What birth control pills (oral contraceptives) are effective in treating acne?

Birth Control Pills for Acne Treatment

Combined oral contraceptives (COCs) containing drospirenone, norgestimate, or norethindrone acetate are the most effective birth control pills for treating acne in women who also desire contraception. 1

FDA-Approved Oral Contraceptives for Acne

Four specific COCs have FDA approval for acne treatment:

1. Norgestimate/ethinyl estradiol
2. Norethindrone acetate/ethinyl estradiol/ferrous fumarate
3. Drospirenone/ethinyl estradiol
4. Drospirenone/ethinyl estradiol/levomefolate 1, 2

How COCs Work for Acne

COCs treat acne through several anti-androgenic mechanisms:

• Decreasing ovarian androgen production
• Increasing sex hormone-binding globulin (which binds free testosterone)
• Reducing free testosterone that would activate androgen receptors
• Reducing 5α-reductase activity
• Blocking androgen receptors 1

Selecting the Right COC for Acne

First-Line Options:

• Drospirenone-containing COCs: Particularly effective due to drospirenone's spironolactone-like anti-androgenic properties 1, 3
• Norgestimate-containing COCs: Good efficacy with lower venous thromboembolism (VTE) risk 4

Important Considerations:

1. Age: FDA-approved for women ≥14 years (drospirenone formulations) or ≥15 years (norgestimate and norethindrone formulations) 1
2. Smoking status: COCs contraindicated in women >35 who smoke 2
3. VTE risk: Drospirenone carries slightly higher VTE risk (9 per 10,000 person-years) compared to other COCs (6 per 10,000 person-years) 1

Efficacy Timeline and Expectations

• Improvement typically begins after 3 months of treatment 1
• Maximum benefit may require 6 months of continuous use 1
• COCs reduce both inflammatory and non-inflammatory acne lesions 1

Safety Considerations and Monitoring

Contraindications:

• Women >35 years who smoke
• History of venous thromboembolism
• Uncontrolled hypertension
• Migraine with aura
• Active liver disease 2

Monitoring:

• Blood pressure measurement before initiating therapy
• No routine Papanicolaou smear or pelvic examination required before starting 1
• Potassium monitoring not necessary in young healthy women, even when combining with spironolactone 5

Common Side Effects

• Breakthrough bleeding (especially in first 2-3 cycles)
• Nausea
• Breast tenderness
• Headache 1

Combination Therapy

For moderate to severe acne:

• COCs can be combined with topical treatments (retinoids, benzoyl peroxide)
• Can be used with spironolactone (100mg daily) for enhanced effect in severe cases 5
• Can be safely used with tetracycline antibiotics without reducing contraceptive efficacy 1

Important Clinical Pearls

1. Avoid in very young adolescents: Generally avoid COCs within 2 years of menarche or in patients <14 years unless clinically warranted 1

2. Progestin-only contraceptives (pills, injections, implants) may worsen acne 1

3. Patient counseling: Inform patients that:

   • Improvement takes at least 3 months
   • COCs should only be used for acne if contraception is also desired 2
   • Risk of serious side effects is very low in young, healthy, non-smoking women 1

4. VTE risk perspective: While COCs increase VTE risk, the absolute risk remains low and is lower than the VTE risk during pregnancy 1