spironolactone in acne vulgaris

Last edited 01/2024

Spironolactone is widely used in the USA in the management of acne - however it is unlicensed for acne in the UK.

A US published systematic review concluded (1)

• (1) there is low-quality, but statistically highly significant, evidence that 200 mg/day effectively reduces inflamed lesion counts;
• (2) side effects, in particular menstrual irregularities, are dose-related; and
• (3) concomitant use of a COC significantly reduces the incidence of menstrual disturbances

• noted:
  • that diuretic effect of spironolactone may benefit women who experience a premenstrual acne flare associated with fluid retention
  • some investigators had reported that certain side effects were considered beneficial: breast enlargement, reduced symptoms of premenstrual syndrome, and less greasy skin and hair

In the UK spironolactone may occasionally be used off-licence on the recommendation of specialists (2)

• this is especially in women with hirsutism or polycystic ovarian syndrome
• spironolactone has antiandrogenic properties
• study evidence with respect to use of spironolactone in women showed (2):
  • spironolactone improved acne on all outcomes: not all outcomes were significant at 12 weeks, but all were significant at 24 weeks
  • spironolactone at doses of 50 mg and 100 mg were well tolerated with mild side effects similar to placebo
    • adverse effects were more common with spironolactone (20% vs. 12%, p=0.02)
  • spironolactone could provide a useful alternative to oral antibiotics for women with persistent acne where first line topical treatments have not worked
• a commentary noted (3):
  • this study shows that, for women with acne that persists despite topical treatment, prescribing oral spironolactone alongside topical treatment has the potential to significantly reduce long term oral antibiotic prescribing
• a review notes (4):
  • is growing evidence for use of spironolactone in women with persistent acne (off-label use at present) - however is likely to take 3-6 months to work
  • evidence suggests that spironolactone is well-tolerated starting at a dose of 50 mg increasing to 100 mg per day - although higher doses can be associated with adverse effects, particularly menstrual irregularity

Reference:

1. Layton, A.M., Eady, E.A., Whitehouse, H. et al. Oral Spironolactone for Acne Vulgaris in Adult Females: A Hybrid Systematic Review. Am J Clin Dermatol 18, 169-191 (2017).
2. Santer M, Lawrence M, Renz S, Eminton Z, Stuart B, Sach T H et al. Effectiveness of spironolactone for women with acne vulgaris (SAFA) in England and Wales: pragmatic, multicentre, phase 3, double blind, randomised controlled trial BMJ 2023; 381 :e074349 doi:10.1136/bmj-2022-074349
3. Santer M, Layton A. What do we know about prescribing spironolactone for acne? BMJ 2023; 381 :p1114 doi:10.1136/bmj.p1114
4. Santer M, Burden-Teh E, Ravenscroft J Managing acne vulgaris: an update Drug and Therapeutics Bulletin 2024;62:6-10.