Hormonal acne looks just like non-hormonal acne, and it’s caused by the same basic factors. However, it has a few unique treatment options, like off-label spironolactone for acne. “Off-label” means spironolactone was originally designed and produced to be a high blood pressure medication 💊, but doctors found that it addressed other health issues too, including moderate to severe acne.
Spironolactone is an aldosterone receptor antagonist, meaning it suppresses the excretion of a class of sex hormones generally associated with hormonal acne. These are referred to as ‘androgens’.
What Does Research Say about Spironolactone as Therapy for Acne?
So far, science seems to love spironolactone for pimples. Many case studies have already been conducted, of which the most recent, reasonably-sized one was done by Vaibhav Garg et al in the United States. The researchers’ objective was to investigate the long-term effects of the drug in adult women with acne, and the study stretched over a period of 11 years. Their results were noted in a paper that was still to be published in the Journal of the American Academy of Dermatology (JAAM) 📚 at the time of writing:
As evaluated by CASS scores, at the first follow up, 75.5%, 84.0%, and 80.2% of patients with available data had reduction or complete clearance of acne on the face, chest, and back, respectively. The mean drug survival was 470.7 days. Menstrual side effects were less common among those using combined oral contraception.
So, spironolactone is a popular option, and doctors often prescribe it for their female patients with acne. However, spironolactone has yet to be officially approved by the US Food and Drug Administration as a treatment of acne vulgaris, and many more long-term, well-designed studies are needed to consider its time-related side effects, its precise mode of action, contraindications, safety, and so forth.
This is important, so read on for more information before you even ask your dermatologist 👩⚕️ about taking spironolactone for acne. You need to make an informed decision – the only type we can recommend! – and for this, you should know:
- if your pimples are really caused by hormones;
- how spironolactone works;
- if spironolactone is indicated for your type of acne; and
- what the riskiest side effects are.
Hormones Cause Acne When They Fluctuate
We all know that hormones can play a major role in acne, but why is that? We all have an array of hormones keeping our body functioning at all times, so when do they cause acne?
How Hormone Fluctuation Can Cause Acne
As the name hints, hormonal acne is the result of hormonal fluctuations 📈. Our natural hormone levels rarely cause acne on their own; it’s only when they deviate from our own personal norm that acne can result.
Generally speaking, increases in androgens, like testosterone, can lead to increased acne because when androgens increase, oil production also increases. This contributes to the formation of all kinds of acne, from blackheads to cysts.
Is Testosterone the Culprit?
However, it’s important to note that testosterone by itself does not lead to more acne. Some people 🧑🤝🧑naturally produce more testosterone than others, yet they are no more prone to hormonal acne than others. That’s because changes in hormone levels differ from one body to the next. This means that regardless of how much testosterone you normally produce – if its level increases, acne could be the result.
Relative Increases in Testosterone
It’s also possible to have “relative increases” in testosterone when the hormones that typically balance out testosterone, like estrogen, decrease. When there’s less estrogen to balance out the testosterone, it’s like their levels have increased, even though there was no change in testosterone-secretion itself.
Taking Oral Spironolactone as Hormonal Therapy
Taking oral spironolactone can help stabilize these hormonal changes by suppressing androgen production, but we’ll explore what that means, how it works, and what its side-effects are in a minute. First, it’s important to understand why suppressing androgens can help, and determine if your acne is in fact caused by hormones.
How Increased Oil Production Leads to All Kinds of Acne
When androgens increase, either literally or in relation to other hormones, one of the side effects is that the skin produces more oil, also called sebum. This can be a big problem for acne because excess oil production is one of the three main causes of acne.
Too much sebum on the skin can cause acne in two ways – by clogging the pores and by encouraging bacterial growth.
On its own, too much oil causes acne because it clogs pores. Typically, our glands produce a small amount of oil, which then travels through the pores to the epidermal surface where it protects the skin from irritation and possible invaders.
When these oil glands start overproducing, though, there’s nowhere for all the extra oil to go once it reaches the skin’s surface, so it gets backed-up in the pore and causes it to clog. This leads to the formation of whiteheads and blackheads. Whiteheads form if the pore is closed, and blackheads form if the pore is open.
Too much oil can also lead to an increase in acne-causing bacteria, known as p. acnes 🦠. These bacteria always live on the surface of our skin and are relatively harmless on their own, but if they get trapped in a pore or if their numbers grow significantly, they can cause pimples and cysts.
Excess oil production can cause bacterial numbers to grow exponentially because oil is their main food source. When there are more of them, p. acnes are more likely to get trapped in pores, where they multiply some more and generate the minor infection that leads to pimples, or the more serious infection that causes cysts.
Is My Acne Hormonal?
We already know that spironolactone will only help if your acne is caused by the androgens that spironolactone can help control, so how can you tell if your acne is hormonal?
There are three classic signs of hormonal acne.
1. You Have Increased Acne when you Know your Hormones are Fluctuating.
The easiest way to tell if hormones could play a role in your acne is by paying attention to when it flares up. If you still menstruate 🩸, you may see a relative increase in acne during the week before your period because that’s when estrogen levels start to drop off. This may indicate that acne is hormone-related, and spironolactone for acne could be a good solution in such a case.
Although menstruation, pregnancy 🤰, and menopause are times of significant hormonal fluctuation, women who don’t menstruate also experience regular, cyclical hormone fluctuations. These may be harder to spot without the clear cycle of menstruation, however, so look out for the next two.
2. Your Skin is Oily.
Hormonal fluctuations lead to increased oil production. Therefore, you will probably notice that your skin is oilier than normal before major breakouts. If your acne appears when your skin is dry or normal, then it may be caused by other factors, like bacteria 🦠 or irritation.
3. You Have All Types of Acne
As discussed, excess oil can clog pores and provide food for acne-causing bacteria, meaning it can create blackheads, whiteheads, pimples, and cysts. If your acne is hormonal, there’s a good chance you’ll have a variety of all the different kinds of acne. However, if you have mainly one type of acne, hormones are less likely to play a part.
The American Academy Dermatology Association also notes that acne occurring mainly along the jawline and lower face tends to react well to hormonal therapy such as spironolactone.
So you’ve determined that your acne is definitely hormonal and now you’re setting out to find the best acne treatment for this. Could spironolactone be right for you?
History Behind Spironolactone As A Treatment for Acne?
Spironolactone was originally designed to treat hypertension by reducing the production of a mineralocorticoid hormone called aldosterone. The adrenals secrete aldosterone, and it’s involved in the management of potassium and sodium in the body. At normal levels, aldosterone balances potassium and sodium, but at higher levels, it’s a different story.
Too much aldosterone causes the body to lose potassium and hold onto sodium, naturally resulting in way too much sodium and too little potassium. This imbalance makes the kidneys hold on to too much water which, in turn, causes what the doctors 👨⚕️ call “plasma volume expansion.” It literally means there’s too much fluid in your circulatory system, and it’s also called high blood pressure.
Enter oral spironolactone and its ability to block aldosterone receptors. In this, it has a diuretic effect.
In higher doses, spironolactone starts a cascade of events in the body that helps aldosterone return to normal levels. This also means that the potassium and sodium balance is restored, and the body can get rid of excess fluid through urination. Less “plasma volume” lowers the pressure in the cardiovascular system, which means high blood pressure is significantly relieved. So, because of its action of retaining potassium, spironolactone is also called a ‘potassium-sparing diuretic’.
The Food And Drug Administration approved spironolactone for high blood pressure already in the 1960s, but curiously enough, well-designed (i.e. randomized, double-blinded, placebo-controlled, clinical) trials with data that support this effect are rather scarce. Most studies are small and/or retrospective in nature, which is not the ideal research methodology.
Off-Label Uses of Spironolactone
Spironolactone is mostly prescribed as a fourth-line therapy for resistant or uncontrolled hypertension. It appears to be far more popular for off-label prescription, of which the indications include female hirsutism (excessive hairiness), female pattern baldness, and, of course, acne in women 👩.
Hirsutism is often a symptom of polycystic ovary syndrome. If taken together with a low-dose oral contraceptive, spironolactone use has been shown to alleviate the condition’s three main symptoms, mentioned above, and also unpredictable menstrual periods. The clinical evidence, or research in humans, indicates only that spironolactone might be an effective treatment for irregular menstruation and acne vulgaris, not for hair loss.
Online reports say that off-label, spironolactone is an effective treatment for congestive heart failure, but there’s little evidential support for it. In fact, the data is conflicting, and one of the most recent studies found the opposite:
In this randomized clinical trial, high-dose spironolactone use in acute heart failure was not associated with greater improvement in natriuretic peptide levels, symptoms, congestion, urine output, weight loss, or clinical outcomes than treatment with usual care.
The authors, therefore, concluded that the routine use of high-dose spironolactone in acute heart failure is not recommended and that “further studies targeting specifically patients who are resistant to diuretics with high-dose spironolactone are needed.”
Yet another recent review of the data stated that
although spironolactone appears to improve diastolic function, induce reverse LV remodeling, and even reduce cardiac hospitalizations and improve quality of life in some studies, on the other hand, there is no definitive demonstrable beneficial effect of spironolactone on all-cause and cardiac mortality in patients with HFpEF (heart failure with preserved ejection fraction).
The authors noted that spironolactone may be an effective treatment for some subgroups of cardiac patients, while others may even be resistant to it. They too concluded that more clinical research 📖 is needed.
Very recently, another possible (and amazing) off-label use emerged – spironolactone seems to offer protection against Covid-19. Research 🔬 uncovered this because, in coronavirus disease-19, four major factors have been identified as high-risk in infected patients: aging, hypertension, obesity, and exposure to androgen hormones. Well, we don’t want to get too technical but if you’ve been paying attention, you’ll have spotted why researchers hypothesized the drug’s potential utility. In the words of authors Flavio A. Cadegiani et al. –
To us, there is sufficient data to support the employment of spironolactone for large-scale studies, and as an empirical alternative for compassionate use due to the lack of risk.
Can Men Safely Take Spironolactone?
Yes, but beware of the side effects. If you’re a guy and determined to try this therapy, you should take spironolactone only under medical supervision 🩺, and also only if you are willing to risk developing gynecomastia (small breasts). In some cases, men found that spironolactone use decreased their facial hair and libido and caused erectile dysfunction as well.
Clinical data in this regard is scarce and not recent at all. However, one review of the data noted that gynecomastia was seen in only 30% low‐dose male subjects and in 62% of the high-dose male subjects of a small study. This means that the incidence of gynecomastia was lower on low-dose spironolactone than on higher doses. Well, thirty percent is not high but it’s not nothing either, so – the choice is yours.
These side effects are due to the fact that spironolactone is, in essence, hormonal therapy, but read on for more about this. Still, it should make more sense why spironolactone is mostly prescribed for women with acne.
By now, you may be wondering exactly how a high blood pressure medication could also be a treatment of acne vulgaris.
So How IS Spironolactone A Treatment Of Acne?
First, let’s be clear – unlike many topical treatments, taking spironolactone won’t get rid of the acne you already have. Rather, it prevents acne vulgaris from forming in the first place 👍.
It turns out that taking spironolactone also suppresses the excretion of certain androgens or sex hormones in the gonads. This makes sense. After all, the endocrine system is just that – a system in the body, so most, if not all of these hormone-excreting organs, are interconnected in some way.
Like we said at the beginning, androgens like testosterone don’t cause acne all on their own, they only cause it if their levels increase or if balancing hormones like estrogen decrease. If androgen levels are kept relatively low or balanced, sebum production is also under control, which means one of the main causes of acne has been successfully addressed.
However, taking spironolactone or other hormonal therapy such as a birth control pill 💊 should not be the only action to consider. Both women and men battling with this skin condition benefit from taking a multi-faceted approach, such as sticking to a regular, consistent skin care routine, and paying attention to their diet as well. But a bit more about this later.
Side Effects Worth Considering
Many women 👩 see significant improvement in their acne while taking spironolactone, and, in general, the drug has a great side-effect profile. Many studies have concluded that this is a well-tolerated therapy for acne and other conditions.
However, there are some significant side effects and risk factors that warrant consideration before taking this as hormonal therapy. The following are important to note.
1) Remember what the drug was originally designed for? Yup, high blood pressure regulation. This means that if you have very low blood pressure, taking spironolactone could exacerbate the problem, which could result in all kinds of side effects such as dizziness, nausea, low energy, fainting, dehydration or unusual thirst, blurred vision, cold and clammy hands, etc.
2) Renal (kidney) failure or injury is often listed among spironolactone’s side effects as a serious concern, but this is another internet-driven half-truth. Research indicates that taking spironolactone can actually benefit the kidneys in certain cases. OK, this needs to be done under medical supervision because of the (slight) risk of hyperkalemia (too much calcium in the body). Yet, a recent review of the data that looked at spironolactone’s long-term safety concerns concluded the following:
Spironolactone represented a promising treatment option to retard CKD (chronic kidney disease) progression to ESRD (end-stage renal disease) amongst stage 3–4 CKD patients, but strategic treatments to prevent hyperkalemia should be enforced.
So, the excessive alarmist reports are not true. There’s a back-story to this – in 2004, a Canadian study reported that spironolactone caused “kidney problems and … high blood potassium levels” and was therefore unsafe for use in patients with kidney problems. This puzzled British researchers as it didn’t reflect their experience with the drug in the National Health Service, so they were inspired to conduct their own study. Their results showed that spironolactone was much safer than the Canadian study suggested, and they also found that kidney-patient intake in the hospitals had actually fallen despite high spironolactone prescription.
As Professor Tom MacDonald, Head of the Medicines Monitoring Unit at the University of Dundee and senior author of the new study 🔬, commented in an interview with Medical Press:
“I think this is due to a combination of the thoughtful prescribing of lower doses and careful monitoring of blood chemistry in the NHS.” So, expect your doctor to want to conduct blood tests if you’re really impaired and are considering taking spironolactone, but the drug was proven safe even in patients on hemodialysis. As mentioned before, spironolactone might have hyperkalemia as a side effect and this could be risky, but it happens only if the drug is taken in doses over 50mg p/d.
4) If you’re able to get pregnant and are sexually active, it would probably be wise to discuss oral contraceptives with your doctor. There’s little to no traceable data, clinical or otherwise, that taking spironolactone will cause birth defects but no woman wants to take that risk.
However, birth control pills are also hormonal therapy and come with their own list of possible side effects, such as weight gain, anxiety, and brain fog, among others.
5) Spironolactone furthermore has a black-box warning label, the most serious warning label the Food and Drug Administration assigns to any drug. This particular warning was issued because spironolactone could cause tumors. However, the study that determined this is nearly 60 years old now, and it studied spironolactone in doses almost 500 times higher than what is prescribed now. No studies conducted in the last ten years have found that modern dosages cause tumors, but it is still a warning you should be aware of.
Other Treatment Options
If spironolactone for acne doesn’t sound like the right fit for you, that doesn’t mean you’re doomed to have hormonal acne forever. Although some medications can prevent hormones from causing increased acne in the first place, there are other treatments that can treat and prevent acne in non-hormonal ways.
Retinoids are one of the most popular types of acne treatment prescribed at dermatologist offices 👩⚕️ right now. This type of acne treatment works by regulating the life cycle of skin cells. By making sure your skin cells are being produced and dying at the right tempo, retinoids help prevent clogged pores and clear away excess oil. This makes them relatively effective in treating hormonal acne specifically since it is driven by excess oil.
Traditionally, retinoids have only been available as prescriptions 📝, but that’s been changing recently. Retinoids like Retin-A, Tazorac, or isotretinoin (Accutane) are still only available through a dermatologist, but new retinoids like Differin are starting to become available over the counter.
If you’re looking for a natural remedy for your acne, we strongly recommend honey 🍯 because it has antibacterial and anti-inflammatory properties, and it can help absorb excess oil. However, make sure you use pure honey. Honey with added ingredients, even just water or fructose, will not be as effective in treating acne. This doesn’t mean you need to buy the most expensive honey on the shelf. Simple clover honey tends to be pure, while other organic, pricey brands have added ingredients that dilute honey’s acne-fighting powers. Some studies show that Manuka honey 🐝, a particular type of honey made using nectar from the tea tree plants that grow in New Zealand, may be even more effective in treating acne, but regular honey can still help reduce acne.
You can apply honey to your skin on its own, or you can create your own DIY face mask. If you have primarily blackheads and whiteheads, add a small amount of freshly squeezed lemon juice 🍋 to the honey to help exfoliate the skin. If you have pimples or cystic acne, try adding a dash of cinnamon. Like honey, cinnamon has antibacterial properties that can help fight the p. acnes infections involved in pimples and cysts. If you have sensitive skin, we recommend combining aloe vera with honey, to help protect and hydrate your skin.
A Consistent Skin Care Routine:
The best treatment for any kind of acne is a gentle skin care routine. Even if you are controlling the hormones causing your acne with spironolactone or oral contraceptives, it’s important to take care of your skin directly. Many acne treatment systems address the two main causes of acne we’ve already discussed, oil production and bacteria 🦠, but they fail to address the third: inflammation 🔥. In their efforts to prevent oil buildup and bacterial growth, some acne treatments are far too harsh on the skin, and this leads to inflammation. The skin tries to protect itself from the harsh products through the inflammation response, which swells the skin slightly and constricts the pores, leading to clogged pores and increased acne.
At Exposed Skin Care 🏆, we know the most important part of acne treatment is to keep your skin healthy, which means treating it gently. That’s why we combine acne-fighting ingredients 💪 and soothing ingredients in all of our products. We utilize green tea extract and aloe vera to protect your skin, and we include ingredients like salicylic acid and tea tree oil to reduce acne. Together, our products take care of your skin and your acne at the same time.