SPIRONOLACTONE FOR ACNE

The drug works by minimizing the excess testosterone that can lead to breakouts, according to San Ramon, California dermatologist Dr. William Ting. “This is not like Accutane, where we’re talking about a ‘cure’ for acne,” Dr. Ting says. “Spironolactone temporarily pauses the effects of hormonal triggers. For a lot of women, acne does slowly become less noticeable, but for others, the hormonal triggers can unfortunately persist [despite the drug].” 

If something other than hormones is responsible for your blemishes, spironolactone won’t be an effective solution for you.

“Spironolactone needs to be taken under the supervision of a dermatologist,” Dr. Ting says. “You should not be blindly asking for it from your primary care doctor, because we often need to adjust the dose, depending on efficacy and patient satisfaction.”

Unlike with Accutane, you will not need to undergo monthly blood tests while taking spironolactone. However, you should meet with your dermatologist on a regular basis to monitor your progress.

Pros

• Spironolactone can be effective at targeting hormonally induced breakouts.
• Prescriptions for acne are usually covered by health insurance.
• Because it decreases androgen production, including testosterone and androstenedione, spironolactone is also prescribed to help control symptoms from PCOS including hirsutism (facial hair growth) and hair loss. It is also sometimes used as part of feminizing hormone therapy in transgender women.

Cons

• Spironolactone treats only hormonal acne, not other forms of pimples.
• Due to its anti-androgen effects, spironolactone can’t be taken by women who are pregnant or planning to become pregnant.
• Spironolactone interacts with many prescribed medications (such as sulfa-based antibiotics). Tell your dermatologist about all the drugs you’re taking.
• It can elevate potassium levels, so you may need to monitor your consumption of high-potassium foods and drinks.
• Common side effects include vomiting, diarrhea, and stomach pain or cramps, as well as dizziness.

Because it's treating a medical condition, spironolactone is usually covered by health insurance.

Dr. Emmy Greber, a dermatologist in Boston, Massachusetts, told the American Academy of Dermatology (AAD) that ideal candidates for spironolactone are female patients with hormonal acne that flares before or after menstrual cycles. If you’ve tried other topical and internal medications (like antibiotics and isotretinoin) and still have persistent acne, spironolactone can be added to your regimen or taken alone.

Because spironolactone decreases testosterone, don’t take the drug if you identify as male. You run the risk of impotence, gynecomastia, and loss of libido. 

If you have liver or kidney diseases (including hyperkalemia or Addison’s, among others), or diseases that may affect the kidneys (diabetes), spironolactone may cause severe complications.

It can take at least six to eight weeks before improvements in your skin will be noticeable, but because hormonal acne is a chronic condition, it’s tough to predict if and when breakouts will stop. “I typically see results from spironolactone in two months, but it can take longer to get the full effect,” says Dr. Melissa Chiang, a Spring, Texas, dermatologic surgeon.

If you aren’t seeing enough change after the three-month mark, talk to your doctor. You may need to adjust the dosage. When you do see results, you’ll need ongoing treatment. In a RealSelf Q&A, Nashville dermatologic surgeon Dr. Michael Gold says, “Most women who start on spironolactone for their acne will remain on it for an extended period of time, with proper monitoring.” 

Once you stop taking the drug, you can expect the improvements to taper off, though you may be able to extend your results with other acne-fighting treatments, such as medicated creams or oral antibiotics. “Your dermatologist will adjust those, depending on how you do,” Dr. Ting says. “Perhaps your topical medication will kick in nicely, allowing you to slowly come off spironolactone. It’s really at the discretion of your dermatologist, depending on how your skin reacts.”

Spironolactone is FDA-approved for a variety of conditions, including the treatment of acne, and low doses are considered safe if you’re an appropriate candidate. Yet, it does come with side effects and risks that can range from uncomfortable to serious. 

• Some doctors also believe that spironolactone can make people more susceptible to contracting COVID-19.  
• Common side effects include vomiting, diarrhea, and stomach pain or cramps, as well as dry mouth or excessive thirst.
• Spironolactone can lower blood pressure, making you light-headed or dizzy. It’s important to drink a lot of water while taking the medication. 
• At high doses, it’s known to cause menstrual cycle irregularities.
• Other side effects include breast tenderness and enlargement.
• Salt can also be a cause for concern; too much salt will cause your body to retain water, which reduces the effectiveness of spironolactone. On the other hand, using salt substitutes that contain potassium can make your levels too high, which can lead to health complications.

Because spironolactone interacts with many medications and shouldn’t be taken by patients with a number of diseases, be up-front with your physician about all the medications you’re taking and share your complete medical history. 

Formal contraindications include sleeping pills, opioids, muscle relaxers, or prescriptions for anxiety, depression, or seizures.

One of the main side effects of spironolactone is that your potassium levels can increase, resulting in muscle cramps or heart palpitations. While some doctors log your baseline potassium levels and keep checking over the following months, that practice is changing. A study from 2015 that had tracked women from 2000 to 2014 concluded that if you’re healthy, with regular potassium levels, you don’t need routine monitoring.

However, your doctor may want you to avoid consuming too many high-potassium foods and beverages, such as sports drinks, bananas, kiwis, avocados, mangos, and coconut water. You may also be counseled on how to spot signs of hyperkalemia.

Drinking alcohol or taking narcotics while taking spironolactone can exacerbate the side effects and leave you dangerously lightheaded, to the point that you may faint when you stand. It's safest to avoid alcohol and recreational drugs while you're taking spironolactone, to avoid the possibility of injury from a fall.

It is safe to take spironolactone in addition to a birth control pill. In a RealSelf Q&A, Dr. Paul says, “Both medications work well together to help control acne. Birth control pills do not interact with spironolactone, so you aren’t at higher risk of pregnancy by taking both.” In fact, some doctors strongly recommend using some kind of birth control while taking spironolactone, if there’s a chance you could get pregnant.  

Another benefit to taking birth control pills: “They keep your cycle regular, so that minimizes one side effect of spironolactone for acne,” Dr. Ting says.

Because spironolactone is a diuretic, you may actually lose “water weight” while taking the drug.

However, many people say they’ve actually gained weight from spironolactone. It increases cortisol levels, which is clinically proven to add adipose fat to the belly, so you may experience spironolactone weight gain.

It also has a side effect of breast enlargement.

“Typically, hormonal acne results in cystic-type acne lesions, and topicals do very little for this type of acne alone. An alternative to spironolactone for this type of acne would most likely be oral antibiotics plus a topical regimen,” says Dr. Peter Malouf, a Fort Worth, Texas, dermatologist. “For women who take hormone replacement therapy that includes testosterone, treating acne in these situations can be an uphill battle.”

Depending on the severity of your situation, your dermatologist might recommend one of these alternatives.

• A topical retinoid like Retin-A speeds cell turnover and reduces the clogged pores that lead to blackheads and whiteheads. 
• Accutane (isotretinoin) is a prescription medication that reduces the amount of oil your skin makes. It’s considered the closest thing to an acne “cure.” However, the drug’s side effects include serious risks, like birth defects. “If you decide spironolactone is absolutely not tolerable, you might consider a course of low-dose Accutane, so long as you aren’t planning pregnancy anytime soon,” says Dr. Amy Paul, a Grand Junction, Colorado, dermatologic surgeon, in a RealSelf Q&A. “I have a lot of adult women who do wonderfully on a four- to six-month course of lower-dose Accutane to treat acne.”
• LED treatments kill acne-causing bacteria while encouraging cell turnover and collagen production, treating both acne and sun damage.
• Chemical peels remove the top layer of pore-clogging dead cells, which are replaced with new layers of healthy skin. This can help reduce acne flares. Common peels for acne include glycolic acid peels and salicylic acid peels, although sometimes a combination treatment works best.
• Photodynamic therapy (PDT) starts with the application of a topical medication, such as Levulan, to make your skin more sensitive to light. Then a practitioner will expose skin to Blu-U or LED light. PDT clears breakouts by killing acne-causing bacteria and reducing the size and activity of your sebaceous glands.

Bowser A., Spironolactone for hormonal acne (2018)

Ghelani R., Spironolactone (Aldactone): diuretic medicine used in heart failure (2019)

Kim G. and Del Rosso J., Oral Spironolactone in Post-teenage Female Patients with Acne Vulgaris (2012)

Plovanich M., Weng Q.Y., Mostaghimi A., Low Usefulness of Potassium Monitoring Among Healthy Young Women Taking Spironolactone for Acne, (2015)

Stimson R., et. al., Cortisol Release From Adipose Tissue by 11β-Hydroxysteroid Dehydrogenase Type 1 in Humans (2009)

U.S. Food and Drug Administration, Aldactone - Spironolactone (2008)

Young E., et.al., The Role of Mineralocorticoid Receptors in Hypothalamic-Pituitary-Adrenal Axis Regulation in Humans1 (1998)