Spironolactone and Acne
Desperately self-conscious about your skin and doing some late night internet research about your treatment options? Or do you have a prescription in for spironolactone in your hot little hands, but something inside you is questioning whether you really want to take it? Then read on…
Spironolactone is a drug that is used primarily as a diuretic however it is also prescribed for the treatment of acne, despite acne not being one of the FDA-approved clinical indications for use. In Australia spironolactone is known as Aldactone.
Spironolactone blocks normal hormonal function, which means it disturbs important processes like ovulation. It also disturbs the metabolism of oestrogen and has been linked to breast cysts, breast pain and potentially even breast cancer. Because it blocks testosterone receptors, it also can kill libido, and mess with menstrual cycle regularity. The testosterone blocking effect is why it works for androgen dominant conditions, however it is not a permanent fix. Intervening with hormonal function in this way also affects the pathway between the nervous system and adrenal glands which can be problematic in terms of your body’s response to stress.
Spironolactone is thought to be helpful in hormonal acne because it has the ability to reduce the effect of androgens on the sebum producing cells of the skin, basically suppressing sebum production(1,2). Read What Really Causes Acne to understand more about how sebum production is regulated.
So, Spironolactone inhibits sebum production which means less oily skin?
Yes, but there is conflicting scientific evidence as to whether this mechanism actually delivers long term results in acne. Because I love you guys, I decided to spend my weekend having a look at the clinical trials behind spironolactone to find out if it is really as good as it sounds.
Is there solid evidence for spironolactone in acne?
The best form of evidence for whether a treatment actually works is called a randomized, double-blind, placebo controlled trial. This usually looks like a trial where one group of people with acne are randomly assigned a placebo, and the other group are assigned the therapeutic treatment - in this case spironolactone. Double-blind means that none of trial participants know whether they received the treatment or the placebo.
Other qualities of a good clinical trial include:
Objective measurements of the symptoms (like actually counting the acne lesions)
before treatment, at intervals during treatment and follow up care after the trial is over
The trial should be un-biased, meaning nobody conducting the trial has an ulterior motive or financial interest in the trial achieving a positive or negative result
There are a handful of randomised controlled trials of spironolactone in acne. I found a systematic review that disqualified all the inadequate trials and then closely examined ten trials of spironolactone to see if the results could be trusted.
What did the review find?
All ten of the randomised controlled trials were at high risk of bias mainly due to a lack of blinding(4)
Six of the trials did not mention where the funding for their trial came from - transparency is important to factor in the risk of bias(4)
Only two trials actually counted acne lesions as a measurement of results and multiple trials didn’t include a baseline acne measurement(4)
Some of the trials didn’t compare spironolactone to a placebo, instead using spironolactone in conjunction with another drug like the pill so it’s hard to tell the efficacy of the spironolactone(4)
Some trials didn’t make their groups equal – for example they gave 18 participants spironolactone but only gave 5 participants the placebo(4)
Other evidence…
In 2009 a respected scientific database ran a review on the clinical trials on spironolactone for use in acne(3).
The researchers found nine clinical trials of spironolactone, but had to exclude eight of them from their review, as only one trial focussed on cases of acne(3).
The review concluded that there is insufficient evidence for the safe use of spironolactone in acne, although it may improve other symptoms of androgen excess such as facial hair growth (hirsutism)(3).
What does all this mean in English?
There is a lack of high quality clinical trials proving that spironolactone is safe and effective for the treatment of acne.
In the real world of patients and doctors, when prescribed at the high dose of 200mg/day for at least three months, clinicians anecdotally report improvements in their clients with very inflamed, hormonal acne when used in combination with a combined oral contraceptive drug like the pill (a whole other kettle of fish).
However in the follow up period after treatment, acne lesions returned to baseline (eg pre-treatment levels)(5). Lower doses of spironolactone seem to be less effective in acne, with the scientific evidence being of low quality(4).
The key things when considering spironolactone for acne:
· Spironolactone can be effective but you might also have to take the pill at the same time to get results - a double whammy of hormone interrupting medication and all the risks associated
· These drugs seem to clear skin because they suppress the effects of hormones like androgens on the sebum glands
· If you don’t address the underlying cause of androgen excess, the acne will keep coming back after you stop taking the drugs, because the glands will respond to androgens again
· You need to consider whether you are willing to take these drugs long term to have clearer skin, despite the limited evidence around long term safety and the side effects
Lastly, based on this evidence, is spironolactone in combination with oral contraceptives really a better option when the relapse rate is so high after ceasing medication, and long term safety of these drugs is questionable? Would it be better to treat the underlying cause of androgen-driven acne with more natural options like zinc, DIM, herbs and dietary changes? In the end it really is an individual choice, based on risk vs benefit and your personal situation.
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Reference List:
1. Berardesca E, Gabba P, Ucci G, Borroni G, Rabbiosi G. Topical spironolactone inhibits dihydrotestosterone receptors in human sebaceous glands: An autoradiographic study in subjects with acne vulgaris. Int J Tissue React. 1988.
2. Hirohiko Akamatsu, C.Zouboulis C, E.Orfanos C. Spironolactone Directly Inhibits Proliferation of Cultured Human Facial Sebocytes.pdf. J Invest Dermatol. 1993.
3. Brown J, Farquhar C, Lee O, Toomath R, Jepson RG. Spironolactone versus placebo or in combination with steroids for hirsutism and/or acne. Cochrane Database Syst Rev. 2009. doi:10.1002/14651858.CD000194.pub2
4. Layton AM, Eady EA, Whitehouse H, Del Rosso JQ, Fedorowicz Z, van Zuuren EJ. Oral Spironolactone for Acne Vulgaris in Adult Females: A Hybrid Systematic Review. Am J Clin Dermatol. 2017. doi:10.1007/s40257-016-0245-x
5. Cusan L, Dupont A, Gomez JL, Tremblay RR, Labrie F. Comparison of flutamide and spironolactone in the treatment of hirsutism: A randomized controlled trial. Fertil Steril. 1994. doi:10.1016/S0015-0282(16)56518-2
Disclaimer: I acknowledge there may be trials on spironolactone that I did not find in my research. This article is not intended to diagnose, treat or replace the advice given to you by a medical professional.