Cyproterone Acetate

In 1986 Mortimer et al. [9] published the first and only study of the effects of CPA in women with HS. This was a double-blind controlled cross-over trial of EE 50 ^g /CPA 50 mg compared to an ordinary OC in combination with EE 50 ^g/norgestrel 500 ^g, in 24 female patients for 12 cycles. They reported substantial improvement in disease activity with both treatments. In fact, only 18 patients out of 24 completed the trial and only 12 patients improved, while 4 deteriorated. No clinically significant differences between the two regimens were noted. Indeed, objective assessments provided insufficient evidence for improvement. "Accurate" assessments could only be made with knowledge of the frequency and severity of attacks of the disease, as judged by the patients themselves [9].

The fact that no difference was noted between the two groups does not favour a role for CPA as an antiandrogen in HS. The combination used in the control group was an OC with an androgenic progestin. In hirsutism, which is a major skin hyperandrogenic condition, and in severe acne, this kind of combination with either 50 ^g or 35 ^g EE is not effective, while 50 mg CPA daily is. If some improvement in HS could be noted in 12 patients out of the initial 24, whichever combination was used, this cannot be related to the antiandrogenicity of CPA. Rather, it may reflect the indirect antiandrogenicity of EE, decreased ovarian androgen production and increased SHBG synthesis, as evidenced by the variations in plasma testosterone,

SHBG and T/SHBG ratio (free androgen index) that were noted.

Also in 1986, Sawers et al. [13] reported the analysis of four women with HS who received CPA in combination with EE according to the then classic reversed sequential regimen of Hammerstein, namely 100 mg CPA per day for 10 days and 50 ^g EE per day for 21 days. This was a classic antiandrogenic regimen used to treat hirsutism. All four patients were reported to exhibit objective clinical improvement and to report a subjective impression of improvement after only one to two cycles of treatment. Three patients experienced a worsening of the symptoms when CPA was reduced. In fact, it is questionable whether these women, or at least two of them, were really suffering from HS and not from acne. Furthermore this was merely an uncontrolled study, an open report of only four cases of "mild" HS under antiandrogen and oestrogen therapy.

In fact there are presently no studies to suggest a role for CPA as an antiandrogen in the management of HS.

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