PracticeUpdate: Dermatology & Rheumatology

AMERICAN ACADEMY OF DERMATOLOGY 73RD ANNUAL MEETING 10

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.

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.”

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.

PRACTICEUPDATE RHEUMATOLOGY & DERMATOLOGY