What is the treatment for hormonal cystic acne?

Treatment for Hormonal Cystic Acne

Spironolactone at doses of 50-100 mg/day is the recommended first-line treatment for hormonal cystic acne in women, showing significant improvement in acne severity and quality of life compared to placebo. 1

Hormonal Treatment Options

Spironolactone

• Spironolactone is an aldosterone receptor antagonist with potent antiandrogen activity that decreases testosterone production and competitively inhibits binding of testosterone and dihydrotestosterone to androgen receptors in the skin 1
• Dosing typically starts at 50-100 mg daily, with effectiveness demonstrated in recent clinical trials 1
• In a large retrospective review of 395 patients, approximately two-thirds (66.1%) had a complete response to spironolactone, with 85.1% having at least a partial response greater than 50% 2
• Efficacy was observed across all severity subtypes of acne, including papulopustular and nodulocystic forms 2
• Median time to initial response is approximately 3 months, with maximum response typically seen at 5 months 2

Monitoring and Side Effects

• Common side effects include menstrual irregularities (15-30%), breast tenderness (3-5%), dizziness (3-4%), nausea (2-4%), and headache (2%) 1
• Potassium monitoring is not routinely required in young, healthy women without risk factors for hyperkalemia 1
• Potassium monitoring should be considered in older patients and those with medical comorbidities such as hypertension, diabetes mellitus, chronic kidney disease, or those taking medications affecting renal function 1
• Spironolactone should not be used during pregnancy due to potential risk of feminization of male fetuses 1

Combined Oral Contraceptives (COCs)

• COCs are effective for hormonal acne and may be used alone or in combination with spironolactone 1
• They decrease free testosterone by 40-50% and reduce the conversion of testosterone to dihydrotestosterone in the pilosebaceous unit 1
• COCs containing drospirenone may be particularly effective for acne compared to other formulations 1
• Acne improvement with COCs typically takes 3 months to become apparent 1
• COCs can be safely combined with spironolactone, even those containing drospirenone, without significant risk of hyperkalemia in healthy women 1, 3

Monitoring and Side Effects

• Common side effects include breakthrough bleeding, nausea, and breast tenderness, which typically resolve within 2-3 cycles 1
• More serious but rare adverse effects include thromboembolic events, with risk of venous thromboembolism increasing from approximately 2 per 10,000 person-years in non-users to 6 per 10,000 person-years in COC users 1
• A thorough medical history and blood pressure measurement are important before prescribing COCs 1

Isotretinoin for Severe Cases

• Oral isotretinoin is FDA-approved for severe recalcitrant nodular acne vulgaris 1
• It reduces sebaceous gland size and secretion, decreases C. acnes indirectly, normalizes keratinocyte keratinization, and has anti-inflammatory properties 1
• Clinical trials show significant improvement across various dosages (0.1,0.5, and 1 mg/kg/day) 1
• Should be considered for patients with severe acne or in those who have failed standard treatment with oral or topical therapy 1
• Requires strict pregnancy prevention due to teratogenic effects 1

Treatment Algorithm for Hormonal Cystic Acne

1. First-line (for women): Spironolactone 50-100 mg daily 1

   • Consider adding a COC if contraception is desired or to help regulate menstrual irregularities 1
   • Allow at least 3 months for initial response assessment 2

2. For severe or recalcitrant cases: Consider isotretinoin 1

   • Particularly appropriate for those with scarring acne or who have failed standard treatments 1

3. Topical adjunctive therapy: Consider adding tretinoin cream/gel to be applied once daily before bedtime 4

   • Apply to affected areas after washing face and allowing skin to dry for 20-30 minutes 4
   • May cause initial irritation or flaring of acne in the first few weeks 4

Common Pitfalls and Caveats

• Expecting immediate results: Both spironolactone and COCs require several months of treatment before maximum efficacy is observed 1, 2
• Unnecessary potassium monitoring: Routine potassium monitoring is not required in young, healthy women taking spironolactone for acne 1
• Discontinuing treatment too early: Once acne is controlled, maintenance therapy should be continued as directed by a physician 4
• Concerns about COC and antibiotic interactions: The tetracycline class of antibiotics does not reduce the effectiveness of COCs when taken concomitantly 1
• Overlooking underlying endocrine disorders: Acne may be a feature in endocrine disorders such as polycystic ovary syndrome, Cushing syndrome, and congenital adrenal hyperplasia 5, 6