Use of combined oral contraceptives in dermatology: a narrative review

Abstract

Combined oral contraceptives (COCs) have emerged as an important therapeutic option in the management of dermatoses associated with hyperandrogenism, such as acne, hirsutism, and androgenetic alopecia—conditions that significantly impact the self-esteem and quality of life of women of reproductive age. Beyond their contraceptive function, these agents exert beneficial effects through modulation of the hormonal axis, promoting a reduction in peripheral androgen activity. Evidence demonstrates that their continuous use is associated with decreased sebum production and cutaneous inflammation, resulting in improvement of acne; reduced density and growth rate of terminal hairs in androgen-dependent areas; and deceleration of progressive hair thinning, contributing to the stabilization of androgenetic alopecia. Thus, not only is objective clinical improvement observed, but also a positive impact on aesthetic perception, self-esteem, and psychosocial well-being. In contrast, progestin-only methods tend to be less effective in these conditions and may, in some cases, worsen acne, and should therefore be prescribed with caution in patients with dermatological conditions sensitive to androgen action, particularly testosterone and dihydrotestosterone (DHT). This is partly due to the absence of the estrogenic component, which normally increases sex hormone-binding globulin (SHBG) levels, thereby reducing the circulating free fraction of androgens. Justification: The relevance of this study is based on the high prevalence of hormone-responsive dermatoses and their significant psychosocial impact on affected patients. Although COCs are widely prescribed, the diversity of formulations and their adverse effect profiles require an updated synthesis of the available evidence. This review is therefore justified by the need to provide clinicians with clear criteria for selecting the most appropriate progestin and for ensuring the safe management of these therapies, aiming to optimize clinical outcomes and minimize systemic risks. Objective: To evaluate the effects of COCs in the treatment of dermatological diseases associated with hormonal imbalance, particularly those related to increased androgen activity, involving hormones such as testosterone, dihydrotestosterone (DHT), androstenedione, and dehydroepiandrosterone sulfate (DHEA-S), discussing efficacy, safety, and selection criteria. Methodology: A literature review was conducted using the PubMed, SciELO, and LILACS databases, including studies published between 2020 and 2026, using the descriptors “oral contraceptives,” “dermatology,” “acne,” “hirsutism,” and “hyperandrogenism.” Conclusion: The analysis of current evidence allows us to conclude that the use of COCs in dermatology should be regarded as a systemic intervention requiring careful pharmacological selection. For the management of hormone-responsive dermatoses, formulations containing progestins with antiandrogenic or neutral profiles, such as those of the third and fourth generations, should be prioritized over earlier-generation compounds with greater affinity for androgen receptors.