Can oral contraceptive pills (OCPs) be used to treat acne?

Can Oral Contraceptive Pills Be Used for Acne?

Yes, combined oral contraceptives (COCs) are highly effective for treating acne in women who also desire contraception, with FDA approval for four specific formulations and strong evidence demonstrating significant reductions in both inflammatory and non-inflammatory acne lesions. 1

FDA-Approved Formulations

Four COCs have FDA approval specifically for acne treatment in women who also desire contraception: 1

• Ethinyl estradiol/norgestimate
• Ethinyl estradiol/norethindrone acetate/ferrous fumarate
• Ethinyl estradiol/drospirenone
• Ethinyl estradiol/drospirenone/levomefolate

Critical caveat: FDA approval explicitly requires that COCs be prescribed for acne only in women who also desire contraception. 1 When COCs are used exclusively for acne without contraceptive need, their cardiovascular and thrombotic risks must be weighed against the risks of acne itself, not pregnancy. 1

Mechanism of Action

COCs treat acne through multiple anti-androgenic pathways: 1

• Decrease ovarian androgen production by inhibiting gonadotropin-releasing hormone, FSH, and LH
• Increase sex hormone-binding globulin (SHBG), which binds free testosterone and renders it unavailable to activate androgen receptors
• Reduce 5-alpha-reductase activity, decreasing conversion of testosterone to dihydrotestosterone
• Block androgen receptor activation directly

All COCs produce a net anti-androgenic effect when estrogen and progestin are combined, regardless of the specific progestin type. 1

Evidence of Efficacy

A 2012 Cochrane meta-analysis of 31 trials with 12,579 women demonstrated that all COCs evaluated in placebo-controlled trials effectively reduce both inflammatory and non-inflammatory acne lesions. 1, 2

Specific findings from the 2024 American Academy of Dermatology guidelines: 1

• Greater proportion of patients achieved Investigator Global Assessment (IGA) success with COCs versus placebo (RR 1.45 [1.06,1.97])
• Significant reductions in inflammatory lesion counts (mean difference in percentage change: 15.81% [20.44%, 11.17%])
• Significant reductions in non-inflammatory lesion counts compared to placebo

First-Line Recommendation

Drospirenone-containing COCs are the preferred first-line option for women with moderate acne who also desire contraception. 3 Drospirenone is a fourth-generation progestin with unique anti-androgenic properties (it's a spironolactone analogue) and demonstrates superior efficacy compared to other progestins in head-to-head trials. 1, 3

Alternative FDA-approved options if drospirenone is contraindicated: 3

• Norgestimate-containing COCs (second-line)
• Norethindrone acetate-containing COCs

Critical pitfall: Progestin-only contraceptives (pills, injections, IUDs, implants) may worsen acne and should be avoided. 1, 3

Timeline for Clinical Response

Patients must be counseled that visible acne improvement requires 3-6 months of continuous therapy. 3, 4

• Statistically significant improvement becomes evident by cycle 3 (approximately 3 months) 1, 3
• Acne reduction may not be appreciated during the first few months 1
• Early combination with topical treatments (retinoids, benzoyl peroxide) is appropriate during this initial period to provide more immediate benefit 3

This delayed response occurs because hormonal changes (40-50% reduction in free testosterone) require time to translate into decreased sebum production and visible acne improvement. 3

Safety Considerations and Absolute Contraindications

Before prescribing COCs for acne, screen for absolute contraindications: 3, 5

• Renal impairment or adrenal insufficiency (specific to drospirenone)
• Current or history of deep vein thrombosis (DVT) or pulmonary embolism (PE)
• Current breast cancer or estrogen/progestin-sensitive cancers
• Severe liver disease or hepatic tumors
• Uncontrolled hypertension or hypertension with vascular disease
• Smoking if ≥35 years of age
• Migraine with aura at any age, or migraine without aura if ≥35 years

Venous Thromboembolism (VTE) Risk Context

The absolute VTE risk with COCs remains low despite increased relative risk: 1

• Baseline risk (non-pregnant, non-COC users): 1-5 per 10,000 woman-years
• Standard COC users: 3-9 per 10,000 woman-years
• Drospirenone-containing COC users: approximately 10 per 10,000 woman-years
• For context, pregnancy: 5-20 per 10,000 woman-years
• Postpartum (within 12 weeks): 40-65 per 10,000 woman-years

A Cochrane meta-analysis found that COCs containing drospirenone, desogestrel, gestodene, or cyproterone acetate have 50-80% higher VTE risk than levonorgestrel-containing COCs. 1 However, the increased relative risk still translates to low absolute risk in women of reproductive age. 1

Cardiovascular Risk

Myocardial infarction and stroke risks are increased in COC users, but remain low in healthy women without risk factors. 1

• Risk is strongly associated with cigarette smoking, diabetes, hypertension, and age ≥35 years
• WHO reports no increased MI risk in healthy, normotensive, nondiabetic nonsmokers at any age 1

Other Safety Considerations

• Small increased risk of breast cancer in current users (RR 1.24 [95% CI 1.15-1.33]), which disappears 10 years after discontinuation 1
• Hyperkalemia risk with drospirenone due to mild potassium-sparing diuretic effects 5

Baseline Monitoring and Follow-Up

Before initiating COCs: 3, 6

• Comprehensive medical history focusing on VTE risk factors and contraindications
• Blood pressure measurement
• Pregnancy test
• Baseline potassium level (for drospirenone formulations, though routine monitoring is not required in young, healthy women without risk factors) 3

Follow-up schedule: 3

• 3 months: Assess initial response and side effects
• 6 months: Assess maximal benefit

Comparative Effectiveness Between COC Types

The 2012 Cochrane review found no consistent differences in acne reduction based on COC formulation or dosage when comparing different COCs head-to-head. 1, 2 However, more recent evidence suggests: 1, 3

• Drospirenone-containing COCs may show slightly superior efficacy compared to other progestins
• COCs containing chlormadinone acetate or cyproterone acetate improved acne better than levonorgestrel 2
• All COCs evaluated in placebo-controlled trials effectively reduce acne 1, 2

Integration with Other Acne Treatments

COCs should be combined with topical acne treatments during the initial 2-3 months to provide more immediate benefit while waiting for hormonal effects. 3 Appropriate adjunctive therapies include: 3

• Topical retinoids
• Benzoyl peroxide
• Fixed-dose combinations of retinoids with benzoyl peroxide

Common pitfall: COCs should not be withheld due to misconceptions about antibiotic interactions. Only rifampin and griseofulvin reduce COC effectiveness. 6

When COCs Are Not Appropriate

Do not prescribe COCs for acne in: 1, 3

• Women who do not desire contraception (unless risks of acne justify COC risks)
• Women with any absolute contraindications listed above
• Women considering progestin-only contraceptives (these may worsen acne)

For women with acne who do not need contraception, spironolactone 50-100 mg daily is the preferred hormonal treatment option. 3