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Hirsutism, acanthosis nigricans
themost reliablemarkers of
polycystic ovary syndrome
Hirsutism and acanthosis nigricans are the most reliable cutaneous markers of polycystic ovary
syndrome and require a comprehensive skin examination to diagnose, results of a retrospective,
cross-sectional study show.
A significant result
of the study is that
it helps identify key
skin features that
distinguishwomen
with polycystic
ovary syndrome
from those
suspected of having
the syndrome but do
not have the disease.
T
imothy Hunter Schmidt, MD, PhD, of the
University of California, San Francisco,
explained that the understanding of the
associations among cutaneous findings, systemic
abnormalities, and fulfilment of diagnostic criteria
in women suspecting of having polycystic ovary
syndrome is incomplete.
Dr Schmidt and a research team led by Kanade
Shinkai, MD, PhD set out to identify cutaneous
and systemic features of polycystic ovary syndrome
to help distinguish women who do and do not meet
diagnostic criteria.
Dr Shinkai said, “We undertook the study to better
understand the skin manifestations of polycystic
ovary syndrome. It was the first study to system-
atically characterise the detailed skin findings of
this disease in a large, racially diverse cohort of
women.”
The team studied a racially diverse referred sample
of women seen at their polycystic ovary syndrome
multidisciplinary clinic over a 6-year period be-
tween 2006 and 2012. Four hundred one women
were referred for suspected polycystic ovary syn-
drome, 68.8% (n=276) who met the Rotterdam
polycystic ovary syndrome diagnostic criteria.
Twelve percent (n=48) did not.
Overall, 11.5% (n=46) had insufficient data to
render a diagnosis, 1.7% (n=7) were excluded,
and 6.0% (n=24) declined to participate in the
study. Patients underwent comprehensive skin
examination and transvaginal ultrasonography and
were tested for total testosterone, free testosterone,
dehydroepiandrosterone (DHEA-S), androstene-
dione, as well as a number of additional hormone
levels.
Serum cholesterol, high density lipoprotein choles-
terol (HDLC), low density lipoprotein cholesterol
(LDLC), and triglyceride levels were also meas-
ured, as well as 0- and 2-h oral glucose tolerance
test (DGTT) results, along with glucose and insulin
levels.
Median patient age was 28 years. Compared with
women who did not meet diagnostic criteria for
polycystic ovary syndrome, women who met cri-
teria had higher rates of hirsutism (53.3% [144 of
270] vs 31.2% [15 of 48], P = 0.005) (with higher
mean modified Ferriman-Gallwey scores of 8.6 vs
5.6, P = 0.001), acne (61.2% [164 of 268] vs 40.4%
[19 of 47], P = 0.004) and acanthosis nigricans
(36.9% [89 of 241] vs 20.0% [9 of 45], P = 0.03).
Cutaneous distributions also varied.
Women who met criteria for polycystic ovary syn-
drome demonstrated more severe hirsutism (espe-
cially on the trunk) and higher rates of acanthosis
nigricans (especially axillary). Women who met
criteria for polycystic ovary syndrome had elevated
total testosterone levels, (40.7% [105 of 258] vs
4.3% [2 of 47], P < 0.001).
Among women with polycystic ovary syndrome,
the presence of hirsutism (43.9% [54 of 123] vs
30.9% [34 of 110], P = 0.04) or acanthosis nigri-
cans (53.3% [40 of 75] vs 27.0% [40 of 148], P <
0.001) was associated with higher rates of elevated
free testosterone levels, as well as several metabolic
abnormalities, including insulin resistance, dyslip-
idaemia, and increased body mass index.
Though the prevalence of acne was increased
among women with polycystic ovary syndrome,
acne types and distribution differed minimally
between women meeting versus not meeting pol-
ycystic ovary syndrome criteria.
The team concluded that hirsutism and acanthosis
nigricans are the most reliable cutaneous markers
of polycystic ovary syndrome and require a com-
prehensive skin examination to diagnose.
When present, hirsutism and acanthosis nigricans
should raise clinical concern that warrants further
diagnostic evaluation for metabolic comorbidities
that may lead to long-term complications. Acne and
androgenic alopecia are prevalent but unreliable
markers of biochemical hyperandrogenism in this
population.
Dr Shinkai said, “A significant result of the study is
that it helps identify key skin features that distin-
guish women with polycystic ovary syndrome from
those suspected of having the syndrome but do not
have the disease. This information will hopefully
improve the diagnostic accuracy of clinicians as-
sessing these patients (and also avoid unnecessary
diagnostic workup of women who do not need it).”
She added, “Future directions include understand-
ing the skin findings in subtypes of polycystic ovary
syndrome and also, the best medical and surgical
treatments for the syndrome.”
PRACTICEUPDATE RHEUMATOLOGY & DERMATOLOGY
AMERICAN ACADEMY OF DERMATOLOGY 73RD ANNUAL MEETING
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