like growth factor

• AN is commonly associated with insulin resistance, including obesity, type

2 diabetes, and PCOS.
• Hyperinsulinaemia plays a central role in the development of AN.
• At high concentrations, insulin can exert more potent growth-promoting
effects through binding to insulin-like growth factor 1 receptors (IGF-1Rs).

18
• Hyperinsulinaemia may also facilitate the development of AN indirectly by
increasing the levels of free IGF-1 in the circulation.
• The activity of IGF-1 is regulated by IGF binding proteins (IGFBPs), which
increase IGF-1 half life.
• IGFBP-1 and IGFBP-2 are both decreased in obese subjects with
hyperinsulinaemia, increasing plasma concentrations of free IGF-1.
• An insulin-induced systemic reduction of IGFBP-1 and IGFBP-2 could
increase local levels of free IGF-1, thereby facilitating the development of
hyperkeratosis and papillomatosis.1
Reference:
1. Higgins SP, Freemark, Neil SP. Acanthosis nigricans: A practical approach to evaluation and
m a n a g e m e n t . D e r m a t o l o g y O n l i n e J o u r n a l . 2 0 0 8 ; 1 4 ( 9 ) : 2 . Av a i l a b l e a t :
http://escholarship.org/uc/item/7mf6g290. Last accessed 20th June 2017.

Pathogenesis of Alopecia

Metabolism of testosterone

Long, thick, pigmented,

Short, fine hypopigmented,
terminal scalp hair
miniaturized hair

5a
– reductase

T DHT

T- Testosterone
DHT- Dihydrotestosterone

Androgenetic alopecia

DHT DHT DHT

Healthy hair (thick, actively Progressive hair thinning

growing and fully pigmented) (thinner, shorter and less pigmented)

19
• Hyperandrogenism is a central pathophysiological process in PCOS.
• Excess of androgen, high levels of 5-a -reductase, higher concentration of
androgen receptors and lower levels of the enzyme cytochrome p450 result in
the shortening of the anagen phase.
• The terminal follicles undergo miniaturization turning into vellus hair.
• These changes are more evident in the frontal and parietal regions.
• Widening of the central partition, receding hairline, thinning of hair over the
temporal aspect of the scalp in females is a common finding in a suspected
case of PCOS, it can start as early as the 2nd decade of life.
• It may be difficult to distinguish female pattern hair loss with other types of
patterned hair loss, associated features of cutaneous hyper-androgenism
like acne; seborrhoea etc can serve as a diagnostic indicator.
Reference:
1. Gonçalves de Moura HH, Costa DLM, Bagati E, et al. Polycystic ovary syndrome: A dermatologic
approach. An. Bras. Dermatol. 2011;86 (1).

Grading of Hirsutism

Upper lip
Upper arms

Chin Thighs

Chest Upper back

Lower back
Abdomen

Pelvis

• Grading of hirsutism is done using the modified Ferriman-Gallwey (mFG)

score.1
• A score of 0 (none) to 4 (severe) in nine areas of the body is assigned with a
maximum possible score of 36.

20
 o Scores < 4 indicate mild hirsutism
o 4–7 indicate moderate hirsutism
8 indicate severe hirsutism1
o ³
Reference:
1. Malik S, Jain K, Talwar P, et al. Management of Polycystic Ovary Syndrome in India. Fertil .Sci.
Res. 2014;1:23–43.

Clinical Evaluation of Hirsutism

Hirsutism significant Virilization rapid progression

No

Reassurance non-pharmacologic Yes Rule out ovarian or adrenal neoplasm

approaches

Laboratory Evaluation Marked elevation

• Total, free testosterone Total testosterone >7 nmol/L (>2 ng/mL)
Normal • DHEAS DHEAS >18.5 µmol/L (>7000 µg/L)
Increased
Treat empirically or Consider further testing
• Dexamethasone suppression ® adrenal vs ovarian causes: R/0 Cushing's
• ACTH stimulation ® assess nonclassic CAH
Final diagnosis

Idiopathic • Nonclassic CAH • PCOS

• Functional adrenal hyperandrogenism • Functional ovarian hyperandrogenism
Other causes

DHEAS: Dehydroepiandrosterone sulfate; ACTH: Adrenocorticotropic hormone; CAH: Congenital adrenal hyperplasia;
PCOS: Polycystic ovary syndrome

• The algorithm depicted in the slide describes the clinical evaluation in

patients with hirsutism.1
Reference:
1. Ehrmann DA. Alterations In Sexual Function and Reproduction. Chapter 68. 331–335. Harrison’s
Principles of Internal Medicine. 19th Edition. McGraw Hill Education.

21
 Grading of Acne1

Table 1: Grading of acne severity: Recommendation of Indian Acne Association

Mild acne (Grade I) Comedones < 30
Predominance of comedones Papules < 10
No scarring
Moderate acne (Grade II) Comedones any number
Predominance of papules Papules > 10
Nodules < 3
With or without scarring
Severe acne (Grade III) Comedones any number
Many nodules Papules any number
Nodules/cysts > 3
With scarring

Table 2: Acne distribution by age groups: Recommendation of Indian Acne Association

Age group Location of lesions Type of lesions Sex
Neonates Cheeks, chin, eyelids, forehead Papules and pustules, no comedones Both
Infants Full face Comedones, papules, nodules, scars Male
Preadolescent Forehead, upper cheeks, nose Predominantly comedonal, occasional papule Both
Adolescent Full face, seborrheic areas of torso All types of lesions Both
Adults Chin, upper lip, jaws Papules, excoriated papules Female

• Acne can be graded as mild, moderate, and severe depending on the number
and types of inflammatory lesions as shown in table 1.
• Typically, in girls, acne starts between 12–14 years of age, and in boys
between 14–16 years of age.
• The location and type of acne lesions according to the age group, as
described by the Indian Acne Association (IAA) has been depicted in the
table 2
Reference:
1. Malik S, Jain K, Talwar P, et al. Management of Polycystic Ovary Syndrome in India. Fertil .Sci.
Res. 2014;1:23–43.

22
 Grading of Acanthosis Nigricans1
Neck grading in acanthosis nigricans

Neck grading Description

I Visible only on close inspection
II Confined to the base of the skull
III Extending laterally up to the posterior border of the sternocleidomastoid muscle. This is
not visible when the patient is viewed from the front
IV Visible (encircling the neck) when the subject is viewed from the front

Neck texture grading in acanthosis nigricans

Neck texture grading Description

0 Smooth to the touch
1 Rough to the touch
2 Coarseness is visible
3 Extremely coarse: “Hills and valleys” are observable on visual examination

Axilla grading in acanthosis nigricans

Classification Description
0 Absent
1 Cleary present on close visual inspection
2 Mild: Localised to the central portion of the axilla
3 Moderate: Involving the entire axillary fossa
4 Severe: Visible from the front or the back of the unclothed participant, when the
arms are left to rest against the patent's side

• The slide depicts neck grading and neck texture grading of AN

• It also shows the axilla grading in AN
Reference:
1. Venkatswami S. Acanthosis nigricans: A flag for insulin resistance. JEMDSA. 2014;19(2):68–74

23
 Management of Hirsutism

Lifestyle modifications1,2
• Weight loss
• Balanced diet
Pharmacological management2,3
• Androgen receptor blockade (spironolactone, flutamide, and cyproterone
acetate, finasteride)
• Insulin sensitizers (metformin or thiazolidinediones)

• In PCOS patients, lifestyle modifications with respect to diet, exercise,

behavioral or combined treatments show improvement in body composition,
hyperandrogenism and insulin resistance.1
• A study showed that 16 weeks of therapy with oral essential amino acids in
patients with PCOS resulted in a significant decrease in the levels of fasting
insulin, LH, follicle-stimulating hormone (FSH), and total testosterone.2
• Anti androgen: Spironolactone competes with the androgens for the
androgen receptor, 5a-reductase, and SHBG. Dose: 100 mg per day are
generally effective for the treatment of hirsutism, higher doses (200–300 mg
per day) may be preferable in the very hirsute or obese women.
• Finasteride at doses of 5 mg/day is beneficial for the treatment of hirsutism
and female pattern hair loss in women.2,3
• Insulin sensitizers such as metformin improve hyperandrogenaemia and
ovulatory function and also prevent pregnancy loss in PCOS.
• OCPs suppress circulating LH and FSH, leading to a decrease in ovarian
androgen production.
• Combined oral contraceptives (COCs) with anti-androgenic progestins such
as cyproterone acetate, drospirenone, desogestrel are used for the
management of hirsutism in PCOS patients.

24
• Cyproterone acetate decreases circulating testosterone and
androstenedione levels through a decrease in circulating LH levels.
• Long-acting Gonadotrophin-releasing hormone (GnRH) agonists suppress
the hypothalamic–pituitary–ovarian axis in severely androgenised or
hyperinsulinaemic patients. Two to three months of treatment may be
required for the full suppressive effect of the agonist to occur and these drugs
should be reserved for women who do not respond to combination hormonal
therapy or those who cannot tolerate OCs
References:
1. Malik S, Jain K, Talwar P, et al. Management of Polycystic Ovary Syndrome in India. Fertil .Sci.
Res. 2014;1:23–43.
2. Hantash BM. Dermatologic Manifestations of Hirsutism Treatment & Management. Medscape.
2017. Available at: http://emedicine.medscape.com/article/1072031-treatment#d9. Last
accessed 21st June 2017.
3. Agarwal NK. Management of hirsutism. Indian J. Endocrinol. Metab. 2013;17(1): S77–S82.

Management of Hirsutism

Hair removal:
Depilation
• Shaving or chemicals
Temporary epilation
• Creams
• Waxing
• Threading
Permanent epilation
• Electrolysis
• Laser1

• Depilatories remove hair from the surface of the skin. Depilatory methods
include ordinary shaving and the use of chemicals which can irritate the skin
and lead to allergic reactions.
• Shaving removes the hair from the surface of the skin as the root is left intact
within the skin and is expensive in the long term scenario.
• Temporary epilation involves plucking, waxing, threading etc. Apart from
being painful they can also lead to superficial bacterial infections and
ingrowth of hair.

25
• Hair destruction by electrolysis, thermolysis, or a combination of both is
performed with a fine, flexible electrical wire that produces an electrical
current after it is introduced down the hair shaft, hence destroying it.
Multiple sessions are required.
• Permanent hair reduction methods with the use of energy and light based
devices is a long term solution and is much more economical than all the
above mentioned methods.
• The laser and light based devices target the melanin in the hair root and in
multiple sittings convert the terminal thick dark hair in vellus light thin hair.
• These procedures are painless and efficient; they also reduce the ingrowths
and chances of infections with waxing etc.
• Women with PCOS who are hirsute respond better to laser hair reduction
when under simultaneous treatment for PCOS.
Reference:
1. Hantash BM. Dermatologic Manifestations of Hirsutism Treatment & Management. Medscape.
2017. Available at: http://emedicine.medscape.com/article/1072031-treatment#d9. Last
accessed 21st June 2017

Management of Hirsutism: Recommendations

• In adult women who do not want to conceive it is recommended to use low-

does COCs with anti-androgen progestin (cyproterone acetate, drospirenone,
or desogestrel) for the management of hirsutism
• For women with menstrual irregularity + hirsutism, low-dose COCs with anti-
androgenic activity (cyproterone acetate, drospirenone, desogestrel) are
suggested
• In adolescents/children with hyperandrogenism, obesity and signs of insulin
resistance, lifestyle modification is first-line therapy; metformin is second-line
therapy with a wait period of 2 years post-menarche in children1

Important recommendations for the management of Hirsutism in Indian

patients have been discussed by Malik S, et al–
• Cyproterone acetate has been shown to be more beneficial than other
progestins in Indian patients.
• If there is no improvement with COCs or COCs are not tolerated, it is
recommended to use spironolactone or finasteride but recommended to stop
6 months before planned pregnancy.

26
4
• Risk of thromboembolism with use of COCs can be managed by identifying
susceptible patients and/or pausing treatment for 3 months after one year of
treatment.
• In adolescents with hyperandrogenism, if glucose intolerance is not
established by oral glucose tolerance test (OGTT), metformin should not be
started.
Reference:
1. Malik S, Jain K, Talwar P, et al. Management of Polycystic Ovary Syndrome in India. Fertil .Sci.
Res. 2014;1:23–43.

Management of Acne

Topical applications:1
• Benzoyl peroxide
• Topical retinoids
• Topical antibiotics
Pharmacological management:2
• COCs
• Anti-Androgens
• Insulin sensitizing agents

• Treatment of acne depends upon the severity.

• Mild acne responds well to topical retinoid, benzoyl peroxide, glycolic and
azelaic preparations.
• Use of sunscreen and moisturiser is beneficial in the treatment of acne.
• For severe acne comprising of multiple pustules, nodules and cysts - oral
antibiotics such as doxycycline, lymecycline can be given for 4–6 weeks
along with topical treatment.
• In case of scarring tendency, it is advisable to start oral retinoid: isotretinoin,
as it helps in preventing development of scars and occurrence of new acne.
This is done under the dermatologist's guidance; hence referral to a
dermatologist for management is crucial.
• Oral retinoid are vitamin A derivatives and act by reducing the sebaceous
gland secretion and altering the keratinocyte activity.
• Procedures such as chemical peels with salicylic and glycolic preparations,
light based therapy: intense pulsed light (IPL) can also serve as an adjuvant
to oral and topical treatment of acne, overall combining treatments with
therapy can significantly reduce the severity and recurrence of acne.

27
26
• It is prudent to understand that when acne occurs in PCOS, the recurrence
rates are high and sometimes the acne may not respond to conventional
therapy. In such a scenario, use of anti androgens such as flutamide, and
COC are used in addition to the above mentioned treatment.
• Spironolactone is a pottasium sparing diuretic which competitively inhibits
androgen receptors and 5-a -reductase and can be used for acne not
responding to isotretinoin, spironolactone is also beneficial in female pattern
hair loss. The dose can range from 50– 200 mg / day.
• Spironolactone also decreases sebum production and improves acne.
• Flutamide may be used for the treatment of mild to moderate acne.
• Insulin sensitizing agents such as metformin and thiazolidinediones
decrease androgen production by lowering hyperinsulinemia.2
• While on the above mentioned medications following monitoring is
necessary: liver function test, lipid profile, serum electrolytes, hormonal
profile and ultrasonography of pelvis.
• COC pills suppress gonadotropin secretion and ovarian steroid synthesis,
leading to decreased androgen production and help in reducing the various
features of cutaneous hyperandrogenism.
• The estrogen component has been shown to stimulate SHBG production by
the liver whereas the progestin component may lower local androgen effect
by inhibiting 5-a-reductase activity in the hair follicle or competitive
inhibition for the androgen receptor.
Reference:
1. Malik S, Jain K, Talwar P, et al. Management of Polycystic Ovary Syndrome in India. Fertil .Sci.
Res. 2014;1:23–43.
2. Sandy S, Chuan R, Chang J. Polycystic Ovary Syndrome and Acne. Skin Therapy Letter.
2010;15(10):1–4.

28
 Management of Acne

Group I Group II
SAHA symptoms (Seborrhea, acne, hirsutism, alopecia)± Resistance to conventional therapy
Late onset of acne/ persistence of acne ± Early relapse/ moderate to severe relapse
Irregular menses± after oral isotretinoin therapy
Obesity

Endocrine evaluation Endocrine evaluation

LH :FSH ratio LH : FSH ratio
DHEAS DHEAS
Free testosterone ± Free testosterone ±
17 (OH) progesterone. prolactin 17 (OH) progesterone, prolactin

Normal Abnormal Abnormal Normal

End organ hypersensitvity ­

LH : FSH ratio Is hormonal therapy
­
­
­Testosterone ­
DHEAS acceptable?
EE-CPA ­
Testosterone
Severe/resistant symptoms
EE-CPA ± Spironolactone
± CPA (Higher doses) 17 OH progesterone Yes No
Others
Newer COCs (EE-drospirenone)
Metformin, Flutamide, Finasteride CPA/EE Isotretinoin/oral
Normal Raised
Acne therapy based on severity antibiotics

Ovarian tumor Adrenal tumor

PCOS Congenital adrenal hyperplasia

EE-CPA± Oral steroids
Spironolactone ± Endocrinologist consultation
CPA (higher doses)
Endocrinologist consultation

Abbreviations: OCP: Oral contraceptive pills; CPA: Cyproterone acetate; EE- Ethinyl estradiol; DHEAS: Dehydroepiandrosterone sulphate;
LH-Luteinizing hormone; FSH: Follicle stimulating hormone, 17 OH progesterone: 17 hydroxyprogesterone; PCOD: Polycystic-ovarian disease

• The slide depicts the management algorithm for acne.1

Reference:
1. Malik S, Jain K, Talwar P, et al. Management of Polycystic Ovary Syndrome in India. Fertil .Sci.
Res. 2014;1:23–43.

29
 Management of Acne and Alopecia : Recommendations 1

• In adults and adolescents with PCOS and acne, it is suggested to use topical
medication along with pharmacological interventions in consultation with a
dermatologist
• Referral to the dermatologist is crucial for management of acne if the latter is
not responding to topical therapy and/ or scarring and post acne pigmentation
is noted with the acne
• In adults with PCOS, it is suggested to use OCPs (cyproterone acetate,
drospirenone, or desogestrel as progestin component) as first-line therapy for
management of all types of acne lesions
• In women with PCOS presenting with alopecia, COCs and androgen blockers
are recommended as first line therapy1

• Malik S, et al recommend for the management of acne and alopecia in Indian

patients with PCOS, cyproterone acetate as a more beneficial option than
other progestins 1
Reference:
1. Malik S, Jain K, Talwar P, et al. Management of Polycystic Ovary Syndrome in India. Fertil .Sci.
Res. 2014;1:23–43.

30
4
 Conclusion

• The pilosebaceous unit is the target of androgen stimulation

• Hirsutism may result from the combined influence of increased androgen
production, increased circulating free testosterone, or greater androgen
activity within the pilosebaceous unit
• Androgens may worsen acne formation by increasing sebum production within
the pilosebaceous unit
• Acanthosis nigricans is an indicator of insulin resistance and may be the
presenting complaint in patients with PCOS

Key Points

• Androgenic alopecia is associated with other cutaneous markers of androgen

excess, including hirsutism and acne
• Use of minoxidil and various peptide preparations is also done by the
dermatologist, this step is key to preventing further hair fall and maintaining
the hair growth throughout treatment.
• In situations where oral medication cannot be given for androgenetic alopecia,
topical preparations are of importance.
• Physical treatments for stimulating hair growth like platelet rich plasma,
mesotherapy and microneedling are also performed by the dermatologist to
provide an optimum end result.
• Hence a multi faceted approach is required under a dermatologist guidance to
effectively tackle androgenetic alopecia.
• Androgen levels within skin are more important mediators of acne than
circulating levels.
• In adult women who do not want to conceive it is recommended to use low
combined oral contraceptive with anti-androgen progestin (cyproterone
acetate, drospirenone, or desogestrel) for the management of hirsutism.
• In adolescents/children with hyperandrogenism, obesity and signs of insulin
resistance, lifestyle modification is first-line therapy.
• In adults with PCOS, it is suggested to use oral contraceptives (cyproterone
acetate, drospirenone, or desogestrel as progestin component) as first-line
therapy for management of all types of acne lesions.
• In women with PCOS presenting with alopecia, combined oral contraceptive
and androgen blockers are recommended as first line therapy.

31
Suggested Readings

1. Keen MA, Shah IH, and Sheikh G. Cutaneous Manifestations of Polycystic

Ovary Syndrome: A Cross-Sectional Clinical Study. Indian Dermatol. Online J.
2017;8(2):104–110.
2. Gowri BV, Chandravathi PL, Sindhu PS, et al. Correlation of Skin Changes
with Hormonal Changes in Polycystic Ovarian Syndrome: A Cross-sectional
Study Clinical Study. Indian J. Dermatol. 2015;60(4):419.
3. Malik S, Jain K, Talwar P, et al. Management of Polycystic Ovary Syndrome in
India. Fertil .Sci. Res. 2014;1:23–43.
4. Gonçalves de Moura HH, Costa DLM, Bagati E, et al. Polycystic ovary
syndrome: A dermatologic approach. An. Bras. Dermatol. 2011;86(1).

32
 PCOS and Cosmetic Issues

POST-TEST
1. Androgen receptors are located in the:

a. Dermal papilla

b. Outer Root sheath

c. Nerve ends

d. Both a and b

2. Hirsutism may be caused due to:

a. Cushing syndrome

b. Thyroid dysfunction

c. Ovarian neoplasms

d. All of the above

3. Causative agent in acne is:

a. Propionibacterium acnes

b. Porphyromonas gingivalis

c. Streptococcus pneumoniae

d. Both b and c

4. Female pattern hair loss is described as:

a. Christmas tree pattern

b. Sunray appearance

c. Hair raised pattern

d. None of the above

5. Acanthosis nigricans can be seen in:

a. Axilla

b. Neck

c. Groin

d. All of the above

6. Skin tags are common after __ years of age.

a. 20

b. 40

c. 50

d. 60

7. ____ hair cover much of the body in men and women.

a. Vellus

b. Terminal

c. Transitional

d. Interstitial

8. Androgen bioactivity is regulated by:

a. 5-ß-synthase

b. 6-?-phosphate

c. 5-a-reductase

d. None of the above

9. Ferriman-Gallwey score of 4–7 indicates:

a. Mild hirsutism

b. Moderate hirsutism

c. Severe hirsutism

d. Androgen failure

10. Which of the following progestins is used in management of

hyperandrogenism?

a. Cyproterone acetate

b. Drospirenone

c. Desogestrel

d. All of the above

Answers: 1. d; 2. d; 3. a; 4. a; 5. d; 6. d; 7. a; 8. c; 9. b; 10. d
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