Is spironolactone used to treat acne?

Spironolactone for Acne Treatment in Women

Yes, spironolactone is an effective treatment for acne in women and should be considered a first-line systemic therapy option for female patients with acne, particularly as an alternative to oral antibiotics. 1

Mechanism and Effectiveness

Spironolactone is a synthetic 17-lactone steroid that works by:

• Antagonizing androgen and progesterone receptors
• Inhibiting androgen receptor activity on sebocytes, reducing sebum production
• Potentially reducing synthesis of androgen precursors in the adrenal glands

Although originally developed as a potassium-sparing diuretic, spironolactone has been used off-label for acne treatment in women for over 30 years 1. Multiple large observational studies support its effectiveness:

• 84-86% of patients show improvement with spironolactone treatment 1
• A recent large-scale study of 395 patients showed complete response in 66.1% of women, with 85.1% having at least a 50% improvement 2
• The 2024 FASCE study demonstrated spironolactone was 2.87 times more successful than doxycycline after 6 months of treatment 3

Dosing and Administration

• Starting dose: Typically 100mg/day in the evening 1
• Dose range: 25-200mg daily 1
• Dose adjustment: Can increase up to 200mg/day, though side effects increase with higher doses 1
• Treatment duration: Several months are typically required to reach full effectiveness 1
• Median time to initial response: 3 months 2
• Median time to maximum response: 5 months 2

Patient Selection

Spironolactone is effective for:

• Women of all ages with acne 1
• All severity subtypes of acne, including papulopustular and nodulocystic forms 2
• Not limited to only adult women or those with lower face acne/menstrual flares 1

Benefits Over Antibiotics

Spironolactone offers several advantages over oral antibiotics:

• Helps improve antimicrobial stewardship 1
• Avoids antibiotic resistance issues 1
• Targets hormonal pathogenesis directly 1
• Recent research shows it is more effective than doxycycline for moderate acne in adult females 3
• Provides better quality of life outcomes compared to doxycycline 3

Side Effects and Monitoring

Common side effects include:

• Menstrual irregularities (15-30% of patients) - dose dependent 1
• Breast tenderness (3-5%) 1
• Dizziness (3-4%) 1
• Headaches (more common than placebo - 20.4% vs 12.0%) 4
• Nausea (2-4%), headache (2%), polyuria (1-2%), fatigue (1-2%) 1

Important monitoring considerations:

• Routine potassium monitoring is not required in young, healthy women without hypertension, renal disease, or cardiac disease 1
• Potassium monitoring should be performed in women with risk factors for hyperkalemia 1
• Pregnancy testing should be performed before starting (Pregnancy category C) 1

Safety Profile

• Long-term use appears safe with few serious adverse effects 5
• In a study with 200 person-years of spironolactone exposure and 506 person-years of follow-up, no serious illnesses attributable to spironolactone were observed 1, 5
• Despite a black box warning based on animal studies using doses 100 times greater than clinical doses, large cohort studies with over 30 million person-years of follow-up have not confirmed increased cancer risk 1

Contraindications

• Significant renal impairment
• Hyperkalemia
• Medications known to increase serum potassium (e.g., trimethoprim, ACE inhibitors)
• Addison's disease
• Pregnancy (category C) - patients should avoid pregnancy while on treatment 1

Cost-Effectiveness

The recent SAFA trial demonstrated spironolactone is cost-effective compared to placebo or oral antibiotics, with an incremental cost per quality-adjusted life-year of £27,879 compared to placebo or £2,683 compared to oral antibiotics 4.

Clinical Pearls

• Consider combining with a combined oral contraceptive or hormonal IUD to minimize menstrual irregularities 1
• Spironolactone is compatible with breastfeeding with minimal risk to the infant 1
• For patients with a family history of breast or ovarian cancer, consider use after thorough discussion of the black box warning 1
• Treatment is typically long-term (median duration 13 months in one study) 2