What is the best treatment for hormonal acne?

Best Treatment for Hormonal Acne

For hormonal acne, combined oral contraceptives (COCs) containing drospirenone are the first-line treatment option for women who also desire contraception, while spironolactone is the preferred treatment for women who do not need contraception. 1, 2

First-Line Treatment Options

Combined Oral Contraceptives (COCs)

• FDA-approved COCs for acne treatment include:

  • Drospirenone-containing pills (e.g., Yaz/Yasmin) - strongest antiandrogenic properties 2, 3, 4
  • Norgestimate-containing pills (e.g., Ortho Tri-Cyclen) 2, 3
  • Norethindrone acetate-containing pills (e.g., Estrostep Fe) 2, 3

• Mechanism of action:

  • Decrease ovarian androgen production 2
  • Increase sex hormone-binding globulin, reducing free testosterone 2
  • Reduce 5α-reductase activity 2
  • Block androgen receptor activation 2

• Clinical considerations:

  • Acne improvement typically takes 3-6 months 1
  • Can be used alone or in combination with other acne treatments 1
  • Beneficial for women with or without clinical signs of hyperandrogenism 1

Spironolactone

• Mechanism: Aldosterone receptor antagonist with potent antiandrogen activity 1

• Dosage: 50-100 mg daily is effective with favorable tolerability 1

• Benefits:

  • 66% of women achieve clear or markedly improved skin 1
  • Can be used as monotherapy or adjunctive therapy 1
  • Can be safely combined with drospirenone-containing COCs 1

• Safety considerations:

  • Routine potassium monitoring not required in young, healthy women without risk factors for hyperkalemia 1
  • Has black box warning due to animal studies, but multiple large cohort studies have not confirmed increased cancer risk in clinical practice 1

Treatment Algorithm

For Women Desiring Contraception:

1. First choice: Drospirenone-containing COC (e.g., Yaz/Yasmin) 2, 3
2. Alternative options:
   • Norgestimate-containing COC (e.g., Ortho Tri-Cyclen) 2, 3
   • Norethindrone acetate-containing COC (e.g., Estrostep Fe) 2, 3
3. For inadequate response after 3-6 months: Add spironolactone 50-100 mg daily 1

For Women Not Desiring Contraception:

1. First choice: Spironolactone 50-100 mg daily 1
2. For inadequate response: Consider adding topical treatments (retinoids, benzoyl peroxide) 1

Topical Treatment Options

• Can be used as adjuncts to hormonal therapy:
  • Topical retinoids (adapalene, tretinoin) 1
  • Benzoyl peroxide 1
  • Fixed-dose combinations of retinoids with benzoyl peroxide 1
  • Clascoterone (topical antiandrogen) 1

Important Safety Considerations

COC Contraindications:

• History of deep vein thrombosis or pulmonary embolism 2, 4
• Uncontrolled hypertension 4
• Smoking in women over 35 years 4
• Current breast cancer 4
• Severe liver disease 4
• Migraine with aura 2, 4

Venous Thromboembolism (VTE) Risk:

• Baseline risk (non-pregnant, non-COC users): 1-5 per 10,000 woman-years 2
• Risk with standard COCs: 3-9 per 10,000 woman-years 2
• 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

Common Pitfalls to Avoid:

• Avoid progestin-only contraceptives as they may worsen acne 1, 2
• Don't expect immediate results with hormonal therapy; improvement takes 3-6 months 1
• Don't withhold COCs from appropriate candidates due to misconceptions about antibiotic interactions - only rifampin and griseofulvin reduce COC effectiveness 1
• Don't routinely monitor potassium in young, healthy women on spironolactone without risk factors for hyperkalemia 1

Monitoring and Follow-up

• For COCs: Blood pressure measurement before initiation 1, 2
• For spironolactone: Consider potassium monitoring only in patients with risk factors for hyperkalemia (renal insufficiency, heart failure, concomitant medications like ACE inhibitors) 1
• Follow-up at 3 months to assess initial response and side effects 1
• Assess for maximal benefit at 6 months 1