Spironolactone to Combat the Hormones of Acne

What Is “Hormonal Acne?”

Acne is a very common skin condition, affecting up to 93% of teenagers and young adults.^[1] There are times during a woman’s menstrual cycle where the fluctuation of sex hormones may cause temporary flaring of acne due to increased oil (sebum) production and plugged pores.^[2] Additionally, in rare cases, people with acne can have increased or imbalanced sex hormone levels (such as free testosterone, dehydroepiandrosterone, and androstenedione) in their blood regardless of menstruation. So why do most people who do not have abnormal blood levels of sex hormones still get “hormonal acne?” This can be explained by increased sensitivity of hair follicles and oil gland stimulation by sex hormones.^[3]

What Is Spironolactone?

Spironolactone is a molecule that binds to sex hormone receptors and limits the effect of circulating hormones in our body. Spironolactone is available as a pill to be taken orally. Spironolactone was initially used as a medication to treat elevated blood pressure and heart failure but has been used off-label for acne since the 1980s. It is now the most commonly used hormone-blocking treatment in the U.S.^[4]

How Does Spironolactone Treat Hormonal Acne? 

Spironolactone inhibits both the production and the effect of sex hormones in our body. As a result, it lowers sebum production in our skin by up to 80%^[5] and prevents sebum-producing cells (sebocytes) from dividing. Lowering sebum production helps prevent plugging of pores, which in turn reduces whiteheads, blackheads (comedones), and inflamed pimples. The typical dose for spironolactone is 25 to 100 mg daily as an oral pill. In some cases, your doctor or dermatologist may prescribe a higher dose up to 200 mg daily or more.^[6]  It can be taken alone or in combination with other topical and oral medications. Researchers have found that a three-month course of spironolactone is effective in treating acne on the face, chest, and back in teenage girls and adult women.^[5]

When Is Spironolactone a Good Option for Acne Treatment?

Spironolactone is an effective treatment option for women with hormone-related acne that cannot be controlled using topical medications, such as topical retinoids, antibiotics, benzoyl peroxide, or salicylic acid. Spironolactone blocks the production and action of sex hormones, particularly male sex hormones. This results in the possibility of a male fetus having an incomplete formation of the male sex organs (feminization).^[7] Therefore, women with child-bearing potential should use reliable form(s) of birth control when taking this medication. Spironolactone should also be avoided during pregnancy.^[3] Other potential side effects of spironolactone include dehydration from increased urination, breast tenderness or enlargement, irregular menses or “spotting,” increased blood potassium and calcium levels, muscle cramps, and decreased sex drive.^[3]

How Quickly Does Spironolactone Work?

One of the challenges with medications for acne is that most medications take time to work. Spironolactone is no different, and most studies have waited 3 months to see the full effects.^[6]

What Are the Side Effects?

Common side effects of spironolactone include abnormal vaginal bleeding and spotting, breast enlargement, and breast tenderness. Because spironolactone acts as a diuretic, it will likely increase the need to urinate. Spironolactone works as a “potassium-sparing diuretic,” meaning that it will keep the body from losing potassium. As a result, the body’s potassium could theoretically increase. Recent studies in otherwise young and healthy women have shown that regular monitoring of potassium may not be necessary.^[8] However, your prescribing doctor will take into account individual factors, such as your kidney function, your history of diabetes, and your diet in determining whether potassium monitoring is right for you. If you eat a lot of potassium-rich foods such as kale, spinach, avocados, bananas, or potassium-rich sports drinks, you should let your doctor know.

When Is Spironolactone Not a Good Option for Acne Treatment?

Spironolactone is not a good option for acne treatment in the following scenarios:

• Mild acne that can be adequately controlled by first-line treatment options such as topical retinoids, topical antibiotics, topical benzoyl peroxide, or topical salicylic acid
• In pregnant or breastfeeding women
• A woman of childbearing age who cannot tolerate birth control and the importance of avoiding pregnancy may be discussed in detail by the prescribing physician
• A woman who cannot tolerate side effects, including those noted above
• A woman with any medical condition that makes her at risk to have high blood potassium levels, such as Addison’s or kidney disease
• A woman taking any medications that increase her risk of having high blood potassium
• Men, due to the risk of enlarged breasts and the disruption of the normal function of male hormones