What are the treatment options for acne caused by Nexplanon (etonogestrel)?

Treatment of Nexplanon-Induced Acne

For acne caused by Nexplanon (etonogestrel implant), switch to a combined oral contraceptive containing drospirenone (ethinyl estradiol 30 mcg/drospirenone 3 mg) and initiate topical retinoid therapy with benzoyl peroxide. 1, 2

Understanding the Problem

Nexplanon is a progestin-only contraceptive that can trigger or worsen acne through androgenic stimulation of sebaceous glands, even at low doses. 3 This occurs because:

• Progestin-only contraceptives lack the protective anti-androgenic effects of estrogen and may worsen acne 1
• Etonogestrel implants have been documented to cause severe acne vulgaris within weeks to months after insertion 3
• The androgenic activity stimulates sebaceous glands, leading to increased acne lesions 3

Primary Treatment Strategy: Switch Contraceptive Method

Remove the Nexplanon implant and transition to a combined oral contraceptive (COC) with proven anti-acne efficacy. 1, 3

First-Line COC Choice

• Drospirenone-containing COC (ethinyl estradiol 30 mcg/drospirenone 3 mg) is the optimal choice for women with contraceptive-induced acne who still desire contraception 1
• This formulation is FDA-approved specifically for acne treatment and provides superior anti-androgenic effects 1
• Drospirenone minimizes the potential negative androgenic effects that other progestins may have on acne 4

Alternative COC Options

If drospirenone is contraindicated or not tolerated:

• Norgestimate-containing COCs (ethinyl estradiol/norgestimate) 1
• Norethindrone acetate-containing COCs (ethinyl estradiol/norethindrone acetate/ferrous fumarate) 1
• All COCs have net anti-androgenic effects when combined with estrogen, regardless of progestin type 1

COC Contraindications to Screen For

Do not prescribe COCs if the patient has: 1

• Current or history of deep vein thrombosis or pulmonary embolism
• Current breast cancer or estrogen/progestin-sensitive cancers
• Severe liver disease or hepatic tumors
• Uncontrolled hypertension
• Smoking if ≥35 years of age
• Migraine with aura at any age, or migraine without aura if ≥35 years
• Pregnancy

Concurrent Topical Acne Therapy

Initiate topical combination therapy immediately upon switching contraceptives to provide more rapid acne improvement. 1, 2

First-Line Topical Regimen

• Topical retinoid (adapalene 0.1-0.3% or tretinoin 0.025-0.1%) PLUS benzoyl peroxide 2.5-5% applied once daily in the evening 2, 5
• Start application every other day initially to minimize irritation, then advance to daily use as tolerated 5
• Topical retinoids address comedone formation and inflammation while benzoyl peroxide reduces bacterial colonization 5

For Moderate-to-Severe Inflammatory Acne

If significant inflammatory lesions (papules, pustules, nodules) are present:

• Add oral doxycycline 100 mg daily for 3-4 months maximum in combination with topical retinoid and benzoyl peroxide 2, 5
• Always combine oral antibiotics with benzoyl peroxide to prevent bacterial resistance 2, 5
• Never use antibiotics as monotherapy 2, 5

Alternative Hormonal Option: Spironolactone

If the patient cannot or prefers not to use COCs, spironolactone 50-100 mg daily is an effective alternative. 1

• Spironolactone has potent anti-androgenic activity and can be used as monotherapy or adjunctive therapy 1
• 66% of women achieve clear or markedly improved skin with spironolactone 1
• Routine potassium monitoring is not required in young, healthy women without risk factors for hyperkalemia 1
• Can be combined with COCs for severe cases: one study showed 85% of women with severe acne achieved clearance or excellent improvement using both spironolactone 100 mg daily and drospirenone-containing COC 6

Timeline for Improvement

Counsel patients that visible acne improvement requires 3-6 months of hormonal therapy. 1

• Statistically significant improvement becomes evident by cycle 3 (approximately 3 months) with COCs 1
• Early combination with topical medications provides more immediate benefit during this initial period 1
• Common COC side effects (breakthrough bleeding, nausea, breast tenderness) typically resolve within 2-3 cycles, often before acne improvement becomes apparent 1

Monitoring and Follow-Up

• Measure blood pressure before initiating COCs 1
• Follow-up at 3 months to assess initial response and side effects 1
• Follow-up at 6 months to assess maximal benefit 1
• If using spironolactone, consider baseline potassium level and repeat at 4-6 weeks only if risk factors for hyperkalemia exist 1, 6

Critical Pitfalls to Avoid

• Never continue progestin-only contraceptives (like Nexplanon) in patients with worsening acne 1
• Do not use topical or oral antibiotics as monotherapy—always combine with benzoyl peroxide 2, 5
• Do not extend oral antibiotics beyond 3-4 months without re-evaluation 2
• Do not withhold COCs from appropriate candidates due to misconceptions about antibiotic interactions 1

Maintenance After Clearance

• Continue topical retinoid therapy indefinitely after achieving clearance to prevent recurrence 2
• Benzoyl peroxide can be continued as maintenance therapy 2
• Continue hormonal therapy (COC or spironolactone) as long as contraception is desired or hormonal acne control is needed 1