Spironolactone Dosing for Acne Treatment
The recommended dose of spironolactone for acne treatment is 50-100 mg daily, with a typical starting dose of 50 mg/day that can be increased to 100 mg/day after 6 weeks if needed, based on the most recent high-quality evidence. 1, 2
Dosing Algorithm
- Initial dose: 50 mg/day for the first 6 weeks
- Maintenance dose: Increase to 100 mg/day if needed after 6 weeks
- Dose range: 25-200 mg daily (though most patients respond at 50-100 mg)
- Administration: Typically taken in the evening
Efficacy at Different Doses
- 25-50 mg/day: Effective for mild-moderate acne with fewer side effects 3
- 50-100 mg/day: Optimal dose range for most patients, with significant improvement in acne-specific quality of life and patient satisfaction 1, 2
- 100-200 mg/day: May be needed for severe or resistant cases, but side effects increase at higher doses 4
Evidence for Efficacy
The most recent high-quality evidence from a 2024 randomized controlled trial (SAFA trial) demonstrated that spironolactone at 50-100 mg/day was significantly more effective than placebo for treating acne in women 1, 2:
- At 12 weeks: 72.2% of patients on spironolactone reported improvement vs 67.9% on placebo
- At 24 weeks: 81.9% of patients on spironolactone reported improvement vs 63.3% on placebo
- Treatment success based on Investigator's Global Assessment was significantly higher with spironolactone (18.5% vs 5.6%)
A retrospective review of 395 patients found that approximately two-thirds (66.1%) had a complete response, and 85.1% had at least a 50% improvement with a median dose of 100 mg daily 5.
Important Monitoring Considerations
- Potassium monitoring: Not routinely required in young, healthy women without risk factors 4, 6
- Potassium monitoring indicated for:
- Older patients
- Patients with hypertension, diabetes, or kidney disease
- Patients taking medications affecting renal/adrenal function (ACE inhibitors, ARBs, NSAIDs, digoxin) 4
Common Side Effects
- Menstrual irregularities (40.6%) - less common with concurrent oral contraceptive use 4
- Headaches (20.4%) 1
- Breast tenderness (3-5%) 6
- Dizziness (3-4%) 6
- Nausea (2-4%) 6
- Fatigue (1-2%) 6
Important Contraindications
- Pregnancy (Category C) - should not be used 4
- Significant renal impairment 4
- Hyperkalemia 4
- Addison's disease 4
Clinical Pearls
- Full effectiveness may take several months to achieve, with median time to initial response of 3 months and maximum response of 5 months 5
- Spironolactone is effective for all severity subtypes of acne, including papulopustular and nodulocystic forms 5
- Consider combining with oral contraceptives to reduce menstrual irregularities 6
- Spironolactone is a valuable alternative to oral antibiotics for women with acne, with similar effectiveness but without contributing to antibiotic resistance 4, 2