An updated clinico-investigative approach to diagnosis of cutaneous hyperandrogenism in relation to adult female acne, female pattern alopecia & hirsutism a primer for dermatologists

ABSTRACT

Introduction

Hyperandrogenism is a clinical state consequent to excess androgen production by the ovary, adrenals, or increased peripheral conversion of androgens. The varied manifestations of hyperandrogenism include seborrhea, acne, infertility, hirsutism, or overt virilization of which adult female acne, hirsutism, and female pattern hair loss are of clinical relevance to dermatologists.

Areas covered

We limited our narrative review to literature published during period from 1 January 1985 to Dec 2022 and searched PubMed/MEDLINE, Web of Science (WOS), Scopus, and Embase databases with main search keywords were ‘Hyperandrogenism,’ ‘Female,’ ‘Biochemical,’ ‘Dermatological’, and ‘Dermatology.’ We detail the common etiological causes, nuances in interpretation of biochemical tests and imaging tools, followed by an algorithmic approach which can help avoid extensive tests and diagnose the common causes of hyperandrogenism.

Expert opinion

Based on current data, total testosterone, sex hormone binding globulin, DHEAS, prolactin, free androgen index, and peripheral androgenic metabolites like 3-alpha diol and androsterone glucuronide are ideal tests though not all are required in all patients. Abnormalities in these biochemical investigations may require radiological examination for further clarification. Total testosterone levels can help delineate broadly the varied causes of hyperandrogenism. Serum AMH could be used for defining PCOM in adults.

KEYWORDS:

• Acne
• alopecia
• androgen
• hirsutism
• hyperandrogenism
• testosterone

Article highlights

• The article gives a detailed insight from the basics of androgen biology, hyperandrogenism (focusing on important causes), biochemical evaluation and updated guidelines and algorithmic management of hyperandrogenism.

• While enumerating the myriad causes the focus is on PCOS, ovarian and adrenal pathologies, hyperinsulinemia and end organ hyperandrogenism which are seen in hirsutism, adult acne and alopecia.

• 3α diol and androstenideone glucuronide (metabolites of dihydrotestosterone) and Anti mullerian hormone are the two underutilized tests and their importance is highlighted.

• The main aim of this article is to guide dermatologists towards the etiology of hyperandrogenism.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.