What is hormonal acne?

Adult female acne can be extremely frustrating and far more common than you might imagine.  It seems to occur at any age and can be very persistent. The classic pattern includes cyclical eruptions of cystic acne on the lower face and jawline.  Hormonally influenced acne, unlike the classic teenage pattern, often appears to arise from underneath the skin rather than from a pre-existing blackhead or whitehead.

We always recommend traditional topical acne treatments (retinoids, topical antibiotics, cleansers) but they can often be underwhelming or insufficient for hormonal acne.  One of our favorite solutions is the use of a medication known as Spironolactone.

How is spironolactone used?

Spironolactone was developed and is used as a diuretic (for blood pressure control, or heart failure).  However, they noticed during the studies that male patients would get enlargement of breasts known as gynocomastia.  This was due to the fact that the medication also has potent androgen blocking properties. Androgens are the male hormone that females have also and significantly contribute to the development or exacerbation of acne.

We use spironolactone in our adult female cystic acne patients with tremendous success.  It may take a couple of months to begin working but when it does patients experience a dramatic reduction or elimination of their acne breakouts.  In addition, spironolactone is considered safe for long term use so is an option for patients who have suffered with this type of acne for years. Often we will initiate the medication at 100mg-150mg daily and remain on that dosage until completely acne free for a few months.  Then we will slowly titrate the medication down to the lowest effective dosage. Some women are able to stop entirely whereas others may remain on varying dosages indefinitely. 

What are the side effects of spironolactone?

The medication is generally well tolerated but like any medication there are potential side effects.  The side effects can occur either as a result of its androgen blocking activity or its diuretic effect. The most common side effects are hormone related such as mild menstrual irregularities or breast tenderness.  This is rarely a problem particularly if combined with an oral contraceptive pill. This medicine should be stopped if you anticipate pregnancy or breast feeding.

 Due to its diuretic action it could cause increased frequency of urination and may affect electrolytes.  In fact, dermatologists previously monitored K+ every 6 months in every individual. However, in healthy individuals <45 years old without risk factors, the incidence is so low that routine testing is not required.  We do recommend avoiding excessive amounts of high potassium foods (hand out provided) or potassium supplements while in use. Special considerations must be given to people with a history of kidney disease, cardiac disease, or while taking certain medications for blood pressure.   Spironolactone should never be combined with Bactrim, Lithium or Digoxin.

Does it influence breast cancer risk?

There was formerly a controversy over some theoretical concerns for the increased risk of breast cancer based on an animal study and concern over unopposed estrogen effects.   But this has not been shown to be clinically relevant. A very large study in Denmark involving 2.3 million women that did not show any increased risk. Nevertheless, if a patient has a personal or very strong family history we will defer to oncologist or avoid as a precaution.

Is spironolactone expensive?

Spironolactone is a generic medication.  These days even generic medications can be very expensive particularly with high deductible medical plans.  Fortunately, spironolactone is still very affordable. According to goodrx.com you can get a 1 month supply for less than $15.

Click this link for patient fact sheet about spironolactone

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