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If you’ve tried countless over-the-counter acne products and you still can’t get your breakouts under control, it may be time to see a dermatologist. Sometimes, hard-to-treat acne requires oral medication that goes beyond the skin and targets the hormones that contribute to your breakouts. Find out how one of these medications—spironolactone—helps treat acne and if it could be an option for you.
What is spironolactone?
Spironolactone (brand name Aldactone) is a prescription diuretic—a type of medication that helps get rid of excess fluid from your body. Healthcare providers used spironolactone’s diuretic action to treat several conditions, including heart failure and hard-to-treat high blood pressure (Pfizer, 2018).
Spironolactone is also an anti-androgen, which means it decreases the production of androgens and blocks their effects. Androgens, including testosterone, are sometimes referred to as male sex hormones, but females also produce these hormones in lower levels (Zaenglein, 2016).
Spironolactone is a versatile drug that can be used for a range of conditions.
The U.S. Food and Drug Administration (FDA) does not officially approve spironolactone for treating acne, but some providers prescribe it off-label for this. When other treatments have failed to treat moderate to severe acne in women, many providers recommend spironolactone (Zaenglein, 2016). Men who take spironolactone often experience breast tissue enlargement and loss of sexual desire, so prescribing spironolactone to treat acne in men is not recommended (Charny, 2017).
Several factors contribute to acne, including excess oil (sebum) production. Androgens increase oil by binding to receptors on sebaceous glands—the oil-secreting glands attached to your hair follicles—and increasing their activity. Some studies have shown that people with acne have higher androgen levels in their skin (Makrantonaki, 2011). By blocking androgens, spironolactone helps decrease oil secretion and improve acne.
Adult acne: symptoms, causes, and treatments
While spironolactone isn’t FDA-approved to treat acne, it is FDA-approved to treat (Pfizer, 2018):
- Fluid buildup caused by liver disease
- Heart failure
- High blood pressure that hasn’t responded to other treatments
- Primary aldosteronism (a hormonal disorder that causes high blood pressure)
In addition to acne, spironolactone can be used “off-label” to treat other conditions, including (Millington, 2019; Patibandla, 2021):
- Hirsutism (excess hair growth) in women (sometimes caused by polycystic ovary syndrome, PCOS)
- Hormone therapy for transgender females
Spironolactone side effects
Many women tolerate spironolactone without any problems, but side effects can happen.
Common side effects of spironolactone include (Charny, 2017):
- Breast tenderness or enlargement
- Frequent urination
- Menstrual irregularities
Hormonal acne: causes, types, treatment
Be sure to let your healthcare provider know about any reactions you experience. They may be able to adjust your dose to limit side effects.
Spironolactone is available in doses of 25 mg, 50 mg, and 100 mg tablets, as well as an oral liquid if you have trouble swallowing pills. The typical starting dose for the treatment of acne is 25–50 mg daily. Your healthcare provider may increase your dose up to 200 mg daily depending on your symptoms and side effects (Zaenglein, 2016).
While spironolactone is generally safe and well-tolerated, there are a couple of important warnings to be aware of.
High potassium levels (hyperkalemia)
Spironolactone is a potassium-sparing diuretic, which means it removes excess fluid from your body without getting rid of potassium. Because of this, spironolactone may increase potassium levels in your blood, which can cause serious heart rhythm problems. Fortunately, studies have shown that this risk is low when spironolactone is prescribed to treat acne in young, healthy women (Plovanich, 2015).
You may be at increased risk of developing high potassium from spironolactone if you (Hunter, 2019):
- are older
- have diabetes
- have kidney disease
- take other medications that can increase potassium, such as ACE-inhibitors (like lisinopril) or ARBs (like valsartan)
- take potassium supplements or use potassium-containing salt substitutes
If you have any of the above risk factors, your healthcare provider may monitor your potassium levels with a blood test while taking spironolactone.
You should not take spironolactone if you’re pregnant or plan to become pregnant since it can affect the sexual development of male babies. For this reason, healthcare providers often recommend taking birth control while on spironolactone (Zaenglein, 2016).
Aside from preventing pregnancy, birth control pills (oral contraceptive pills) have several other benefits. Birth control pills themselves are an effective acne treatment, so you’ll get additional pimple-fighting effects when they’re combined with spironolactone. Birth control also helps regulate your menstrual cycle—important since spironolactone can cause spotting or breakthrough bleeding and irregular periods (Zaenglein, 2016).
Tips on when to start birth control pills
Spironolactone may interact with other drugs you take. Always keep an updated list of all your medications, including over-the-counter products, and share this information with your healthcare providers and pharmacist any time there are changes.
Common drug interactions include (Zaenglein, 2016):
- Other medications that increase potassium:
- ACE-inhibitors (ex. lisinopril, benazepril, enalapril)
- ARBs (ex. valsartan, olmesartan, losartan)
- NSAIDs (ex. ibuprofen, naproxen)
- Potassium supplements or potassium-containing salt substitutes
- Trimethoprim or trimethoprim/sulfamethoxazole (brand name Bactrim)— oral antibiotics also used for acne treatment
- Other potassium-sparing diuretics:
- Eplerenone (brand name Inspra)
- Triamterene (brand name Dyrenium), also found in combination products such as Maxide
This is not a complete list of all the medications that can interact with spironolactone. Always talk to your healthcare provider before starting anything new.
The impact of acne
Acne is not just a cosmetic problem. People suffering from uncontrolled breakouts may struggle with poor self-esteem and can even develop depression or anxiety. Fortunately, clear skin is possible. While there are many topical products available, sometimes these aren’t enough. Talk to your dermatologist about your options. They may recommend oral spironolactone as part of your skincare regimen to get you looking and feeling your best.
- Charny, J. W., Choi, J. K., & James, W. D. (2017). Spironolactone for the treatment of acne in women, a retrospective study of 110 patients. International Journal of Women’s Dermatology, 3(2), 111–115. doi: 10.1016/j.ijwd.2016.12.002. Retrieved from https://pubmed.ncbi.nlm.nih.gov/28560306/
- Hunter, R. W. & Bailey, M. A. (2019). Hyperkalemia: pathophysiology, risk factors and consequences. Nephrology, Dialysis, Transplantation. 34(Suppl 3), iii2–iii11. doi: 10.1093/ndt/gfz206. Retrieved from https://pubmed.ncbi.nlm.nih.gov/31800080/
- Makrantonaki, E., Ganceviciene, R., & Zouboulis, C. (2011). An update on the role of the sebaceous gland in the pathogenesis of acne. Dermato-endocrinology, 3(1), 41–49. doi: 10.4161/derm.3.1.13900. Retrieved from https://pubmed.ncbi.nlm.nih.gov/21519409/
- Millington, K., Liu, E., & Chan, Y. M. (2019). The utility of potassium monitoring in gender-diverse adolescents taking spironolactone. Journal of the Endocrine Society, 3(5), 1031–1038. doi: 10.1210/js.2019-00030. Retrieved from https://pubmed.ncbi.nlm.nih.gov/31065620/
- Patibandla, S., Heaton, J., & Kyaw, H. (2021). Spironolactone. [Updated Jul 18, 2021]. In: StatPearls [Internet]. Retrieved on Sep. 27, 2021 from https://www.ncbi.nlm.nih.gov/books/NBK554421/
- Pfizer. (2018). Highlights of prescribing information: Aldactone. Retrieved from https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/012151s075lbl.pdf
- Plovanich, M., Weng, Q. Y., & Mostaghimi, A. (2015). Low usefulness of potassium monitoring among healthy young women taking spironolactone for acne. JAMA Dermatology, 151(9), 941–944. doi: 10.1001/jamadermatol.2015.34. Retrieved from https://pubmed.ncbi.nlm.nih.gov/25796182/
- Zaenglein, A. L., Pathy, A. L., Schlosser, B. J., Alikhan, A., Baldwin, H. E., Berson, D. S., et al. (2016). Guidelines of care for the management of acne vulgaris. Journal of the American Academy of Dermatology, 74(5), 945–73.e33. doi: 10.1016/j.jaad.2015.12.037. Retrieved from https://pubmed.ncbi.nlm.nih.gov/26897386/
Dr. Steve Silvestro is a board-certified pediatrician and Senior Manager, Medical Content & Education at Ro.