mackjacks Posted February 27, 2013 Share Posted February 27, 2013 24 yo F presents w 7 month hx of acne across upper back. Pt states that the acne began 2 months after insertion of a Mirena (levonorgestrel) IUD and has been getting worse since. For 6 years prior to the IUD she had been taking Lo-ovral (estradiol/norgestrel) for contraception. No prior hx of acne besides an "occasional pimple". The patient has been using topical clindamycin and salicylic acid bid, adding benzoyl peroxide in the am, for 4 months with no reduction in the number of lesions. PE: thin, well-appearing female w 20-30 papules interspersed w open comedones and seven 1 cm pustular lesions, spanning shoulder-shoulder and extending inferiorly to the spine of the scapula The pt does not want to remove the Mirena as they like the security of it, but would consider other po meds. I would love to hear what others thoughts are! Try doxycycline? Add-on an oral contraceptive? Other ideas? Link to comment Share on other sites More sharing options...
SocialMedicine Posted February 28, 2013 Share Posted February 28, 2013 15% of people on mirena develop acne. doxycycline can potentially decrease effectiveness of birth control from what I understand. Not sure how this applies to IUD. Can someone comment on that? Yea I would not waste time or money running a bunch of tests and prescribing medications .... she should have the IUD removed. I cannot imagine a 24 y/o woman that would choose to keep an IUD in and have her back covered with cystic acne. On a side note using stricly Abx topical for acne is no longer recommended due to resistance ... good to add the benzoyl peroxide. Link to comment Share on other sites More sharing options...
jen0508 Posted February 28, 2013 Share Posted February 28, 2013 this is why i work in EM.. anywho, to answer the question, i would never place a patient on longterm abx for something cosmetic like acne, especially when it is barely ever effective for acne tx. doxy is one of the few (affordable) PO meds effective against MRSA. why place ppl on it for ACNE?? seems like a waste.. spironolactone (anti-androgen) is an option, derm folks use it for adult acne in women, which is 99% of the time hormonal. Other than abx and accutane type meds i dont know of any other PO meds Link to comment Share on other sites More sharing options...
GingersHuman Posted February 28, 2013 Share Posted February 28, 2013 Take out Mirena ASAP! I fought w/ acne from age 12-24. Over the years I had multiple docs managing it so I basically was on abx for about a decade which is a horrifying thought. Along w/ every prescription topical from the benzyls to sulfas to retinoids etc. It wasn't TOO terrible in my 20s but at 22 I wanted an IUD and naturally the docs first inclination was Mirena. Well my acne had worsened, especially w/cystic acne around my jawline, but I was in complete denial that Mirena had anything to do w/it. My gyno insisted that there was not any systemic absorption thus it'd be impossible for there to be a connection. Around that time I finally decided to choose the health risks of Accutane over the health risks of continued abx use. After 12 weeks on Accutane, my acne had not budged, and my derm really urged me to consider the possibility that Mirena was the culprit, esp considering the hormonal involvement when a 20something has jawline cystic acne. Whatever, despite the ridonkulous co-pays I swapped Mirena for Paraguard and VOILA!!! Life changed. My acne cleared up quickly. My skin looks amazing, I've finished my first and only Accutane cycle probably 2 years ago now and it's crazy to not even remember what life was like with acne. I have no complaints w/Paraguard - sure I menstruate now (unlike Mirena) but can I really complain about that? lol. Anyway, your pt's Mirena has got to go! :;;D: Link to comment Share on other sites More sharing options...
Joelseff Posted February 28, 2013 Share Posted February 28, 2013 Take out Mirena ASAP! I fought w/ acne from age 12-24. Over the years I had multiple docs managing it so I basically was on abx for about a decade which is a horrifying thought. Along w/ every prescription topical from the benzyls to sulfas to retinoids etc. It wasn't TOO terrible in my 20s but at 22 I wanted an IUD and naturally the docs first inclination was Mirena. Well my acne had worsened, especially w/cystic acne around my jawline, but I was in complete denial that Mirena had anything to do w/it. My gyno insisted that there was not any systemic absorption thus it'd be impossible for there to be a connection. Around that time I finally decided to choose the health risks of Accutane over the health risks of continued abx use. After 12 weeks on Accutane, my acne had not budged, and my derm really urged me to consider the possibility that Mirena was the culprit, esp considering the hormonal involvement when a 20something has jawline cystic acne. Whatever, despite the ridonkulous co-pays I swapped Mirena for Paraguard and VOILA!!! Life changed. My acne cleared up quickly. My skin looks amazing, I've finished my first and only Accutane cycle probably 2 years ago now and it's crazy to not even remember what life was like with acne. I have no complaints w/Paraguard - sure I menstruate now (unlike Mirena) but can I really complain about that? lol. Anyway, your pt's Mirena has got to go! :;;D: I would have to agree. D/C mirena and Try paragard. Sent from my myTouch_4G_Slide using Tapatalk Link to comment Share on other sites More sharing options...
Moderator ventana Posted February 28, 2013 Moderator Share Posted February 28, 2013 switch to a cooper IUD simple and done I try to avoid at all cost - treating the side effect of one drug with another drug - just seems stupid.... Link to comment Share on other sites More sharing options...
mackjacks Posted March 1, 2013 Author Share Posted March 1, 2013 doxycycline can potentially decrease effectiveness of birth control from what I understand. Not sure how this applies to IUD. Can someone comment on that? I'd think it wouldn't have any effect, since the Mirena releases the hormones right onto the uterine tissue. The issue w abx is they can kill the bacteria that facilitate enterohepatic recycling or increase liver breakdown of estrogens. With mirena there should be no systemic circulation of the drug. I agree that doxy shouldn't be used for acne, standard of care is to go to doxy or minocycline if topicals fail.... Was thinking the pts issue is not that mirena caused the acne but rather that her acne was masked by having been on combo oral contraceptives for years, which is why I was looking into mirena+po contraceptive. It'd be interesting to see if switching to paraguard would lead to improvement! Any info on the statistic that 15% of pts get acne on mirena? Could those pts have previously been taking po contraceptive? Link to comment Share on other sites More sharing options...
thecurlyblonde Posted March 1, 2013 Share Posted March 1, 2013 Just commenting from personal experience - when I started Mirena, I noticed a slight change in my skin a few months in, but it progressively got worse along my jawline and a BIG issue on my upper back. Tried treating w/ OTC acne treatments, to little avail. Finally went to my derm-- she attributed the issue completely to the IUD, stating that "Mirena is a skin doctor's worst nightmare". My derm suggested 25 mg/day spironolactone about a 1.5 months ago, and am seeing a very noticeable difference already. I would def recommend trying it before completely giving up on the Mirena.Side note, I do think you may be right about the acne being masked (atleast to a point) by combo contraceptives in the past, because I know I had similar acne in my early teens before I started taking the pill. People tend to forget this when they've been on birth control for so long. Link to comment Share on other sites More sharing options...
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