Oral Contraceptives for Acne Treatment
Yes, oral birth control pills (combined oral contraceptives or COCs) are effective in treating acne in women, with multiple randomized controlled trials showing significant reductions in both inflammatory and non-inflammatory acne lesions compared to placebo. 1
Mechanism of Action
COCs help treat acne through several anti-androgenic mechanisms:
- Decrease androgen production at the ovarian level 1
- Increase sex hormone-binding globulin, which binds free testosterone making it unavailable to activate androgen receptors 1, 2
- Reduce 5-alpha-reductase activity, decreasing conversion of testosterone to the more potent dihydrotestosterone 1, 2
- Block androgen receptor activation in the skin 1, 2
FDA-Approved COCs for Acne
Four COCs are specifically FDA-approved for acne treatment in women who also desire contraception:
- Ethinyl estradiol/norgestimate 1, 2
- Ethinyl estradiol/norethindrone acetate/ferrous fumarate 1, 2
- Ethinyl estradiol/drospirenone 1, 2
- Ethinyl estradiol/drospirenone/levomefolate 1, 2
Efficacy
- Multiple randomized controlled trials consistently demonstrate that COCs reduce acne lesion counts (both inflammatory and non-inflammatory) compared to placebo 1, 3
- Significant improvement is typically seen by the end of cycle 3 (approximately 3 months of use) 1
- A 2012 Cochrane meta-analysis of 31 trials with 12,579 women confirmed that all studied COCs effectively reduced acne compared to placebo 1, 3
- COCs can be used alone for mild acne or in combination with other acne treatments for moderate to severe acne 1, 4
Clinical Considerations
- COCs may be beneficial for women with or without clinical signs of hyperandrogenism 1
- Women should be informed that acne improvement may not be noticeable for the first few months of treatment 1
- COCs can be safely combined with other acne treatments including topical agents and oral antibiotics 1
- Common misconception: tetracycline antibiotics (frequently used for acne) do NOT reduce contraceptive efficacy when taken with COCs 1
- Only rifampin and griseofulvin are known to interact with COCs and reduce their effectiveness 1
Safety Considerations
- Baseline risk of venous thromboembolism (VTE) in non-pregnant, non-COC users: 1-5 per 10,000 woman-years 1, 2
- VTE risk with standard COCs: 3-9 per 10,000 woman-years 1, 2
- VTE risk with drospirenone-containing COCs: approximately 10 per 10,000 woman-years 1, 2
- For context, pregnancy VTE risk is 5-20 per 10,000 woman-years 1, 2
- COCs should generally be avoided in women under 14 years of age unless clinically warranted 1
- Contraindications include pregnancy, current breast cancer, history of deep vein thrombosis or pulmonary embolism, ischemic heart disease, severe liver disease, and migraine with aura 2, 5
Best Practices
- Obtain a thorough medical history and blood pressure measurement before prescribing COCs 1
- A Papanicolaou smear and bimanual pelvic examination are no longer required before initiating COCs 1
- For women with moderate acne who also desire contraception, drospirenone-containing COCs are often recommended as first-line options due to their anti-androgenic properties 2, 6
- Alternative options include norgestimate-containing and norethindrone acetate-containing COCs 2, 7
- Avoid progestin-only contraceptives as they may worsen acne 2, 7
Additional Benefits
Beyond acne improvement, COCs offer several other benefits: