What are the best oral birth control pills (oral contraceptive pills (OCPs)) for a female patient of reproductive age with acne?

Best Oral Birth Control Pills for Acne

For women with acne who also desire contraception, prescribe a combined oral contraceptive containing drospirenone 3 mg with ethinyl estradiol (either 20 or 30 mcg), as this is FDA-approved for acne treatment and demonstrates superior anti-androgenic effects compared to other formulations. 1, 2

FDA-Approved Options (Listed in Order of Preference)

First-Line: Drospirenone-Containing COCs

• Ethinyl estradiol 30 mcg/drospirenone 3 mg (Yasmin) or ethinyl estradiol 20 mcg/drospirenone 3 mg (Yaz) are the preferred first-line options for moderate acne in women who also desire contraception 1, 3, 2
• Drospirenone has unique anti-androgenic properties similar to spironolactone, decreasing ovarian androgen production, increasing sex hormone-binding globulin, reducing 5-alpha-reductase activity, and blocking androgen receptor activation 1, 3
• Clinical trials demonstrate significant reductions in inflammatory, non-inflammatory, and total acne lesions compared to placebo, with drospirenone showing slightly superior efficacy compared to other progestins in head-to-head trials 1, 3, 4

Second-Line: Norgestimate-Containing COCs

• Ethinyl estradiol/norgestimate (Ortho Tri-Cyclen) is FDA-approved for acne and represents the best alternative if drospirenone is contraindicated 1, 3
• Norgestimate has the lowest venous thromboembolism risk among COCs as established by the European Medicine Agency, while maintaining excellent efficacy 5, 6
• Aggregate analysis shows greater than 50% reduction in inflammatory lesions (from 19.0 to 8.2), comedones (from 35.2 to 17.7), and total lesions (from 54.3 to 25.9) 5

Third-Line: Norethindrone Acetate-Containing COCs

• Ethinyl estradiol/norethindrone acetate/ferrous fumarate is FDA-approved for acne treatment and shows better results for clinician global assessment of no acne to mild acne 1, 4

Fourth-Line Option

• Ethinyl estradiol/drospirenone/levomefolate is FDA-approved for acne and provides the added benefit of folate supplementation 1, 3

Critical Timeline Expectations

• Counsel patients that visible improvement requires 3-6 months of continuous therapy, with statistically significant improvement typically evident by the end of cycle 3 (approximately 3 months) 1, 3
• Patients should be explicitly warned that acne reduction may not be appreciated during the first few months to prevent premature discontinuation 3
• Continue or add topical acne treatments (retinoids, benzoyl peroxide) during the first 2-3 months to provide more immediate benefit while waiting for the COC's full hormonal effect 3

Absolute Contraindications (Screen Before Prescribing)

• Current or history of deep vein thrombosis or pulmonary embolism 1, 3
• Current breast cancer or estrogen/progestin-sensitive cancers 1, 3
• Severe liver disease, hepatic dysfunction, or liver tumors 1, 3
• Uncontrolled hypertension 1, 3
• Smoking if ≥35 years of age 1, 3
• Migraine with aura at any age, or migraine without aura if ≥35 years 1, 3
• Renal dysfunction or adrenal insufficiency (specific to drospirenone) 3
• Ischemic heart disease 1, 3

Safety Considerations: VTE Risk in Perspective

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

The slightly elevated VTE risk with drospirenone must be weighed against its superior anti-androgenic efficacy for acne treatment. 1, 3

Required Pre-Treatment Evaluation

• Comprehensive medical history focusing on VTE risk factors, cardiovascular disease, migraine characteristics, liver disease, and smoking status 1, 3
• Blood pressure measurement (mandatory) 1, 3
• Pregnancy test 3
• Baseline potassium level if prescribing drospirenone (though routine monitoring is not required in young, healthy women without kidney, liver, or adrenal disease) 3

Critical Pitfalls to Avoid

• Never prescribe progestin-only contraceptives for acne—they consistently worsen acne 3, 6
• Do not withhold COCs from appropriate candidates due to misconceptions about antibiotic interactions 3
• Do not use COCs exclusively for acne in women who do not desire contraception—FDA approval specifies use only in women who also need contraception 1, 2
• Routine potassium monitoring is not required in young, healthy women on drospirenone without risk factors for hyperkalemia 3

Monitoring Schedule

• Follow-up at 3 months to assess initial response and side effects 3
• Follow-up at 6 months to assess maximal benefit 3
• Common side effects (breakthrough bleeding, nausea, breast tenderness) tend to resolve within the first 2-3 cycles, often before acne improvement becomes apparent 3