What is the recommended dosage of spironolactone (spirolactone) for acne treatment?

Recommended Dosage of Spironolactone for Acne Treatment

The American Academy of Dermatology recommends an initial dose of 100mg daily of spironolactone for female patients with acne, with the option to increase to 150mg daily if there is an inadequate response, and further to 200mg daily if necessary. 1

Dosing Algorithm

• Start with 100mg daily in the evening for females with acne 1
• Evaluate response after 3-6 months of treatment 1
• If inadequate response, increase to 150mg daily 1
• May further increase to 200mg daily if necessary, though side effects become more common at this dose 1, 2
• Lower doses of 50mg daily may be effective for some patients, particularly when combined with topical treatments like benzoyl peroxide 3

Efficacy by Dose

• At 100mg daily, approximately 84% of patients show initial improvement, with 40% achieving complete clearance 1
• In a large retrospective study of 395 patients, 66.1% had complete response and 85.1% had at least 50% improvement at a median dose of 100mg daily 4
• Increasing to 150-200mg daily may provide additional benefit for those with inadequate response to lower doses 1, 2
• A recent randomized controlled trial showed that even 50mg daily (increased to 100mg after 6 weeks) was significantly more effective than placebo for improving acne-specific quality of life 5

Side Effects and Monitoring

• Menstrual irregularities are common (15-30% of patients) and dose-dependent, with higher risk at 200mg daily 1, 2
• Other common side effects include:
  • Breast tenderness (3-5%) 2
  • Dizziness (3-4%) 2
  • Nausea (2-4%) 2
  • Headaches (2%) 2, 5
  • Polyuria and fatigue (1-2%) 2
• Routine potassium monitoring is not required in young, healthy women without risk factors 6, 1, 2
• Consider potassium monitoring in:
  • Older patients 6, 1
  • Patients with medical comorbidities (hypertension, diabetes, chronic kidney disease) 6, 2
  • Patients taking medications affecting renal, adrenal, or hepatic function (ACE inhibitors, ARBs, NSAIDs, digoxin) 6, 2
• Advise patients to avoid foods high in potassium 6

Important Considerations

• Spironolactone is not FDA-approved for acne treatment 6
• Concomitant use of combined oral contraceptives (COCs) is recommended to:
  • Regulate menses 6, 2
  • Prevent pregnancy (spironolactone is pregnancy category C) 6, 2
  • Reduce menstrual irregularities 2, 7
• Spironolactone can be safely used with drospirenone-containing COCs without increased risk of hyperkalemia 6, 2
• Treatment duration is typically long-term, with a median of 13 months in one large study 4
• Response to treatment may take several months, with median time to initial response of 3 months and maximum response of 5 months 4

Contraindications

• Pregnancy (risk of feminization of male fetus) 6, 2
• Significant renal impairment 1, 2
• Hyperkalemia 1, 2
• Addison's disease 1, 2
• Concomitant use of eplerenone or triamterene 1, 2