44. Females only - Flutamide, nilutamide, and bicalutamide

Doctor Jacob here, and today this episode is on flutamide, nilutamide, and bicalutamide. These are drugs which potentially could be used for treating hormonal acne in women. They work as strong blockers of the androgen receptor, much stronger than spironolactone.

They were developed for use in metastatic prostate cancers, and their use in acne and related endocrine disorders such as hirsutism (excess body hair) as well as hair loss - a female pattern hair loss type has been written about in some publications, but is widely considered experimental. I generally do not prescribe any of these drugs for the treatment of acne because of a paucity of data on the subject.

Additionally, flutamide is known in roughly 3 out of 10,000 cases to cause serious liver damage, sometimes resulting in liver transplantation.

Also, the next drug, nilutamide has been known to cause serious types of lung damage, which can be fatal. Given the side effect profile, I really wouldn't prescribe either of those drugs. I certainly wouldn't take any of them myself if I were a female with acne. For prostate cancer, that's a disease if it's metastatic that people might die of, and so the risks are justified. But for acne, no way.

Bicalutamide, the newest of these three drugs, seems to be the safest of these three drugs, in that there are far fewer cases reported of liver toxicity. That being said, we need more data on it before I can recommend it or before I would prescribe it for a patient. I would still consider the use of any of these drugs in acne experimental.

With regard to their safety, birth defects are a very, very serious concern. Women taking these drugs should not handle the drugs if there's any chance that they are pregnant, let alone ingest them - that's how severe the warning is for pregnant ladies and these drugs.

So that being said, if for any reason a doctor were to prescribe these drugs for hormonal acne, birth control two forms would be mandated.

In summary, I wouldn't prescribe any of these drugs yet, because they are experimental. Flutamide can cause serious liver problems, nilutamide can cause serious lung problems and bicalutamide seems to be the safest of the bunch but is not something I would recommend until more data on the subject is available.

That leaves the potential maximal therapy for adult onset female acne at a combination of birth control pills plus full dose spironolactone.

That's all for today. I'm Doctor Jacob, we'll see you next time.