What is the best birth control for acne?

Best Birth Control for Acne

Combined oral contraceptives (COCs) containing drospirenone are the most effective birth control option for treating acne due to their strong anti-androgenic properties. 1

Mechanism of Action of COCs for Acne

COCs treat acne through several anti-androgenic mechanisms:

• Decrease ovarian androgen production 1
• Increase sex hormone-binding globulin, reducing free testosterone 1
• Reduce 5α-reductase activity 1
• Block androgen receptor activation 1

FDA-Approved COCs for Acne Treatment

Four COCs are FDA-approved specifically for acne treatment in women who also desire contraception:

• Ethinyl estradiol/norgestimate 1
• Ethinyl estradiol/norethindrone acetate/ferrous fumarate 1
• Ethinyl estradiol/drospirenone 1, 2
• Ethinyl estradiol/drospirenone/levomefolate 1

Comparative Efficacy of COCs for Acne

Drospirenone-Containing COCs

• Drospirenone is a fourth-generation progestin with unique properties:
  • Spironolactone analogue not derived from testosterone 1
  • Has inherent anti-androgenic properties 1
  • Clinical trials show superior efficacy for total lesion count reduction compared to other COCs 3
  • Investigators' assessments showed clearer skin with drospirenone (OR 3.02; 95% CI 1.99 to 4.59) 4

Other COC Options

• Norgestimate-containing COCs showed significant reduction in total lesion counts (MD -9.32; 95% CI -14.19 to -4.45) 4, 5
• Norethindrone acetate COCs demonstrated better clinician global assessment of acne improvement (OR 1.86; 95% CI 1.32 to 2.62) 4
• Comparative studies suggest drospirenone may be more effective than norgestimate but less effective than cyproterone acetate (not available in US) 4, 6

Safety Considerations

Venous Thromboembolism (VTE) Risk

• Baseline VTE risk in non-pregnant, non-COC users: 1-5 per 10,000 woman-years 1
• VTE risk with standard COCs: 3-9 per 10,000 woman-years 1
• VTE risk with drospirenone-containing COCs: approximately 10 per 10,000 woman-years 1
• For context, pregnancy VTE risk: 5-20 per 10,000 woman-years 1

Other Safety Considerations

• COCs are associated with small increases in myocardial infarction and stroke risks, particularly in:
  • Women over 35 who smoke 1
  • Women with hypertension, diabetes, or migraines 1
• Contraindications include:
  • Pregnancy 1
  • Current breast cancer 1
  • History of deep vein thrombosis or pulmonary embolism 1
  • Ischemic heart disease 1
  • Severe liver disease 1
  • Migraine with aura at any age or without aura if ≥35 years 1

Clinical Decision Algorithm

1. First-line option: Drospirenone-containing COCs (e.g., ethinyl estradiol/drospirenone) for women with moderate acne who also desire contraception 1, 2, 3

2. Alternative options if drospirenone is contraindicated or not tolerated:

   • Norgestimate-containing COCs 1, 5
   • Norethindrone acetate-containing COCs 1, 4

3. Avoid: Progestin-only contraceptives (pills, injections, IUDs, implants) as these may worsen acne 1

Monitoring and Expectations

• Improvement typically begins after 3 months of treatment 4
• Maximum benefit may take up to 6 months 2, 4
• Common side effects include:
  • Headache/migraine (6.7%) 2
  • Menstrual irregularities (4.7%) 2
  • Nausea/vomiting (4.2%) 2
  • Breast pain/tenderness (4%) 2
  • Mood changes (2.2%) 2

Important Caveats

• COCs should only be used for acne in women who also desire contraception 2, 1
• A comprehensive medical history and blood pressure measurement should be performed before prescribing 1
• Progestin-only contraceptives may worsen acne and should be avoided 1
• All COCs have a net anti-androgenic effect when combined with estrogen, regardless of progestin type 1