Spironolactone: A Highly Effective Treatment for Adult Acne in Women

by

Michael H. Berkson, M.D.

Wouldn’t it be nice if there was an effective and convenient  way to treat acne without the need to rely on potentially irritating topical medications and long term antibiotics?   Well, for many women with adult acne there is, and it consists of a diuretic, or water pill, that’s been used by internists for years to treat  other medical problems. It is readily available, safe, cheap, and most importantly, it works!  It’s called  Spironolactone.  First, some background information.

Unfortunately acne is not only a problem that affects teenagers.  There are many adults, especially women, who suffer from acne in their 20’s, 30’s, and beyond. For about 75% of adults who have acne, it is a continuation of what began during their teen years, but a sizable minority first start to have breakouts in their mid 20’s or later.

Hormones are a potent driver of acne, especially in women, and specifically the androgen hormones testosterone, dihydrotestosterone ( DHT), and DHEAS.  These androgen molecules interact with receptors on the sebaceous (oil) glands causing them to produce sebum, a prerequisite for the formation of acne.

Adult acne in women oftentimes consists of deep seated nodules which tend to form along the lower face and jawline.  These underground lesions represent pockets of intense inflammation that can be painful and slow to heal. The breakouts characteristically flare up a few days to a week or two before the menstrual period corresponding to the spike in circulating androgen hormones from the ovaries and adrenal glands.

Although topical treatments such as combinations of retinoids like Retin-A and Differin, benzoyl peroxide, and sometimes antibiotics may help curtail the breakouts, more often than not, systemic treatment ( oral medication) is required to adequately control this type of acne.

For many decades oral antibiotics have been a mainstay in the treatment of acne when topical treatments are not enough.  They still have an important role in the management of acne including that in adult women, but in recent years dermatologists have sought out other treatments that don’t rely on the long term use of antibiotics.  One of the primary reasons for this is the increasing problem of bacterial resistance. Over time the P. acnes bacteria, a key player in the formation of acne, has become less sensitive, and in some cases, outright resistant to the antibiotics ( primarily clindamycin, tetracycline, doxycycline, and to a lesser extent, minocycline) that were formerly highly effective in most cases of acne.

Additionally it makes sense to target the hormonal component which predominates in adult acne in women.  The birth control pill is one such type of medication that can have a positive effect on a women’s androgen profile, and can thus have a beneficial effect on acne.  The birth control pill works by preventing ovulation and thus limits the output of hormones, including androgens, by the ovaries. It also increases levels of a carrier protein known as sex hormone binding globulin (SHBG) which also results in less circulating androgen.  Less androgen results in less stimulation of the sebaceous glands and less acne. The combination birth control pill  can be very helpful in some women with acne, but in many it is not sufficient as a stand-alone treatment and may need to be combined with topical medications or other systemic treatment.

Then, there is Spironolactone (SPL). That’s a long, hard to pronounce word for a medication that’s been around for nearly half a century!  SPL is a type of water pill known as a potassium sparing diuretic. A diuretic is a class of medication that helps the kidneys rid the body of excess fluid.  SPL is officially used for the treatment of high blood pressure, congestive heart failure, and the fluid accumulation that can sometimes accompany severe liver disease. The diuretic effect, however, is not relevant to how SPL can be useful in acne. SPL works in acne because it is an androgen receptor blocker. It binds to the sites on the sebaceous glands where androgens normally attach and signal the sebaceous glands to make sebum.  The net effect is less sebum, and less acne. SPL also blocks the conversion of testosterone to the more potent DHT which is the most active androgen that acts on sebaceous glands, and this also contributes to less sebum output.

SPL is being used off label with increasing frequency by dermatologists and other health care providers to directly counter  the effects of hormones in women with adult acne. It can be highly effective, and for many it is an excellent alternative to oral antibiotics.   It often works by itself without the need for other treatment such as topical medications. With that, said, SPL can be paired with other treatments if needed,  and it is very compatible with the birth control pill.

SPL is user friendly.  It is inexpensive and can be taken once daily at anytime, although dosing early in the day is recommended.  Taking with food enhances the absorption, but is not required. The usual starting dose is between 50 and 100 mg daily, and can be increased up to as high as 200mg per day.   A decrease in the frequency and severity of breakouts can be noticed within a few weeks, but the maximal response may take up to a few months.

Any side effects from SPL tend to be mild and most often consist of more frequent urination ( diuretic effect) around the time that the medication is taken.  Some women also note irregularity of their menstrual period and breast tenderness, especially if they are not also on the birth control pill.  Finally, light headedness and dizziness occassionally can occur in some because of a  mild blood pressure lowering effect.

SPL should not be taken during pregnancy and should not be combined with potassium supplements and certain medications such as Lithium, ACE inhibitors, and other diuretics.  SPL is not recommended for use in men as it is not as helpful and can have a feminizing effect.

In conclusion, Spironolactone is a very effective medication for women with adult acne.  It directly targets the effect of androgens on the sebaceous glands. For many, it is an excellent alternative to oral antibiotics and even isotretinoin( Accutane). It is safe, cost effective, user friendly and can be taken over an extended period of time, if needed.

References:

An Overview of Acne Therapy, Part 2: Hormonal Therapy and Isotretinoin.  Marson JW, Baldwin HE.  Dermatol Clin. 2019 Apr;37(2):195-203.

Combined oral contraceptive pills for treatment of acne.  Arowojolu AO, Gallo MF, Lopez LM, Grimes DA. Cochrane Database Syst Rev. 2012 Jul 11;(7):CD004425.

Hormonal therapy for acne: why not as first line therapy?  Facts and controversies.  Katsambas AD, Dessinioti C.  Clin Dermatol. 2010 Jan-Feb;28(1):17-23.

Oral Spironolactone for Acne Vulgaris in Adult Females: A Hybrid Systematic Review. Layton AM et al. Am J Clin Dermatol. (2017)

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