Treatment of Acne Caused by Birth Control
Direct Answer
If birth control is causing acne, switch to a combined oral contraceptive containing drospirenone (3 mg drospirenone with 20 or 30 mcg ethinyl estradiol), which is FDA-approved specifically for acne treatment and demonstrates superior anti-androgenic effects compared to other formulations. 1, 2
Understanding the Problem
Acne caused by hormonal birth control typically occurs with progestin-only contraceptives (depot injections, subdermal implants, hormonal IUDs, and progestin-only pills), which consistently worsen acne due to their androgenic effects without the counterbalancing estrogen component. 1, 3, 4
Treatment Algorithm
Step 1: Identify the Culprit Contraceptive
Contraceptives that worsen acne:
- Depot medroxyprogesterone acetate injections (Depo-Provera) 3, 5
- Subdermal implants (Nexplanon) 3, 4
- Hormonal intrauterine devices (Mirena, Skyla) 3, 4
- Progestin-only pills 1, 4
- Combined oral contraceptives containing levonorgestrel or norethindrone (less anti-androgenic progestins) 3
Step 2: Switch to First-Line Treatment
Prescribe drospirenone-containing combined oral contraceptives as first-line therapy:
- Yaz (ethinyl estradiol 20 mcg/drospirenone 3 mg in 24/4 regimen) 1, 2
- Yasmin (ethinyl estradiol 30 mcg/drospirenone 3 mg in 21/7 regimen) 1, 2
Mechanism: Drospirenone has unique anti-androgenic properties that decrease ovarian androgen production, increase sex hormone-binding globulin (reducing free testosterone by 40-50%), reduce 5α-reductase activity, and block androgen receptor activation. 1, 6, 7
FDA approval: Drospirenone/ethinyl estradiol is specifically FDA-approved for treatment of moderate acne vulgaris in women at least 14 years of age who desire oral contraception. 2
Step 3: Alternative FDA-Approved Options (If Drospirenone Contraindicated)
If drospirenone cannot be used due to contraindications (see below), consider these FDA-approved alternatives in order of preference:
- Ortho Tri-Cyclen (ethinyl estradiol/norgestimate) - second-line choice with demonstrated efficacy in reducing total lesion counts 1, 8
- Estrostep Fe (ethinyl estradiol/norethindrone acetate/ferrous fumarate) - shows benefit for clinician global assessment of acne 1, 8
Evidence hierarchy: Patient-reported outcomes show drospirenone > norgestimate and desogestrel > levonorgestrel and norethindrone for acne improvement. 3
Critical Timeline Expectations
Counsel patients explicitly that visible improvement requires 3-6 months:
- Statistically significant improvement becomes evident by the end of cycle 3 (approximately 3 months) 1, 9
- Assess maximal benefit at 6 months 1, 9
- Common side effects (breakthrough bleeding, nausea, breast tenderness) typically resolve within the first 2-3 cycles, often before acne improvement becomes apparent 1
Bridge therapy during initial months:
- Continue or add topical treatments (retinoids, benzoyl peroxide, or fixed-dose combinations) during the first 2-3 months to provide more immediate benefit while waiting for hormonal effects to develop 10, 1
Combination Topical Therapy
Initiate concurrently with hormonal switch:
- Topical retinoids (adapalene, tretinoin, or tazarotene) - address comedonal components and are the core of topical acne therapy 10
- Benzoyl peroxide (alone or in fixed combinations with clindamycin or erythromycin) - prevents bacterial resistance and treats inflammatory lesions 10
- Topical dapsone 5% gel - particularly effective in adult females with inflammatory acne 10
Rationale: Combination therapy addresses different aspects of acne pathogenesis and should be used in the majority of patients. 10
Absolute Contraindications to Combined Oral Contraceptives
Screen carefully before prescribing - these are absolute contraindications:
- Renal dysfunction or adrenal insufficiency (specific to drospirenone) 1, 2
- Current or history of deep vein thrombosis or pulmonary embolism 1, 2
- Current breast cancer or estrogen/progestin-sensitive cancers 1, 2
- Severe liver disease, hepatic dysfunction, or liver tumors 1, 2
- Uncontrolled hypertension 1, 2
- Smoking if ≥35 years of age 1, 2
- Migraine with aura at any age, or migraine without aura if ≥35 years 1, 2
- Ischemic heart disease 1, 2
Safety Considerations: VTE Risk in Context
Understand relative risks when counseling patients:
- Baseline VTE risk (non-pregnant, non-COC users): 1-5 per 10,000 woman-years 1
- Standard COCs: 3-9 per 10,000 woman-years 1
- Drospirenone-containing COCs: approximately 10 per 10,000 woman-years 1
- Pregnancy: 5-20 per 10,000 woman-years 1
- Postpartum (within 12 weeks): 40-65 per 10,000 woman-years 1
Clinical implication: While drospirenone has slightly higher VTE risk than other COCs, the absolute risk remains low and is lower than pregnancy itself. 1
Required Pre-Treatment Evaluation
Before prescribing combined oral contraceptives:
- Comprehensive medical history focusing on VTE risk factors, cardiovascular disease, migraine characteristics, liver disease, and smoking status 1
- Blood pressure measurement (mandatory) 1
- Pregnancy test 1
- For drospirenone specifically: baseline potassium level if patient has risk factors for hyperkalemia (renal insufficiency, heart failure, concomitant ACE inhibitors) 1, 2
Monitoring: Potassium recheck at 4-6 weeks after starting drospirenone only in patients with risk factors; routine monitoring is not required in young, healthy women. 1
Common Pitfalls to Avoid
Do not continue progestin-only contraceptives while treating acne - these will continue to worsen acne and undermine treatment efforts. 1, 4
Do not switch between combined oral contraceptives prematurely - allow at least 3 months before concluding lack of efficacy, as hormonal effects take time to manifest. 1, 9
Do not prescribe combined oral contraceptives for acne alone - they should only be used in women who also desire contraception. 2
Do not withhold COCs from appropriate candidates due to misconceptions about antibiotic interactions - concomitant use of antibiotics typically prescribed for acne does not impair contraceptive efficacy. 1, 6
If Inadequate Response After 6 Months
Add spironolactone 50-100 mg daily to the drospirenone-containing COC for enhanced anti-androgenic effect. 1
Alternative: Switch to a different FDA-approved COC if drospirenone was not initially used. 1
Referral: Consider dermatology referral for moderate to severe acne not responding to hormonal therapy combined with topical treatments. 6