Treatment Guidelines for Hormonal Acne
Combined oral contraceptives (COCs) are the first-line treatment for hormonal acne in women, with spironolactone as an effective alternative or adjunct therapy. 1
Diagnosis and Identification of Hormonal Acne
Hormonal acne is characterized by:
- Predominance in adult women
- Flare-ups related to menstrual cycle
- Distribution along jawline, chin, and lower face
- Deep, tender, inflammatory nodules
- Resistance to conventional acne treatments
First-Line Treatment Options
Combined Oral Contraceptives (COCs)
FDA-approved COCs for acne treatment 2, 1:
- Ethinyl estradiol/norgestimate
- Ethinyl estradiol/norethindrone acetate/ferrous fumarate
- Ethinyl estradiol/drospirenone
- Ethinyl estradiol/drospirenone/levomefolate
Mechanism of action 2:
- Decrease ovarian androgen production
- Increase sex hormone-binding globulin (SHBG)
- Reduce 5-alpha-reductase activity
- Block androgen receptors
Efficacy: Multiple randomized controlled trials demonstrate that all COCs effectively reduce both inflammatory and comedonal acne lesions 2
Important considerations:
- FDA approval specifies use in women who also desire contraception 2
- Assess for contraindications using WHO eligibility criteria
- Monitor for cardiovascular risks, particularly venous thromboembolism (VTE)
Spironolactone
- Dosage: 100-150 mg daily 1
- Mechanism: Blocks androgen receptors and reduces sebum production
- Efficacy: Effective as first-line treatment for women with acne 3
- Monitoring: Potassium monitoring generally unnecessary unless patient has specific risk factors for hyperkalemia 3
- Contraindications: Pregnancy, breastfeeding women 1
Topical Treatment Options
Standard Topical Treatments
Topical retinoids: Apply tretinoin (0.025-0.1%), adapalene (0.1-0.3%), or tazarotene (0.05-0.1%) once daily 1, 4
Benzoyl peroxide (2.5-5%): Helps prevent bacterial resistance 1
- Apply with moisturizer afterward to minimize irritation 1
Newer Topical Options
- Clascoterone: A topical anti-androgen effective for acne treatment in both men and women with limited systemic effects 3
Treatment Algorithm for Hormonal Acne
Mild hormonal acne:
- Start with topical retinoid + benzoyl peroxide
- Add COC for women who also desire contraception
Moderate hormonal acne:
- COC (for women desiring contraception) OR
- Spironolactone 100-150 mg daily
- PLUS topical retinoid + benzoyl peroxide
Severe hormonal acne:
- COC + spironolactone
- PLUS topical retinoid + benzoyl peroxide
- Consider isotretinoin if no response after 3-6 months
Special Considerations
Monitoring and Follow-up
- Assess treatment efficacy after 6-8 weeks 1
- Allow 3-6 months for full hormonal therapy benefits
- Be aware that initial flare-ups may occur with retinoid use 4
Common Pitfalls to Avoid
- Treating hormonal acne with antibiotics alone without addressing the underlying hormonal cause 1
- Failing to consider hormonal therapy in women with treatment-resistant acne 1
- Not screening for contraindications before prescribing hormonal therapies 1
- Discontinuing treatment too early (before 6-12 weeks) 4
Other Hormonal Options
- Finasteride: 1.25-5 mg daily (off-label) 1
- Metformin: 500 mg 2-3 times daily (for patients with insulin resistance) 1
Skincare Recommendations
- Use mild, non-medicated soap for cleansing 4
- Avoid frequent washing and harsh scrubbing 4
- Choose non-comedogenic moisturizers with ingredients like niacinamide or tea tree oil 1
- Apply sunscreen daily, especially when using retinoids 4
Hormonal therapies represent an essential strategy for treating acne, particularly in women with hormonal fluctuations or resistance to conventional treatments. With proper patient selection and monitoring, these treatments can provide significant improvements in acne and quality of life.