Best Oral Contraceptives for Acne Treatment
For women seeking both acne treatment and contraception, drospirenone-containing combined oral contraceptives (COCs) are the most effective option for treating acne due to their potent anti-androgenic properties. 1
Mechanism of Action of COCs in Acne
COCs treat acne through several anti-androgenic mechanisms:
- Decrease androgen production at the ovarian level 2
- Increase sex hormone-binding globulin, binding free testosterone and making it unavailable to activate androgen receptors 2
- Reduce 5-alpha-reductase activity 2
- Block androgen receptor activation 2
FDA-Approved COCs for Acne Treatment
Four COCs are currently FDA-approved for acne treatment in women who also desire contraception:
- Ethinyl estradiol/norgestimate 2
- Ethinyl estradiol/norethindrone acetate/ferrous fumarate 2
- Ethinyl estradiol/drospirenone 2, 3
- Ethinyl estradiol/drospirenone/levomefolate 2
Evidence for Effectiveness
- Drospirenone-containing COCs have shown significant reductions in inflammatory, non-inflammatory, and total acne lesions compared to placebo 2, 4
- A recent study demonstrated that drospirenone 3 mg/ethinyl estradiol 20 μg in a 24/4 regimen reduced total acne lesions by 46.3% compared to 30.6% with placebo (p<0.001) 4
- Patients using drospirenone-containing COCs were three times more likely to have "clear" or "almost clear" skin compared to placebo (odds ratio 3.13,95% CI 1.69-5.81; p=0.001) 4
- A 2012 Cochrane meta-analysis of 31 trials with 12,579 women found that all COCs evaluated were effective in reducing acne lesions 5
Comparative Effectiveness of Different COCs
- Drospirenone-containing COCs appear to be more effective than those containing norgestimate or nomegestrol acetate 5
- COCs containing chlormadinone acetate or cyproterone acetate showed better acne outcomes than those with levonorgestrel 5
- Cyproterone acetate-containing COCs demonstrated better acne outcomes than those with desogestrel in some studies, though results were inconsistent 5
Safety Considerations
Venous Thromboembolism (VTE) Risk
- Baseline VTE risk in non-pregnant, non-COC users: 1-5 per 10,000 woman-years 2
- VTE risk with standard COCs: 3-9 per 10,000 woman-years 2
- VTE risk with drospirenone-containing COCs: approximately 10 per 10,000 woman-years 2
- For context, pregnancy VTE risk: 5-20 per 10,000 woman-years 2
Other Safety Considerations
- COCs are associated with small increases in myocardial infarction and stroke risks, particularly in women over 35 who smoke 2
- Women with hypertension, diabetes, or migraines with aura have increased cardiovascular risks with COC use 2
- Cigarette smoking significantly increases cardiovascular risks with COC use, particularly in women over 35 years of age 3
Clinical Decision Algorithm
First-line option: Drospirenone-containing COCs for women with moderate acne who also desire contraception 1, 6
- Drospirenone 3 mg/ethinyl estradiol 20-30 μg is particularly effective 4
Alternative options if drospirenone is contraindicated:
Avoid: Progestin-only contraceptives as they may worsen acne 2
Important Clinical Pearls
- COCs should only be used for acne in women who also desire contraception 2, 3
- A comprehensive medical history and blood pressure measurement should be performed before prescribing COCs 2
- Acne improvement with COCs takes time, with statistically significant improvements typically seen after 3 months of treatment 2
- COCs may be used in combination with other acne treatments, including topical medications and oral antibiotics 2
- The tetracycline class of antibiotics does not reduce the effectiveness of COCs when taken concomitantly 2
- For severe acne, combination therapy with spironolactone (100 mg daily) and a drospirenone-containing COC has been shown to be effective and well-tolerated without significant elevation of serum potassium 7