Spironolactone Acne Treatment

Spironolactone acne treatment is becoming common for many women. Spironolactone, through its anti-androgen properties, targets one of the most important factors contributing to acne. With more than 2 decades in clinical use, oral spironolactone is effective and well-tolerated in adult women suffering from hormonal acne over a prolong period.

Why Spironolactone?

Acne affects more than 85% of adolescent and can persists into adulthood for many women. Acne varies in severity, from mild to severe cystic variants.  Although oral antibiotics are commonly prescribed for acne, they are associated with side effects, antibiotic resistance and acne recurrence. On the other hand, oral isotretinoin is reserved for acne that is not responding to standard treatments or for nodulo-cystic acne.

Many women may not be comfortable taking oral isotretinoin due to the side effects, be poor candidates for it or may have relapsed after a course of therapy. Oral spironolactone is a treatment alternative available for women with long standing acne.

How Does Spironolactone Work For Acne?

Oral spironolactone is a diuretic and has traditionally been in use in medical conditions such as heart failure, hypetension and swelling associated with liver disease. However, over the decades, there has been off-label use of oral spironolactone for several dermatological conditions such as acne, female pattern hair loss and hidradenitis suppurativa.

Oral spironolactone works to improve acne through its anti-androgen properties. This reduces sebum production and hyperkeratinisation in acne associated hair follicles.

Improved clinical outcomes and tolerance of oral spironolactone acne treatment

From studies, it has been shown that more than 66% of individuals treated with oral spironolactone noticed an improvement in their acne appearance. Improvement in acne clearance increased over time with the peak effect taking place between the 4th to 6th month. 

In addition, women with co-existing truncal or back acne had good clearance while on treatment.

Oral spironolactone acne treatment is generally well-tolerated in most women, however most of its side effects are dose related. 

Common side effects (15-30%) include menstrual irregularities. This can be managed with an oral contraceptive or a intra-uterine device if necessary.

Less common side effects (<5%) include breast tenderness, headache, nausea, dizziness, increased frequency of urination and high blood potassium levels.

Oral spironolactone treatment is contraindicated in individuals who have a history of high serum potassium levels, or those at risk of hyperkalaemia. It is also contraindicated with individuals with kidney failure, inability of the kidneys to produce urine and those with significant impairment of kidney function.

It is generally not prescribed for women who are pregnant, who intend to get pregnant and who are breastfeeding.

Drugs that can potentially increase blood potassium levels should not be taken together with oral spironolactone. Some of these include anti-hypertensive medicaltion such as ACE inhibitors, potassium sparing diuretics and anti-inflammatory medicines such as NSAIDS.

Avoid food or supplements rich in potassium, including salt substitutes.

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References:
  1. Roberts EE, Nowsheen S, Davis MD, McEvoy MT, Newman CC, Sartori Valinotti JC, Sciallis GF, Torgerson RR, Wetter DA. Treatment of acne with spironolactone: a retrospective review of 395 adult patients at Mayo Clinic, 2007–2017. Journal of the European Academy of Dermatology and Venereology. 2020 Sep;34(9):2106-10.
  2. Garg V, Choi JK, James WD, Barbieri JS. Long-term use of spironolactone for acne in women: A case series of 403 patients. Journal of the American Academy of Dermatology. 2021 May 1;84(5):1348-55. 
  3. Han JJ, Faletsky A, Barbieri JS, Mostaghimi A. New acne therapies and updates on use of spironolactone and isotretinoin: a narrative review. Dermatology and Therapy. 2021 Feb;11(1):79-91.