Chief Complaint: ER is a 23-year-old female with persistent acne on the jawline and chin

HPI:
ER is a 23-year-old female competitive collegiate and Olympic track and field athlete presenting to the clinic complaining of worsening acne over the past 8 months, primarily on her jawline, chin, and lower cheeks. She reports that the acne seems to be cyclical and flares up around her menstrual period. She has tried over-the-counter options, like benzoyl peroxide and salicylic acid cleansers, but has not seen much improvement. She is very self-conscious about the breakouts, mainly due to increased media coverage of her competing as she trains for the Olympics.

Medical History
Past Medical History: No significant medical history, regular menstrual cycles, no personal history of clotting or thrombosis
Social History: non-smoker, occasional alcohol use (social drinking with friends 1 night per week, two drinks per sitting), highly active (trains 5-6 days per week)
Family History: Mother with a history of hormonal acne treated with spironolactone
Current Medications: over-the-counter benzoyl peroxide 5% gel and salicylic acid cleanser
Allergies: NKDA

Physical Examination
General: Well-developed, well-nourished female
Vital Signs: BP 115/72 mmHg, HR 62 BPM
System-Specific Findings: Abdomen, Neurological, Psychological, MS/extremities, CV, HEENT, Pulmonary: No relevant findings
Skin: Moderate inflammatory acne on lower face, especially perioral and mandibular regions. No signs of hirsutism or virilization

Symptoms and Factors
Major Symptoms: Self-reported: Cyclical acne on face

ROS: Moderate inflammatory acne
Aggravating Factors: Onset of menstrual cycle, liquid makeup/concealers, frequent exercise
Easing factors: End of menstrual cycle, breaks from exercise

Lab Values
SCr: 0.8 mg/dL
Serum K: 4 mEq/L
Serum Testosterone: 40 ng/dL

Clinical Questions

1. The team doctor suggests starting ER on spironolactone based on his assessment that the acne has not responded to over-the-counter medication options, and the patient’s mother responded well to this medication in the past. He asks you what the next steps for prescribing the drug are.
A. Send the prescription as is because spironolactone does not need a Therapeutic Use Exemption (TUE) as it is not on the NCAA or WADA Banned Substances List
B. Submit a TUE to be approved for the medication before sending the prescription for the patient, because spironolactone is on the NCAA and WADA Banned Substances list
C. Send the prescription and send a retroactive TUE, because spironolactone is on the NCAA and WADA Banned Substances list, but the medication is considered urgently medically necessary
D. Suggest looking into other medication choices, as spironolactone is on the NCAA and WADA Banned Substances list, and a TUE would likely not get approved

Rationale: Spironolactone is considered a banned drug, as it falls under the class of diuretics or masking agents. Because it is on the banned substances list, for the patient to take the medication as an Olympic athlete, a TUE would need to be completed. A TUE will be approved when the medication is prescribed for a diagnosed medical condition in which no reasonable alternative is available for treatment, and there will be no performance enhancement seen from the medication. A retroactive TUE would not be appropriate in this case, as it is not a medication that must be urgently administered. Because there are several other medication options for acne, a TUE would not be approved because there are multiple acne treatments that the patient has not tried yet. For the NCAA, the patient would not need to submit a medical exemption before use of spironolactone, as this only needs to be completed for anabolic agents, hormone and metabolic modulators, peptide hormones, and growth factors. However, the school would need documentation on file to ensure it meets the reason for needing it. It’s often good to refer to the WADA TUE Physician guidelines to ensure the athletes meet the criteria for use. To learn more about TUE and Medical Exemptions, please check WADA and the NCAA for more resources.

2. As the acne seems to cycle and worsen with ER’s menstrual cycles, after further discussion with the team doctor and ER, you decide that starting a combined oral contraceptive would be an appropriate choice, and would not require approval for use. Which combined oral contraceptive would be ideal to start?
A. Drosperinone-Ethinyl Estradiol
B. Levonorgestrel-Ethinyl Estradiol
C. Norgestimate-Ethinyl Estradiol
D. Desogestrel-Ethinyl Estradiol

Rationale: Choosing a combined oral contraceptive that includes a progestin component that is anti-androgenic would be best in helping with ER’s hormonal acne. The progestin, drospirenone, is anti-androgenic; a 3mg dose provides the same anti-androgenic effect as 25mg of spironolactone. Levonorgestrel is the most androgenic, while norgestimate and desogestrel are considered less androgenic agents.

3. ER agrees to trial the combined oral contraceptive that has been prescribed, but she is also interested in any vitamins or supplements she can add to her diet and routine to help with acne. What would you recommend (select all that apply)
A. Daily multivitamin that includes Vitamin A, C, D, E, and B
B. Ashwagandha
C. Zinc
D. Omega-3 fatty acids

Rationale: Although substantial data on the safety and efficacy of using vitamins and supplements in health conditions can be hard to find, Vitamins A, C, D, E, B, Zinc, and Omega-3 fatty acids may help with acne in some patients. The thought process is that these vitamins and supplements have anti-inflammatory effects in the body, which can help reduce acne severity. As with any vitamin or supplement that we would recommend for our athletes, it is essential to ensure that they are obtained from a legitimate source with third party testing, to ensure that the patient is only getting the expected product, and not any adulterated vitamins or supplements, which could cause them to fail drug testing. As a bonus, taking these supplements for acne can help replace some of the vitamins and minerals that oral hormonal contraceptives can deplete (Vitamin B, C, and E, and Zinc).

4. As part of ER’s training schedule, she frequently flies to LA, where the 2028 Olympics will be held, to train in conditions similar to those she will face in competition. What would you ensure to counsel ER on when picking up her new combined oral contraceptive medication, knowing this?
A. Must be taken at the same time daily so the medication will be effective
B. Discuss increased clotting risk associated with estrogen, and recommend ER to ambulate during lengthy flights regularly
C. Recommend that ER place any prescription medications in her checked luggage
D. There is nothing important to note regarding traveling while being on this medication

Rationale: Because ER is starting an agent with estrogen for the first time, it is important to counsel on the possible effects on the body seen with increases in estrogen, especially the increased risk of clotting. New start counseling for combined hormonal oral contraceptives should include possible warning signs of a clot (new or worsening migraines, changes in vision, pain in chest/difficulty breathing, severe abdominal pain, or swelling/redness in extremities) as well as ways to help mitigate increased clotting risk (ambulation on long flights). Although we do suggest that patients try to take the medication at the same time of day, for a combined hormonal contraceptive product, this is not as much of a concern for efficacy compared to progestin-only agents. Any time a patient is traveling with their medication, recommend keeping the medicines in the original package and labeling as dispensed by the pharmacy, and placing them in their carry-on luggage in case checked baggage is lost.

5. ER returns to the clinic in 3 months, and notes some improvement with acne after starting the combined oral contraceptive, but still notes occasional breakouts. What would be a reasonable next step?
A. Continue the combined oral contraceptive and start oral isotretinoin
B. Stop the combined oral contraceptive and start oral isotretinoin
C. Continue the combined oral contraceptive and start topical tretinoin cream at night
D. Continue the combined oral contraceptive and start spironolactone

Rationale: Because ER has noticed some improvement with the oral contraceptive, we would not want to stop this medication. Depending on which form of drospirenone-containing combined hormonal contraceptive the patient is taking, consider switching to one with a higher dose of drospirenone. Alternatively, adding a topical agent may be helpful at this step. When adding an agent like tretinoin, counsel the patient on using sunscreen during the day and the possibility of dryness and redness on the face when using the medication. It would also be helpful to ensure that ER engages in non-pharmacological management for acne, including washing her face with a non-scented face wash after training or other times with increased sweat production, and ensuring that any sunscreen used is non-comedogenic. Starting oral isotretinoin would be many steps down the treatment algorithm, so this is not the best choice. If ER were to start on this medication, it would be essential that she remained on the contraceptive agent, as oral isotretinoin is a REMS medication due to its risk to fetal development. The last option of continuing the oral combined hormonal contraceptive and starting spironolactone could be a reasonable option in a patient who is not an athlete. However, because ER would need to submit a TUE to be approved for this medication, and there are still multiple acne treatments that she has not tried, this is not the best approach.

WRAP UP

A 23-year-old competitive Olympic track athlete presents with worsening, cyclical acne on her lower face, likely hormonal in nature, flaring around her menstrual cycle. She has tried over-the-counter products without success and is self-conscious due to media exposure. With no significant medical history and a family history of success with spironolactone, her care team considers treatment options. She is started on a combined oral contraceptive containing drospirenone for its anti-androgenic effect. She is also counseled on vitamins and non-pharmacologic recommendations, including face hygiene and travel-related clot risk. At follow-up, with partial improvement, topical tretinoin is added rather than switching or escalating systemic therapies. This case highlights the importance of safe, effective, and regulation-compliant acne management in elite athletes.

The role of sports pharmacists in athlete acne management

• Medication Expertise: They evaluate pharmacologic options’ safety, effectiveness, and regulatory status.
• Tailored Non-pharmacological Recommendations: Careful counseling and recommendations for products that provide sun-protection, hydration, and skin cleansing based on an athlete’s needs.
• Clean Sport Support: Sports pharmacists stay current with sport-governing bodies’ Prohibited/Banned Substance Lists to keep athletes compliant, especially when competing in NCAA and Olympic events, which can have different requirements.
• Interdisciplinary Collaboration: Work alongside healthcare providers, mental health professionals, and athletic trainers to ensure comprehensive care.
• Education: Teach athletes how to manage acne through medications and non-pharmacological options while providing all information needed to keep them safe and informed.