14 HIRSUTISM (H) & ACNE (A) ARE VARIABLE MANIFESTATIONS OF ANDROGEN EXCESS

Abstract

Paradoxically, the hyperandrogenemia of congenital adrenal hyperplasia and polycystic ovary syndrome may be “cryptic,” i.e. without H, although plasma free testosterone (fT) is known to be elevated in most moderately severe H and A. We tested the hypothesis that this disparity is related to common variations in end-organ sensitivity to androgens.Plasma fT, H (scores 8–16 mild, 17–25 moderate) and A scores were obtained from 51 volunteers and 9 hirsute females homogeneous for age (18–21 yrs) and race (Caucasian).Among subjects with an elevated fT all possible combinations of skin manifestations were seen: 5 had H alone, 4 had A alone, 5 both H and A, and 1 neither. Mild acne (3–9 comedones) was often the only manifestation of hyperandrogenemia. Although plasma fT was significantly elevated (p<.05) in the 12 subjects with mild hirsutism alone (12.7±5.5, SD, vs 7.4±2.7 pg/ml) and was elevated (13–19 pg/ml) in all 3 cases with moderate hirsutism, no correlations were discerned between H and fT. Similarly, no correlation was apparent between A and fT. The coefficient of variation of fT was 2-fold greater among than within mild H cases.Our data support a model in which normal variations in the “apparent sensitivity” of the pilosebaceous unit to androgen play at least as great a role in the appearance of H and A as androgen excess. We propose that cryptic hyperandrogenemia lies at the opposite end of a spectrum (relatively resistant to androgen excess) from idiopathic hirsutism or acne (relatively sensitive to unremarkable androgen levels).