Acne is a common skin condition. In the UK, more than 3.5 million visits are made by patients to GP practices, who seek the treatment for this condition. The first-line treatment for acne includes topical preparations, such as topical retinoid products, topical antibiotics, alone or in combination with benzoyl peroxide (NICE, 2018). Hormonal treatment is recommended when patients do not respond to first-line therapy and as an optional treatment to systemic (oral) antibiotics. Today, I review the use of Dianette for acne treatment, a hormonal (contraceptive) pill available as a prescription-only medication.
What is Dianette® pill?
Dianette® pill, also known under a generic name of Co-cyprindiol, contains a mixture of cyproterone acetate (an antiandrogen) and ethinylestradiol (oestrogen). Dianette® is licensed for:
- Treatment of moderate-severe acne linked to androgen sensitivity in women in the childbearing potential where other therapies such as topical and systemic antibiotics failed to produce results.
- Treatment of hirsutism (excessive hair growth in women)
- Hormonal contraceptive (although it is not recommended for use as a contraceptive only (NICE, 2019))
Dianette for acne: treatment guidelines
Hormonal contraceptives such as Dianette are not recommended as first-line treatment in the management of acne. Combined oral contraceptives are used for people with moderate acne, who did not respond to topical (skin) treatment. This form of acne treatment is optional to the treatment with oral antibiotics such as Lymecycline or Doxycycline. Dianette (Co-cyprindiol) should be used in combination with topical treatment (NICE, 2018).
The official, NICE guide for the treatment of acne vulgaris recommends discontinuation of the treatment with Co-cyprindiol (Dianette®) three months after symptoms of acne has been resolved / under control (ibid).
How long does it take for Dianette pill to work?
Treatment of at least three months is needed to relieve symptoms of acne (eMC, 2019).
How is Dianette for acne taken?
One Dianette pill is taken daily for 21 days, followed by 7 pill-free days. The first pill should be taken on day one of the menstrual cycle.
Since Dianette is a contraceptive pill, no other contraceptive pill should be taken at the same time.
How does Dianette® pill help with acne?
The sebaceous glands and the production of sebum are in the centre of acne development. Sebum is an oily substance that has a role in the skin and hair lubrication. Production of sebum in the body is controlled with the use of androgens (sex hormones). Sebum production increases from around the age of 9 until the age of 17 when adulthood levels are reached (Zouboulis, 2004). Overproduction of sebum leads to blockage of hair follicles, and consequently start the acne.
Cyproterone acetate, one of the components of Dianette, is an antiandrogen, which reduces the actions of hormones such as testosterone and consequently helps with the management of acne symptoms.
Dianette for acne: a review of side effects
Common side effects associated with Dianette use:
- Abdominal pain
- Weight gain
- Depressed mood
- Breast pain and/or breast tenderness
Additionally, as with other combined oral contraceptives, taking Dianette for acne slightly increases the risk of venous thromboembolism (VTE), an emergency situation, where a blood clot is formed in the body. This usually happens in a deep vein of leg or groin (this type of thromboembolism is called Deep Vein Thrombosis), or a clot that is formed travels to the lungs and cause a blockage (this type of thromboembolism is called pulmonary embolism). Formation of a blood clot in the artery in the brain may cause a stroke, whereas a block of the vein in the heart can lead to a heart attack. VTE can be fatal.
Dianette blood clot risk (eMC, 2019)
- Up to 40 women out of 100,000 women who take Dianette or the pill will have a clot in a year
- About 5-10 women out of 100,000 who are not taking Dianette or other pill and are not pregnant will have a blood clot in a year
The overall risk of VTE for women taking combined oral contraceptives is small (FSRH, 2019).
Certain factors increase the risk of having a blood clot in the artery, some of which include:
- Being a smoker
- Being overweight
- High blood pressure
- Being a diabetic
- Having a close family member who had a heart attack or stroke at a young age
- Being immobilised for a long time (for example after a surgery)
- Increasing age
What about breast and cervical cancer risks?
Other risks associated with the use of combined oral contraceptives include (ibid)):
- A small increased risk of breast cancer which reduces with time after the combined oral contraceptive is stopped
- A small increased risk of cervical cancer in patients who take combined oral contraceptives for more than five years, which reduces with time after the combined oral contraceptive is stopped. Risk is no longer increased ten years after stopping the combined pill.
Published research calls the above risks as ‘misconceptions’ of combined oral contraceptive use (Katsambas & Dessinioti, 2010).
Refer to product information leaflet for a list of all risk factors.
Can anyone use Dianette for acne?
Certain patients cannot use Dianette pill for the treatment of acne.
- Patients with history or present venous thrombosis
- Patients with current or history of myocardial infarction (heart attack), angina or ‘mini’ stroke
- History of present cerebrovascular accident
- Patients with multiple health-related risk factors such as diabetes, severe high blood pressure or high cholesterol or triglycerides (fats)
- History of migraines with aura
- History or present liver tumour or breast cancer
- Suspected pregnancy or breastfeeding
- Liver disease
- Predisposition for venous or arterial thrombosis, for example, a family history
World Health Organisations list the following ‘absolute’ contraindications for the use of combined oral contraceptives (WHO, 2003):
- History of heart disease or thromboembolism (obstruction of a blood vessel by a blood clot)
- History of liver disease
- Patients aged 35 or over and who are smokers
Dianette for acne: prescription charges
In the UK, all contraceptive pills are free of charge; however, this does not apply to Dianette or Co-cyprindiol when prescribed for the treatment of acne. Most commonly, Dianette is prescribed for acne treatment rather than as oral contraceptive, although both are licensed indications for this pill. To avoid a prescription charge, a prescriber needs to add an endorsement to the prescription ‘CC’, ‘OC’, or the female symbol (♀) to make it clear that Dianette is (also) used as a contraceptive.
Dianette for acne: what are the alternative options?
As we learned from this post, Dianette is not recommended as a first-line treatment of acne. The following classes of drugs are used in the management of acne:
- Topical preparations of benzoyl peroxide and azelaic acid
- Topical antibiotics with or without benzoyl peroxide, for example, Duac Once Daily Gel. Read Duac Once Daily Gel – 15 Facts You Must Know to learn more about Duac.
- Oral antibiotics such as Lymecycline
- Topical retinoids (tretinoin) and adapalene
- Oral isotretinoin
Dianette for acne: conclusion
Dianette is an effective contraceptive pill that is licensed for the treatment of acne. Although not recommended as first-line treatment of acne, Dianette® offers a good treatment option for women require acne treatment and hormonal contraception. Patients should have a discussion with their prescriber on the most suitable treatment and possible risks associated.
How do you take Dianette for acne?
Dianette is taken at the same time, each day for 21 days, followed by 7 days pill-free interval.
How quickly does Dianette clear skin?
Treatment of at least three months is needed to clear the symptoms of acne.
Can Dianette cause depression?
Depression is listed as a common side effect of Dianette use. Reports of severe depression in patients using Dianette exist. Depressed mood and depression are a known side effect of hormonal contraceptive use.
Which birth control pill is best for acne?
In the UK, hormonal contraceptive licensed for the treatment of acne contains Co-cyprindiol (cyproterone acetate with ethinylestradiol). Co-cyprindiol is available as a generic drug or under the branded name of Dianette.
- eMC (2019). Summary of product characteristics: Dianette ®. Available at: https://www.medicines.org.uk/emc/product/1122/smpc Accessed on 28/12/2019
- FSRH (2019). Hormonal Contraception. Available at: https://www.fsrh.org/standards-and-guidance/documents/combined-hormonal-contraception/ Accessed on 28/12/2019
- Katsambas Andreas D., Clio Dessinioti (2010). Hormonal therapy for acne: why not as first line therapy? facts and controversies. Clinics in Dermatology, Volume 28, Issue 1, 2010, Pages 17-23, ISSN 0738-081X. Available at: https://doi.org/10.1016/j.clindermatol.2009.03.006 Accessed on 29/12/2019
- NICE (2018). Acne vulgaris. Scenario: Management of acne vulgaris in primary care. Available at: https://cks.nice.org.uk/acne-vulgaris#!scenarioRecommendation Accessed on 27/12/2019
- NICE (2019). BNF: Rosacea and acne (treatment summary). Available at: https://bnf.nice.org.uk/treatment-summary/rosacea-and-acne.html Accessed on 29/12/2019
- WHO (2003). World Health Organization. Improving access to quality care in family planning: medical eligibility criteria for contraceptive use. 2nd ed. WHO: Geneva; 2003. Available at: https://apps.who.int/iris/handle/10665/61086 Accessed on 29/12/2019
- Zouboulis, Christos C. MD (2004). Acne and sebaceous gland function. Available at: https://doi.org/10.1016/j.clindermatol.2004.03.004 Accessed on 27/12/2019