Progestin-Only Pills Should Not Be Used for Acne Treatment
Progestin-only pills (POPs) are contraindicated for acne treatment and may actually worsen acne symptoms. The American Academy of Dermatology explicitly recommends avoiding progestin-only contraceptives as they consistently worsen acne 1.
Why Progestin-Only Pills Worsen Acne
The mechanism behind this adverse effect is straightforward:
- POPs lack the estrogen component that is essential for acne improvement 1, 2
- Estrogen is necessary to suppress ovarian androgen production and increase sex hormone-binding globulin (SHBG), which reduces free testosterone levels 1
- Without estrogen, the progestin component can have unopposed androgenic effects that exacerbate acne 2
What Should Be Used Instead
For women desiring contraception who also have acne, combined oral contraceptives (COCs) containing both estrogen and progestin are the appropriate choice:
First-Line Recommendation
- Drospirenone-containing COCs (ethinyl estradiol 20-30 mcg/drospirenone 3 mg) are the preferred first-line option 1
- These demonstrate superior anti-androgenic effects compared to other formulations 1
- Expect visible improvement in 3-6 months, with statistically significant changes by cycle 3 1
Alternative FDA-Approved Options
If drospirenone is contraindicated or not tolerated:
- Ethinyl estradiol/norgestimate (Ortho Tri-Cyclen) 1
- Ethinyl estradiol/norethindrone acetate/ferrous fumarate 1
For Women Not Desiring Contraception
- Spironolactone 50-100 mg daily is the preferred treatment 1
- This provides potent antiandrogen activity without the need for hormonal contraception 1
Critical Safety Screening
Before prescribing any COC, screen for absolute contraindications 1:
- Current or history of deep vein thrombosis or pulmonary embolism
- Current breast cancer or estrogen/progestin-sensitive cancers
- Severe liver disease, hepatic dysfunction, or liver tumors
- Uncontrolled hypertension
- Smoking if ≥35 years of age
- Migraine with aura at any age, or migraine without aura if ≥35 years
- Ischemic heart disease
Common Pitfall to Avoid
The most important caveat: POPs are sometimes prescribed for contraception in women with contraindications to estrogen 3. While they serve an important contraceptive role in selected patients with excellent medication adherence 3, they should never be chosen specifically for acne treatment or prescribed to women whose primary concern is acne management 1, 2.