What's the best birth control for acne?

Acne is one of those things many of us thought we'd left behind in our teenage years, only to find a face full of pimples in our 30s and beyond. Getting a zit as an adult is just as frustrating as when you were a teenager—it might be painful, you feel self-conscious, and you just want to get rid of it. Fast. 

Hormonal changes are often the culprit for adult acne in women, and birth control is one of the mainstays of treatment for hormonal acne. 

In this article, we'll look at which birth control options are best for treating acne and how they work. We'll also go over the most important side effects of birth control and some other treatments for acne if birth control isn't a good option for you. 

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There are many birth control options available, but combined oral contraceptives (COC) are the best for treating hormonal acne in women. Combined oral contraceptives are birth control pills that have a combination of two hormones, estrogen, and progestin (a synthetic form of progesterone). That's different from birth control pills that only contain progestin (called the "mini-pill"). 

When it comes to treating acne, there doesn't seem to be much difference between the many COC options, but the FDA has only officially approved four types for treating acne (Trivedi, 2017):

• Ortho Tri-Cyclen (a combination of norgestimate and Ethinyl estradiol)

• Estrostep Fe (a combination of norethindrone acetate and Ethinyl estradiol) 

• Yaz (a combination of drospirenone and Ethinyl estradiol)

• Beyaz (a combination of drospirenone, Ethinyl estradiol, and levomefolate calcium)

The study linked above compares many other types of birth control pills, showing that across the board, taking combined oral contraceptives can improve acne. Most patients see some changes by the third month, but the most dramatic improvements happen at the 6-month mark.

So, why do you have these breakouts, anyway? Let's start with a quick overview of what acne is. There are different types of lesions that form acne—four, to be precise (Sutaria, 2020): 

• Comedones—There are two types of comedones, both of which are considered non-inflammatory. Closed comedones occur when a plug made of oil and proteins fills a gland opening (called the pilosebaceous orifice) just beneath the surface of the skin. This forms what we typically think of as a "whitehead." Open comedones are what we usually call "blackheads." They're similar to whiteheads, but the plugged up sebaceous gland is open to the air. 

• Papules—These are inflamed bumps on the skin that don't have any pus in them. These happen when a hair follicle gets infected. 

• Pustules—When a papule fills with pus, it becomes a pustule, an inflamed, pus-filled sore on the skin. 

• Nodules and cysts—When pustules become very inflamed, they can form nodules or cysts, both of which can be severe and painful. 

You can have any combination of these lesions. 

We don't usually know the exact cause of acne in any given person, but there's usually some combination of excess oil production, bacterial overgrowth, inflammation, and hormonal factors that causes acne flare-ups. And, of course, genetics plays a big role, so you may be more prone to acne if other people in your family have acne. 

Certain medications, such as corticosteroids (for example, prednisone and hydrocortisone), can also contribute to acne. Even what you wear or the laundry detergent you use can have an impact, as can stress and smoking. 

Bottom line: Acne can happen for all sorts of reasons. If your healthcare provider suspects your acne may be coming from a hormonal component (often when pimples form along the jawline or on the chest), he or she may decide to prescribe a combined oral contraceptive to see if it helps in your case (Bagatin, 2019). 

In women with acne, excess androgen hormones (male hormones) often play a role in causing those unwanted pimples to show up. Male hormones, such as testosterone, dehydroepiandrosterone sulfate (DHEA), and dihydrotestosterone (DHT), are normal parts of the female hormone system, too, but in much lower levels than in men.

Sometimes, though, these androgen hormone levels become too high in certain women (called hyperandrogenism—literally, too much androgen hormone) and can cause a variety of symptoms, including acne. 

The reason excess androgen hormones lead to acne is that testosterone, DHEA, and DHT cause the body to produce more sebum (the oily substance that plugs up glands, resulting in pimples).

When you take combined oral contraceptives, the estrogen in the pill causes the liver to increase the production of a protein called sex hormone-binding globulin (SHBG), which binds testosterone, making it inactive. This results in less active testosterone in the body, lowered sebum production, and less acne (Trivedi, 2017). 

The pill is an effective treatment for acne in many women, but it's not without its side effects. Every specific pill has its own quirks, and each woman will respond differently to various combinations and dosages of hormones. Taken as a whole, though, these are the most common possible side effects of combined oral contraceptives (Cooper, 2020):

• Breakthrough bleeding

• Nausea 

• Headaches

• Abdominal cramping

• Breast tenderness

Mood changes are commonly reported, too, but are most likely to happen in women with a previous history of depression (Lewis, 2019). Many women worry about weight gain on the pill, but there is little evidence to show weight gain is associated with the pill (Mayeda, 2014). 

Combined oral contraceptives are not right for everyone and can be potentially dangerous for some patients. If you have a history of any of the following conditions, the combined birth control pill is not recommended for you (Trivedi, 2017). 

• Blood clots 

• Stroke

• Migraine with aura

• If you smoke and you're over the age of 35

• Known heart disease or history of heart attack

• Uncontrolled high blood pressure

• History of breast or endometrial cancer 

• Abnormal liver function

Taking the pill if you have any of these conditions puts you at higher risk of serious side effects. But don't worry, there are other options available for the treatment of acne. Your healthcare provider will work with you to find the right options for you. 

If birth control is not an appropriate acne treatment for you, there are several other options you can try to treat and prevent unwanted acne breakouts. In some cases, even if you can take the pill without any issues, your healthcare provider may also recommend using one of these other treatments together with the pill. 

Topical retinoids

These are creams or gels made from vitamin A that go directly on the skin. There are four FDA-approved topical retinoids: tretinoin (brand name Retin-A), tazarotene (brand names Zorac, Tazorac, and Fabior), adapalene (brand names Differin and Epiduo), and trifarotene (brand name Aklief). Topical retinoids do come with some side effects, like redness and peeling, but they're the first-line treatment for mild acne (Latter, 2019). 

It is not recommended to use topical retinoids during pregnancy, so you'll need to either be on hormonal birth control or using another form of contraception while using topical retinoids (Bozzo, 2011).

Topical antibiotics 

Topical antibiotics can be an effective treatment for inflammatory acne. Erythromycin and clindamycin are the two main topical antibiotics used, and they come in different forms, including saturated pads, lotions, and gels. These also sometimes come with some redness and peeling, but these side effects tend to be mild (Lazic Mosler, 2018).

Benzoyl peroxide 

This is one of the most commonly recommended topical treatments for acne since it's mild, safe, and is available over-the-counter. Benzoyl peroxide comes in a few different forms, including cleansers, and is available in several different strengths (Matin, 2020). If you're using a topical antibiotic, it's usually a good idea to make benzoyl peroxide part of your regimen, too, since it can help the topical antibiotic work more effectively (Dutil, 2010). 

Spironolactone 

Spironolactone is an oral medication often used to treat acne with those hormonal patterns we discussed earlier (pimples along the jawline and chest). It's not a first-line treatment, though, and is usually reserved for more difficult cases of acne. Because it has antiandrogenic effects (meaning, it suppresses the male hormones in the body), spironolactone is considered unsafe during pregnancy. Therefore, pregnancy should be avoided while on this medication.

If your healthcare provider prescribes spironolactone to you, she may recommend taking birth control together with it. If combined oral contraceptive pills are not an option for you, you'll need to use another reliable form of birth control while taking spironolactone (Kim, 2012). 

Isotretinoin (brand name Accutane) 

Isotretinoin (brand name Accutane) is only used in the most severe cases of inflammatory acne when no other treatments have worked well. It's highly effective but has some severe potential side effects. This oral medication is teratogenic, meaning it can cause serious birth defects if taken during pregnancy. Because of that, female patients are required to sign a consent agreeing to be on two forms of birth control while taking isotretinoin.

If you can't take combined oral contraceptives, your healthcare provider will help you figure out which two forms of contraception are appropriate for you while taking isotretinoin (Pile, 2020). 

We know how upsetting acne can be, especially if you've tried many over-the-counter options without seeing much of a change. Birth control is an effective treatment option for many women, but it might not be the right option for you. Speak with your dermatologist or other healthcare provider to find the best treatments to get your acne under control.

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Current version

December 29, 2020

Written by

Rachel Honeyman

Fact checked by

Mike Bohl, MD, MPH, ALM

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About the medical reviewer

Mike Bohl, MD, MPH, ALM

Dr. Mike is a licensed physician and a former Director, Medical Content & Education at Ro.