Endocrinologic testing: Recommendations

What is the role of microbiological and endocrine testing in evaluating patients with adult acne and acne vulgaris in adolescents to adults?

  • Routine endocrinologic evaluation (e.g., for androgen excess) is not recommended for the majority of patients with acne. 
  • Laboratory evaluation is recommended for patients who have acne and additional signs of androgen excess.

Strength of Recommendation: B  Level of Evidence: I, II

While the role of androgens in acne pathogenesis is well known, endocrinologic evaluation is only warranted in certain cases, because most acne patients will have normal hormone levels. Testing is primarily indicated for patients with clinical features or a history of hyperandrogenism. In prepubertal children, these features include: acne, early-onset body odor, axillary or pubic hair, accelerated growth, advanced bone age, and genital maturation. Growth charts and a hand film for bone age are good screening tools before specific hormonal testing.1,49 In postpubertal females, clinical signs, such as infrequent menses, hirsutism, androgenetic alopecia, infertility, polycystic ovaries, clitoromegaly, and truncal obesity warrant further hormonal testing.1,2,50-52,165 Recalcitrant acne caused by androgen excess can also be seen in both men and women with nonclassical congenital adrenal hyperplasia (eg, 21-hydroxylase deficiency).166,167

The most common cause of elevated androgens of ovarian origin is polycystic ovarian syndrome (PCOS).53 It has recently been proposed that diagnosis of PCOS in adult females requires 2 of the 3 following criteria: androgen excess (clinical or biochemical), ovulatory dysfunction (oligo- or anovulation), or polycystic ovaries (based on ultrasonographic findings). In adolescent females, the diagnosis of PCOS can be made based on hyperandrogenism (clinical or biochemical) in the presence of persistent oligomenorrhea.168 The differential diagnosis of PCOS includes thyroid disease, prolactin excess, and nonclassical congenital adrenal hyperplasia, among others.168

Hormonal testing and interpretation of testing is complex. A typical hormone-screening panel includes free and total testosterone, dehydroepiandrosterone sulfate (DHEA-S), androstenedione, luteinizing hormone, and follicle-stimulating hormone.49,51-54,165 Growth hormone, insulin-like growth factor, lipid levels, insulin, sex hormone–binding globulin, free 17-β-hydroxysteroids, free androgen index, prolactin, estrogen, and progesterone may also be abnormal in those with severe acne.52,54-56,165,169 Insulin resistance may also represent a risk factor for acne in certain patients.170 Patients with abnormal test results, or in whom there is a persistent concern for a hormonal disorder, should be further evaluated by an endocrinologist.

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