Which birth control (contraceptive) pills are approved for the treatment of acne?

FDA-Approved Birth Control Pills for Acne Treatment

There are currently four combined oral contraceptives (COCs) that are FDA-approved for the treatment of acne in women who also desire contraception: ethinyl estradiol/norgestimate, ethinyl estradiol/norethindrone acetate/ferrous fumarate, ethinyl estradiol/drospirenone, and ethinyl estradiol/drospirenone/levomefolate. 1

Mechanism of Action

All COCs work to treat acne through their anti-androgenic properties by:

• Decreasing androgen production at the ovarian level
• Increasing sex hormone-binding globulin, which binds free testosterone
• Reducing 5-alpha-reductase activity
• Blocking androgen receptors 1

Efficacy for Acne Treatment

Clinical evidence strongly supports the effectiveness of COCs for acne treatment:

• All FDA-approved COCs have demonstrated significant reductions in both inflammatory and non-inflammatory acne lesions compared to placebo 1
• A 2012 Cochrane meta-analysis of 31 trials with 12,579 women found that all studied COCs effectively reduced acne compared to placebo 1, 2
• Recent studies show COCs provide approximately 45% greater likelihood of achieving treatment success compared to placebo (RR, 1.45 [1.06,1.97]) 1

Comparing Different COC Formulations

While all COCs are effective for acne, there are some considerations when selecting between them:

• The most recent evidence does not consistently demonstrate superiority of any particular COC formulation for acne treatment 1
• Drospirenone-containing COCs may have slightly stronger anti-androgenic effects as drospirenone is a spironolactone analogue not derived from testosterone 1, 3
• A recent study showed drospirenone 3 mg/ethinyl estradiol 20 μg effectively reduced truncal acne lesions 1

Important Safety Considerations

When prescribing COCs for acne, be aware of these key safety issues:

• Venous thromboembolism (VTE) risk: All COCs increase VTE risk compared to non-users

  • Baseline risk in non-users: 1-5 per 10,000 woman-years
  • COC users: 3-9 per 10,000 woman-years
  • Drospirenone-containing COC users: approximately 10 per 10,000 woman-years 1

• Cardiovascular risks: COCs are associated with increased risk of myocardial infarction and stroke, particularly in:

  • Women over 35 who smoke
  • Those with hypertension, diabetes mellitus, or migraines 1

• Absolute contraindications include:

  • History of deep vein thrombosis or pulmonary embolism
  • Known thrombogenic mutations
  • Migraine with aura
  • Breast cancer
  • Liver tumors or severe liver disease 1

Practical Prescribing Approach

1. Verify eligibility: Ensure patient has no contraindications to COC use
2. Measure blood pressure before prescribing
3. Consider starting with lower estrogen formulations (20 μg ethinyl estradiol) to minimize side effects while maintaining efficacy 4
4. Allow adequate treatment time: Improvement typically begins after 3 cycles, with maximum benefit seen at 6 months
5. Monitor for side effects: Common adverse effects include headache/migraine (6.7%), menstrual irregularities (4.7%), nausea/vomiting (4.2%), and breast pain/tenderness (4%) 5

Key Pitfalls to Avoid

• Don't expect immediate results: Acne improvement with COCs takes time, typically 3-6 months
• Don't prescribe COCs as sole acne therapy for severe cases: Consider combination with topical treatments
• Don't overlook contraindications: Careful screening for VTE risk factors is essential
• Don't forget to counsel on proper use: Missed pills can reduce both contraceptive and anti-acne efficacy
• Don't prescribe progestin-only contraceptives for acne: These may actually worsen acne 1

Remember that FDA approval for all COCs for acne specifies they are approved for women who also desire contraception, not solely for acne treatment 1.