What is the best treatment for hormonal acne in adult women?

Best Treatment for Hormonal Adult Female Acne

For adult women with hormonal acne who desire contraception, start with a combined oral contraceptive containing drospirenone 3 mg/ethinyl estradiol (either 20 or 30 mcg); for those not desiring contraception, spironolactone 50-100 mg daily is the preferred first-line treatment. 1

Treatment Algorithm Based on Contraceptive Need

For Women Desiring Contraception

First-line: Drospirenone-containing COC

• Drospirenone 3 mg/ethinyl estradiol (20 or 30 mcg formulation) demonstrates superior anti-androgenic effects compared to other COC formulations 1, 2
• This is FDA-approved specifically for acne treatment in women ≥14 years who have achieved menarche 2
• Drospirenone works through multiple mechanisms: decreasing ovarian androgen production, increasing sex hormone-binding globulin (reducing free testosterone by 40-50%), reducing 5α-reductase activity, and blocking androgen receptor activation 1

If inadequate response after 3-6 months:

• Add spironolactone 50-100 mg daily to the drospirenone-COC 1
• Continue topical retinoid + benzoyl peroxide throughout treatment 1

Alternative COCs if drospirenone is contraindicated:

• Ethinyl estradiol/norgestimate (Ortho Tri-Cyclen) - FDA-approved for acne 1
• Ethinyl estradiol/norethindrone acetate/ferrous fumarate - FDA-approved for acne 1

For Women NOT Desiring Contraception

First-line: Spironolactone

• Start at 50-100 mg daily 1, 3
• 66% of women achieve clear or markedly improved skin 1
• Potent antiandrogen activity effective as monotherapy or adjunctive therapy 1
• Routine potassium monitoring is NOT required in young, healthy women without kidney disease, heart failure, or medications like ACE inhibitors 1, 3

If inadequate response:

• Add topical retinoid (adapalene 0.1-0.3%) + benzoyl peroxide 2.5-5% 1, 4
• Consider topical clascoterone (topical antiandrogen) as adjunct 1

Critical Timeline Expectations

Counsel patients explicitly that visible improvement requires 3-6 months of continuous hormonal therapy 1

• Statistically significant improvement becomes evident by cycle 3 (approximately 3 months) in clinical trials 1
• Early combination with topical treatments (retinoids, benzoyl peroxide) provides more immediate benefit during the first 2-3 months while waiting for hormonal effects 1
• Common COC side effects (breakthrough bleeding, nausea, breast tenderness) typically resolve within 2-3 cycles, often before acne improvement becomes apparent 1

Essential Topical Adjuncts

All hormonal therapy should be combined with topical treatments:

• Topical retinoid (adapalene, tretinoin, or tazarotene) - addresses comedone formation and maintenance 5
• Benzoyl peroxide 2.5-5% - antimicrobial properties and prevents bacterial resistance 5, 3
• Fixed-dose combination products (retinoid + benzoyl peroxide) provide superior efficacy 5, 3
• Never use topical antibiotics as monotherapy due to rapid resistance development 5, 4

Absolute Contraindications to COCs

Do NOT prescribe drospirenone-containing COCs if patient has: 1, 2

• Age ≥35 years AND smoking (increased thrombotic risk)
• 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
• Ischemic heart disease
• Migraine with aura at any age, or migraine without aura if ≥35 years
• Renal dysfunction or adrenal insufficiency (specific to drospirenone)

Pre-Treatment Evaluation

Before prescribing COCs: 1

• Comprehensive medical history focusing on VTE risk factors, cardiovascular disease, migraine characteristics, liver disease, and smoking status
• Mandatory blood pressure measurement
• Pregnancy test

Before prescribing spironolactone: 3

• Baseline potassium level only if risk factors for hyperkalemia present (renal insufficiency, heart failure, concomitant ACE inhibitors/ARBs)

Laboratory Testing for Hormonal Evaluation

Routine endocrinologic testing is NOT recommended for most acne patients 5

Laboratory evaluation IS indicated when patient has acne PLUS signs of hyperandrogenism: 5

• Hirsutism
• Oligomenorrhea or irregular menses
• Androgenic alopecia
• Infertility
• Clitoromegaly
• Truncal obesity

Appropriate hormone screening panel includes: 5

• Free and total testosterone
• Dehydroepiandrosterone sulfate (DHEA-S)
• Luteinizing hormone (LH)
• Follicle-stimulating hormone (FSH)
• Consider 17-hydroxyprogesterone if nonclassic congenital adrenal hyperplasia suspected

Refer to endocrinology if: 5

• Abnormal endocrine testing results
• Persistent concern for underlying hormonal disorder despite normal labs

VTE Risk in Perspective

Understanding relative risks helps informed decision-making: 1

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

When to Consider Isotretinoin

Isotretinoin should be considered for: 5, 4

• Severe acne
• Treatment-resistant moderate acne after 3-4 months of appropriate therapy
• Any acne with scarring or significant psychosocial burden
• Standard dosing: 0.5-1.0 mg/kg/day targeting cumulative dose of 120-150 mg/kg 4
• Monitor liver function tests and lipids only (CBC not needed in healthy patients) 5, 4

Critical Pitfalls to Avoid

Never prescribe progestin-only contraceptives for acne - they consistently worsen acne 1

Do not use topical or oral antibiotics as monotherapy - resistance develops rapidly without concurrent benzoyl peroxide 5, 4

Do not extend oral antibiotics beyond 3-4 months without re-evaluation - dramatically increases resistance risk 4

Do not underestimate severity when scarring is present - warrants more aggressive treatment regardless of lesion count 4

Do not withhold COCs due to misconceptions about antibiotic interactions - appropriate candidates should not be denied therapy 1

Monitoring and Follow-Up

3-month follow-up: 1

• Assess initial therapeutic response
• Evaluate side effects (breakthrough bleeding, nausea, breast tenderness)
• Repeat blood pressure measurement if on COC

6-month follow-up: 1

• Assess maximal benefit
• Decide whether to continue, adjust, or add additional therapy

Maintenance Therapy

After achieving clearance: 4

• Continue topical retinoid monotherapy indefinitely to prevent recurrence
• Benzoyl peroxide can be continued as maintenance
• Continue hormonal therapy (COC or spironolactone) as long as contraception or hormonal regulation is desired