What is the recommended dose of Aldactone (spironolactone) for acne in females?

Dosing of Spironolactone for Acne in Females

The recommended dose of spironolactone for acne in females is 25-200mg daily, typically starting at 100mg daily in the evening. 1

Dosing Algorithm

• Initial dose: 100mg daily in the evening 1
• Duration before assessing response: Several months (typically 3-6 months) 1
• Dose adjustment:
  • If inadequate response at 100mg daily, can increase to 150mg daily 1
  • If still inadequate, can further increase to 200mg daily 1
  • For patients concerned about side effects, can start at lower doses (25-50mg daily) 2

Efficacy by Dose

• 100mg daily: 84% of patients show initial improvement, with 40% achieving complete clearance 1
• 150mg daily: Additional improvement seen in patients who had inadequate response to 100mg 1
• 200mg daily: Further improvement possible, but side effects increase at higher doses 1
• Low dose (25-50mg daily): May be effective when combined with topical treatments like benzoyl peroxide, with 50mg showing significantly higher success rates than placebo 2

Clinical Considerations

• Treatment duration: Median time to initial response is 3 months, with maximum response at 5 months 3
• Efficacy: 85.1% of patients have complete or >50% partial response 3
• Response by acne type: Effective across all severity subtypes, including papulopustular and nodulocystic acne 3
• Long-term use: Median treatment duration of 13 months is well-tolerated 3

Side Effects and Monitoring

• Common side effects:

  • Menstrual irregularities (15-30% of patients) - dose dependent, higher risk at 200mg/day 1, 4
  • Breast tenderness (3-5%) 1, 4
  • Dizziness (3-4%) 1
  • Nausea (2-4%) 1
  • Headache (2%) 1
  • Polyuria (1-2%) 1
  • Fatigue (1-2%) 1

• Monitoring:

  • Routine potassium monitoring is not required in young, healthy women without hypertension, renal, or cardiac disease 1
  • Consider potassium monitoring in older patients or those taking medications that can increase potassium levels (ACE inhibitors, ARBs, NSAIDs, trimethoprim) 1, 4
  • If monitoring is needed: check at baseline, 1-4 weeks after initiation, and after dose increases 4

Important Contraindications

• Significant renal impairment 1, 4
• Hyperkalemia 1, 4
• Addison disease 1
• Pregnancy (Category C) - potential risk of feminization of male fetus 1
• Concomitant use of eplerenone or triamterene 1

Clinical Pearls

• Consider concomitant use of combined oral contraceptives to regulate menses and prevent pregnancy 1
• Spironolactone can be safely used with drospirenone-containing oral contraceptives without increased risk of hyperkalemia 1
• Despite the black box warning about potential carcinogenicity (based on animal studies using doses 100+ times greater than clinical doses), large cohort studies with over 30 million person-years of follow-up have not confirmed such risks 1, 4
• Spironolactone is compatible with breastfeeding with minimal risk to the infant 1
• Not typically used in men due to risk of feminization 5