Combined Oral Contraceptives (COCs) Have the Fewest Acne-Related Side Effects
Combined oral contraceptives, particularly those containing norgestimate or drospirenone, are your best choice for minimizing acne as a contraceptive side effect—they actually improve acne rather than cause it.
Why COCs Are Superior for Acne
Combined oral contraceptives containing both estrogen and progestin have been proven in multiple placebo-controlled trials to reduce acne lesion counts, severity grades, and self-assessed acne 1. The estrogen component helps counteract androgenic effects that contribute to acne development.
Specific COC Formulations Ranked by Acne Benefit
Based on patient-reported outcomes from 2,147 acne patients, a clear hierarchy exists 2:
Best to Worst:
- Drospirenone (most helpful for acne)
- Norgestimate and desogestrel (moderate benefit)
- Levonorgestrel and norethindrone (least helpful among COCs)
Triphasic progestin dosing in COCs also showed positive effects on acne, while estrogen dose variation did not significantly impact outcomes 2.
Methods That Worsen Acne
Avoid these if acne is a concern:
- Copper IUD: 14% increased risk of acne encounters and 44% increased risk of requiring escalation to oral antibiotics 3
- Levonorgestrel IUD: 9% increased risk of acne encounters and 34% increased risk of treatment escalation 3
- Depot injections (DMPA): Worsened acne on average 2
- Subdermal implants: Worsened acne on average, with acne being a common complaint leading to premature removal 4, 2
Important Caveats
While COCs are superior for acne, you must weigh this against their venous thromboembolism (VTE) risk. Combined oral contraceptives increase VTE risk from 2-10 events per 10,000 women-years to 7-10 events per 10,000 women-years 5. For women with VTE risk factors, progestin-only or non-hormonal methods may be necessary despite their potential to worsen acne.
The absolute differences in acne outcomes between contraceptive methods are modest 3, so if a patient has strong preferences for long-acting reversible contraception (LARC) for its superior pregnancy prevention (failure rate <1% vs 4-7% for pills 4, 5), this benefit may outweigh acne concerns for some women.
Practical Algorithm
- If acne-prone and no VTE risk factors: Choose COC with norgestimate or drospirenone
- If acne-prone with VTE risk factors: Consider barrier methods or carefully counsel about progestin-only options potentially worsening acne
- If using progestin-only methods: Counsel upfront about irregular bleeding 4 and potential acne worsening; ensure patient knows acne can be managed with dermatologic treatments if needed
- Avoid: Copper IUD, levonorgestrel IUD, DMPA, and implants if acne is a primary concern
Hormonal contraceptives alone are not considered acne therapy 6, but when contraception is needed, COC selection can meaningfully impact acne outcomes.