Good news: Not every pimple is acne. Bad news: Most pimples are acne.
Back to the good news. Spironolactone* has been used for over 30 years as an off-label treatment for acne and male pattern hair growth in women (hirsutism).1 It is often the medication of choice to treat hair loss, ovary dysfunction, menstrual irregularities, and other hormonal-related conditions in women. Acne is also caused by imbalance of sex hormones in menopausal or post-menopausal women and can be treated with Hormone Replacement THerapy (HRT).
June is acne awareness month, so let's focus on acne.
- About 85% of females and males between the ages of 12 and 24 have at least one minor acne outbreak.2
- Acne can occur at any time and continue through an adult's 30s and 40s.2
- During adolescence, 95% of males get acne compared to 82% or more of females, but that's the only time that male cases surpass female.3
- Between 12% and 22% of adult women have acne in the US vs 3% of adult men.3
Acne has many faces, both literally and figuratively. Up to 50 million teenagers and adults in the US are affected by acne.3 Acne aliases include pimples, zits, cysts, pustules, nodules, blackheads, and whiteheads. Breakouts range from patches of small, red pimples to dark, almost purple cystic lesions on the face, shoulders, upper back, and torso.
Unless, your acne is acute and limited to a short period in your life when hormonal fluctuation is expected, like adolescence or pregnancy, your hormonal imbalance may be chronic or a sign of something more serious.
Are All Pimples Acne?
Not always but usually. If you can pinpoint the cause of your pimple, it goes away quickly and doesn't come back, then you're probably in luck. A "simple pimple" might stem from a new moisturizer, not washing your face after a greasy meal or something else that's obvious. Persistent pimples that don't clear with normal cleansing and reoccur are usually acne.
How Hormones Affect Your Skin
High levels of the androgens testosterone, dehydroepiandrosterone (DHT) and dehydroepiandrosterone (DHEA) are the origins of acne.4 In both men and women, elevated androgens cause overactive sebaceous glands and retention hyperkeratosis.4 The job of sebaceous glands is to produce sebum, a fatty substance that carries oil and bacteria to the skin's surface for removal. When there's too much of it, hair follicles become clogged. Retention hyperkeratosis occurs when skin cells become sticky and clump together leading to blocked hair follicles. Acne is plugged hair follicles that form fluid-filled sacs beneath the skin called comedones.
Low estrogen can trigger acne in women. Estrogen doesn't exactly prevent acne but it can counteract the effects of acne-causing androgen hormones.4
What Do Hormones Do?
Hormones are chemical substances that provide direction to cells. Testosterone, DHT, and DHEA occur naturally in women and men. They are naturally higher in men. Testosterone specifically is responsible for male secondary sex characteristics. Luteinizing hormone (LH) and follicle stimulating hormone (FSH) are responsible for female secondary sex characteristics, ovulation, and the menstrual cycle. Men also have LH and FSH, but they are naturally higher in women.
Typical acne treatments focus on the last stage of acne and work to unplug hair follicles and don't address the role of hormonal imbalance. Of course, topical treatments for the appearance of acne are important, but individuals with severe acne and other hormonal conditions may stay two steps behind the chronic condition. The emotional toll of acne is overwhelming. More than 75% of adult women report that acne makes them feel less confident or more self-conscious around other people.5
How Does Spironolactone Work?
Spironolactone, sometimes just called "spiro," inhibits the effects of androgens that are already present in the body. It has also been shown to correct the overproduction of androgens by the adrenal gland.
- Spironolactone increases the amount of steroid hormone binding globulin (SHBG). SHBG binds to testosterone making it unusable by the body.6
- Spironolactone reduces the amount of the enzyme 5-alpha-reductase (5-AR).6 Studies show that acne-prone skin has higher 5-AR levels than non-acne prone skin.6 Patients who previously had high levels of 5-AR show lower levels after taking spironolactone.6
- By lowering 5-AR, spironolactone reduces the body's DHT levels. 5-AR is required for the conversion of testosterone to DHT.5
To beat acne, you need to know why it's there
Is PCOS Causing Your Acne?
Polycystic Ovary Syndrome (PCOS) is a medical condition causing elevated androgen hormones in women. Over 80% of women with PCOS have acne.7 Other PCOS symptoms include infertility, hair loss at the top of the scalp along the part called Female Pattern Hair Loss, and male-type hair growth on the upper lip, and torso (hirsutism).
80% of Women with PCOS Have Acne
Why Typical Acne Treatments May Fail
Exfoliators help unplug hair follicles, antibiotics kill bacteria, and topicals like benzoyl peroxide dry out oil. Unfortunately, studies show these treatments are not enough for the vast majority of women. They don't treat hormonal imbalance, which is always the origin of acne.
Failure Rates with Traditional Acne Treatments
A review of data and clinical experience of acne treatments reported6
- As many as 82% of women reported traditional acne treatments did not work.6
- 81% of women who used systemic antibiotics reported that they did not treat their acne effectively.6
- 15 to 30% of women also said isotretinoin didn't clear their acne.6
Spironolactone Success in Treating Acne
The same review reported that studies showed patients treated with spironolactone experienced:
- 30 to 50% reduction in sebum secretion6
- 50 to 100% acne lesion reduction6
- 50% or higher reduction in acne on their torso6
A University of Pennsylvania study supports other research that spironolactone is as effective in treating acne vulgaris as antibiotics. The study also recommended spironolactone for acne over antibiotics when possible. Spironolactone is a viable alternative for women who cannot take combined oral contraceptives due to their age, medical history or sensitivity to estrogen, or are over age 35 and smoke.
How Long Does it Take For Spironolactone to Work?
Spironolactone may begin clearing acne within 3-12 weeks.6 Spironolactone may take up to 6 months to treat hirsutism and other hormone-related conditions in women.7 Acne doses range between 25 mg to 200 mg daily, but researchers note 50 mg works to control breakouts in many women.
Because of its feminizing effects, spironolactone is not usually prescribed to treat male dermatological conditions.
What Does Off-Label Use Mean?
According to the US Department of Health and Human Services, physicians may prescribe medications for uses other than their FDA-approved indication. Off-label prescribing is legal. In fact, one out of 5 prescriptions written today is off-label.
What is Spironolactone?
Spironolactone, generic for Aldactone and CaroSpir, is classified as a potassium-sparing diuretic and aldosterone receptor antagonist. It is FDA-approved to treat heart failure, excess sodium retention and swelling caused by liver cirrhosis, nephrotic kidney syndrome, and other conditions. It is also prescribed as an add-on therapy for hypertension.
While you’re treating the underlying cause of your acne, you’ll want to reduce the appearance of active outbreaks and dark scarring left behind
*Because of the potential risk to the male fetus due to anti-androgenic properties, spironolactone should not be used by women who are pregnant or trying to become pregnant. ;Additionally, women who are breastfeeding should not use spironolactone. Spironolactone may cause dangerously high potassium levels called hyperkalemia. Its use should be monitored by a physician. For full warnings and prescribing information, refer to prescription inserts and follow instructions provided by your doctor and pharmacist.
1 Ebede TL, Arch EL, Berson D. Hormonal treatment of acne in women. J Clin Aesthet Dermatol. 2009;2(12):16–22
2 American Academy of Dermatology Association Skin Brief “Skin Conditions by the numbers. https://www.aad.org/media/stats/conditions/skin-conditions-by-the-numbers
3 Skroza N, Tolino E, Mambrin A, et al. Adult Acne Versus Adolescent Acne: A Retrospective Study of 1,167 Patients. J Clin Aesthet Dermatol. 2018;11(1):21‐25.
4Ebede TL, Arch EL, Berson D. Hormonal treatment of acne in women. J Clin Aesthet Dermatol. 2009;2(12):16–22./p>
5 Tanghetti EA, Kawata AK, Daniels SR, Yeomans K, Burk CT, Callender VD. Understanding the burden of adult female acne. J Clin Aesthet Dermatol. 2014;7(2):22–30.
6 Kim GK, Del Rosso JQ. Oral Spironolactone in Post-teenage Female Patients with Acne Vulgaris: Practical Considerations for the Clinician Based on Current Data and Clinical Experience. J Clin Aesthet Dermatol. 2012;5(3):37–50.
7 Barthelmess EK, Naz RK. Polycystic ovary syndrome: current status and future perspective. Front Biosci (Elite Ed). 2014;6:104–119. Published 2014 Jan 1.