What is Polycystic Ovarian Syndrome (PCOS)?
Polycystic Ovarian Syndrome (PCOS) is the most common endocrinological disorder
within the female population and is characterised by clinical hyperandrogenism,
ovulatory dysfunction and polycystic ovarian morphologic features. According to
present statistics PCOS approximately affects between 10-15% of reproductive aged women. Although, these prevalence rates do vary amongst ethnic origin, race and other environmental factors. Currently the exact pathogenesis of PCOS is unclear and not yet completely understood. It has been postulated through evidence that PCOS is a genetic disorder resultant of high androgen levels which result in hyperandrogenemia. PCOS is associated with an increased risk of cardiovascular disease, hypertension, dyslipidaemia and impaired glucose tolerance or type 2 Diabetes. Additionally, PCOS also brings many reproductive and health implications such as, higher rates of obstructive sleep apnoea, non-alcoholic steatohepatitis, menstrual cycle disturbances, fertility problems, obesity and
psychiatric disorders including anxiety, depression, eating disorders and an overall
decreased quality of life.
Common skin conditions linked with PCOS
Due to the elevation in circulating androgen levels, approximately 40 per-cent of
PCOS patients present with various cutaneous manifestations comprising hirsutism,
acne, acanthosis nigricans and psoriasis.
Hirsutism: Hirsutism is an indicator of elevated serum androgen levels and is
characterised by the conversion of fine, non-pigmented, short vellus hairs into
coarse, stiff, dark terminal hairs. These terminal hairs present in a male pattern
distribution in the chin, upper-lip, chest, upper and lower back, upper and lower
abdomen, upper arm, thighs and buttocks areas. It is estimated up to 60%
of women with PCOS will extant with hirsutism, although the commonness does
vary significantly amongst ethnicities.
Acne: Acne is a multifactorial skin disorder of the pilosebaceous unit, and it has
been affirmed that over 90% of PCOS sufferers have been diagnosed with
acne. In PCOS patients ovarian and adrenal androgens stimulate the production
of acne by binding to androgen receptors on the pilosebaceous unit. This action
increases the sebaceous gland size, activates sebum production and causes
abnormal follicular epithelial cell keratinisation. The sebum production leads to
Propionibacterium acnes (P.acnes) overgrowth and then triggers the pathways
that result in the formation of inflammatory acne lesions. Women with PCOS
present with predominantly inflammatory lesions on the lower face, neck and
chest and upper aspect of the back.
Acanthosis Nigricans: Acanthosis Nigricans is a marker of insulin resistance and
is caused by hyperinsulinemia and increased binding of excessive serum insulin
to insulin-like growth factor 1 (IGF-1). Acanthosis Nigricans presents with velvety,
thickened, hyperpigmented patches on the nape, axilla, groin and antecubital
fossa, and affects 50 per-cent of obese women with PCOS, and 5-10 per-cent of
non-obese women with PCOS.
Psoriasis: Psoriasis is a chronic inflammatory, immune mediated skin disease
characterised by marked proliferation of keratinocytes leading to pronounced
epidermal hyperplasia elongation of rete ridges and hyperkeratosis, and recently
research has demonstrated that in psoriatic populations the prevalence of PCOS
is remarkably greater, although the mechanism of this correlation is currently
unknown.
Treatment options and the Dermal Clinician
Laser hair removal or Intense Pulsed light (IPL): Laser hair removal and IPL are effective treatment for the management of hirsutism and if successful can positively impact the patient’s emotional burden and quality of life. These modalities target melanin (pigment) within the hair bulb with the aim to destruct the hair follicles that are within the anagen phase. This treatment requires multiple sessions, and it is recommended that hormonal agents are administered and used concurrently to maximise the treatment results.
Intense Pulsed Light (IPL): IPL relies on a combination of photochemical and photothermal mechanisms of action. Owing to IPL’s wide range of visible and near-infra red light spectrum it has been used for some time in the treatment and management of acne. The theory behind the success of IPL in the treatment of acne is based upon the photochemical and photothermal effects on the bacteria- derived porphyrins, as well as the inflammatory cells which mediate the inflammatory cascade and heating of the sebaceous glands.
Near-infrared laser: Near-infrared lasers have been used in the treatment of acne lesions owing to its potential to target the depth in the skin where sebaceous glands are located. The near-IR pulse heats the dermal volume encompassing the sebaceous glands, whilst the epidermal cooling method preserves the epidermis from thermal damage.
Monopolar Radiofrequency (RF): RF has been employed for the successful treatment of acne owing to its abilities in reducing perifollicular inflammation and sebaceous glands, however it is highly endorsed when treating inflammatory acne lesions that RF should be combined with IPL for greatest outcomes.
Retinoids: Dependant on the severity of the acne, topical retinoids can be used independently or alongside other agents. Topical retinoids possess anti-inflammatory properties and have a comedolytic action, therefore they are able to normalise desquamation of keratinocytes.
Low-Level Laser Therapy (LLLT) and Light Emitting Diodes (LED): LLLT and LED devices have been recognised in the treatment of acne due to their photochemical effects. Blue light, at a wavelength of 407-420nm exhibits the strongest porphyrin photoexcitation coefficient and therefore is the most effective wavelength in photo activating the endogenous porphyrins contained in P. acnes. Whilst red light, through its ability to penetrate the skin deeper than blue light and reach the sebaceous glands it is capable of inducing an anti-inflammatory effect.
Isotretinoin: Isotretinoin is the only acne medication that targets all of the pathophysiological factors of acne, and is only administered in severe acne cases, where first line treatments have elicited no successful response. This is administered by Dermatologists only however the Dermal Clinician may support this intervention through skin health management.
Owing to the nature of these conditions and due to their ability to greatly affect ones
self-image and psychological state, PCOS patients will commonly seek assistance
from a Dermatologist, Endocrinologist, General Practitioner and Dermal Clinician. Therefore it is important for clinicians to gain a greater understanding and awareness of these conditions and the presently available treatment options in order to manage these patients collaboratively and inter-professionally with fellow health care professionals.
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