What is the best oral birth control (oral contraceptive) for treating acne?

Best Oral Contraceptives for Acne Treatment

Drospirenone-containing combined oral contraceptives (COCs) are the most effective oral birth control option for treating acne in women who also desire contraception. 1, 2

Mechanism of Action

COCs treat acne through their anti-androgenic properties by:

• Decreasing ovarian androgen production
• Increasing sex hormone-binding globulin
• Reducing free testosterone
• Reducing 5α-reductase activity
• Blocking androgen receptors 1

FDA-Approved COCs for Acne

There are four FDA-approved COCs for acne treatment:

1. Ethinyl estradiol/drospirenone
2. Ethinyl estradiol/norgestimate
3. Ethinyl estradiol/norethindrone acetate/ferrous fumarate
4. Ethinyl estradiol/drospirenone/levomefolate 1, 3

Comparative Efficacy

While all COCs are effective for acne, drospirenone-containing COCs demonstrate superior results:

• Drospirenone-COCs showed greater improvement in investigator assessment of clear or almost clear skin (OR 3.02; 95% CI 1.99 to 4.59) 4
• Drospirenone-COCs demonstrated greater percent changes for total lesion count (MD 29.08; 95% CI 3.13 to 55.03) 4
• Drospirenone is a spironolactone analogue with potent anti-androgenic properties 1
• Drospirenone appears more effective than norgestimate or nomegestrol acetate 4

Progestin Generations and Acne Effects

The progestin component significantly impacts acne outcomes:

• First-generation (norethindrone, ethynodiol diacetate): Moderate anti-acne effects
• Second-generation (levonorgestrel, norgestrel): Less effective for acne
• Third-generation (norgestimate, desogestrel): Better anti-acne effects than earlier generations
• Fourth-generation (drospirenone): Most effective anti-androgenic properties 1, 3

Safety Considerations

When prescribing COCs for acne, consider these safety factors:

1. VTE Risk: All COCs increase venous thromboembolism risk compared to non-users:

   • Non-users: 1-5 per 10,000 woman-years
   • COC users: 3-9 per 10,000 woman-years
   • Drospirenone-COC users: ~10 per 10,000 woman-years 1

2. Contraindications:

   • Women over 35 who smoke
   • History of VTE, stroke, or myocardial infarction
   • Uncontrolled hypertension
   • Migraine with aura 2

Enhanced Treatment Options

For severe or resistant acne:

• The combination of drospirenone-containing COCs with spironolactone 100mg daily has shown excellent efficacy (85% of patients completely clear or with excellent improvement) without significant adverse effects 5
• This combination provides enhanced anti-androgenic effects 3

Treatment Algorithm

1. First-line for mild-moderate acne in women desiring contraception:

   • Drospirenone-containing COC (e.g., ethinyl estradiol 20-30μg/drospirenone 3mg)

2. For women with VTE risk factors:

   • Norgestimate-containing COC (lower VTE risk than drospirenone) 6

3. For severe or resistant acne:

   • Consider adding spironolactone 100mg daily to drospirenone-COC 5

4. For women with contraindications to estrogen:

   • Consider non-hormonal acne treatments (topical retinoids, benzoyl peroxide)
   • Avoid progestin-only contraceptives as they may worsen acne 1

Common Pitfalls

• Inadequate treatment duration: COCs typically require 3-6 months for maximum acne improvement
• Ignoring VTE risk factors: Always assess cardiovascular risk before prescribing
• Using progestin-only methods: These may worsen acne 1
• Stopping too early: Continue treatment for maintenance after improvement
• Failure to combine with topical treatments: COCs work best as part of a comprehensive acne regimen 3

Remember that COCs should only be prescribed for acne in women who also desire contraception, as specified in the FDA approval 1, 2.