From the Guidelines
Hormonal cystic acne should be treated with spironolactone (50-200 mg daily) as a first-line option for women, due to its effectiveness in blocking androgen receptors and reducing sebum production, as supported by recent guidelines 1, 2. The treatment of hormonal cystic acne involves a combination of topical and systemic medications.
- Topical treatments include benzoyl peroxide (2.5-10%), retinoids like tretinoin (0.025-0.1%), or adapalene (0.1-0.3%), and antibiotics such as clindamycin.
- Systemic medications include oral contraceptives containing ethinyl estradiol with norgestimate, norethindrone acetate, or drospirenone, which are FDA-approved first-line options.
- Spironolactone is a synthetic 17-lactone steroid that has antagonistic effects on the androgen and progesterone receptors, making it an effective option for women with hormonal cystic acne, as shown in a study published in the Journal of the American Academy of Dermatology 3.
- The starting dose of spironolactone is typically 100mg/day in the evening, with doses up to 200mg/day used in some cases, although side effects increase with higher doses 3.
- Recent guidelines recommend spironolactone as a conditional option for the treatment of acne, with a moderate level of certainty of evidence 2.
- Patients should expect to use these medications for at least 2-3 months before seeing significant improvement, and consistent use is essential for maintaining results.
- It is also important to note that potassium monitoring is not needed in healthy patients taking spironolactone, but consideration should be given to potassium testing for those with risk factors for hyperkalemia 2.
From the FDA Drug Label
The exact mechanism of action of isotretinoin is unknown. Nodular Acne Clinical improvement in nodular acne patients occurs in association with a reduction in sebum secretion The decrease in sebum secretion is temporary and is related to the dose and duration of treatment with isotretinoin, and reflects a reduction in sebaceous gland size and an inhibition of sebaceous gland differentiation.
Isotretinoin is used for the treatment of nodular acne, and it works by reducing sebum secretion, which is associated with clinical improvement in patients with nodular acne.
- The reduction in sebum secretion is temporary and depends on the dose and duration of treatment.
- Isotretinoin can be used for hormonal cystic acne as it reduces sebum secretion, which is a key factor in the development of acne. 4
From the Research
Treatment Options for Hormonal Cystic Acne
- Combined oral contraceptives (COC) are FDA-approved for acne treatment and have generally similar efficacy in treating acne, regardless of brand or dosing 5.
- Spironolactone is an effective acne treatment, particularly for women, and can be used as a first-line treatment with clinical trial data to support its use 5, 6.
- Clascoterone is a safe and effective topical anti-androgen for the treatment of acne in men and women with limited systemic effects on reproductive hormones 5.
- Topical retinoids, such as tretinoin or adapalene, can be used in combination with spironolactone for the treatment of female cyclical acne, showing superior response to retinoids alone in clearance of acne 6.
Considerations for Treatment
- Patient concerns, barriers to care, and individualized care needs should be discussed when considering hormonal therapies for acne treatment 5.
- Potassium monitoring is of low value for patients on spironolactone unless patients have specific risk factors for hyperkalemia 5.
- Hormonal therapies, such as COC or spironolactone, can be used in combination with topical or systemic agents for more severe disease 7.
Emerging Therapies and Uses
- Spironolactone has emerging utility in dermatology beyond acne treatment, including hidradenitis suppurativa, female pattern hair loss, and hirsutism 8.
- Hormonal therapy can be considered as first-line therapy for acne in certain patients, including those with proven ovarian or adrenal hyperandrogenism or recalcitrant acne 9.