Last Updated on October 2nd, 2019
Have you ever considered using spironolactone for acne treatment? It’s okay if you haven’t—it isn’t right for everyone, and it wasn’t even designed to treat acne. However, studies show that it can be effective. For many people, acne is closely tied to fluctuations in hormones, meaning topical treatment is only playing catch-up, never solving the real problem.
Spironolactone is an anti-androgen, which we will explain more about in a moment, but generally speaking, it can suppress the hormones that promote acne1. But it’s important to note that this doesn’t come without side effects. Our hormones control countless bodily functions, so messing with them, even just a little, to clear your skin could cause disturbances elsewhere in the body as well. This article will explain what causes acne and how spironolactone can help, who usually benefits the most from using spironolactone for acne, and some other acne treatment options if spironolactone isn’t for you.
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If you’ve tried almost every acne treatment out there and you’ve never heard of using spironolactone for acne, there’s a good reason for that: it wasn’t actually meant for acne. Invented in the 1950s, it was designed to treat hypertension, or high blood pressure. In the 1990s, doctors found that it was also useful for treating congestive heart failure2.
These conditions are obviously very different from acne, so it makes sense if spironolactone hasn’t exactly been on your radar. But even though acne isn’t one of its official uses, many dermatologists have found it to be very effective. This is because spironolactone blocks certain hormones. It was designed to block aldosterone, a hormone involved in sodium and potassium absorption. For those with hypertension or congestive heart failure, this helps regulate blood pressure to promote a healthy heart.
Aldosterone doesn’t have much of an impact on acne, but androgens do. Androgens are a group of hormones primarily known as “male” sex hormones, including testosterone, dihydrotestosterone (DHT), and others. In large amounts these hormones can lead to masculinizing features like increased hair growth or lowered voice, but they are produced in people of all sexes, just at varying levels.
Dermatologists discovered they could use spironolactone for acne because it doesn’t just block aldosterone, it’s also an anti-androgen. This is basically just a medication that lowers the body’s androgen levels by suppressing their production. But why does that help with acne? First let’s take a look at how acne is formed.
Acne isn’t caused by any one thing: too much stress can cause acne, genetics have been proven to play a large part, even diet could have an effect (but be careful not to get too caught up in that; very little conclusive research has been conducted). But that’s looking at the big picture, at you as a person. When it comes to the skin level, acne is primarily caused by three things3: inflammation, bacteria, and oil production.
For many years, dermatologists believed that a particular kind of bacteria called p. acnes was responsible for acne. Oil production and inflammation just added to the problem. As a result, many of our acne treatment options today focus primarily on killing bacteria. For example, antibiotics are still one of the most popular acne treatments, despite their growing ineffectiveness due to antibiotic resistance.
In the last decade or so, doctors have discovered that while p. acnes may contribute to the problem, the root of it all is actually inflammation. P. acnes bacteria always live on your skin, and at reasonable levels, they can even help. Their main food source is sebum (just another word for the oil your skin naturally produces), meaning they can actually keep your face from becoming too oily. Similarly, your skin always produces sebum as a way to protect itself.
So by themselves, oil production and bacteria don’t seem to cause much damage. Why do they lead to acne then? The short answer: inflammation. Not the kind of inflammation you see with a painful pimple; that comes later. Acne starts with very mild swelling. The skin is sensitive to all kinds of irritants that it can’t always protect itself against, so the pores swell slightly. This traps bacteria and sebum in the pore as it closes. This can create whiteheads, pimples, or even cysts. Using spironolactone for acne won’t kill p. acnes or prevent all inflammation, but it does suppress oil production which can have a profound effect for some people.
For some people, reducing your androgen levels can be a huge help in clearing acne, but why is that? What about androgens is so bad for the skin, and why only certain people? Well, we don’t want to give androgens a bad rap. On their own, they don’t contribute to acne more than any other hormone. If they did, men would have acne much more than women, and current data suggests that men and women experience acne almost equally. It’s only when androgen levels are out of proportion with other hormones that they become a problem.
Estrogen and progesterone are often considered the “female” hormones, but like androgens, everyone produces them to some degree. When androgen levels rise significantly above their normal level, or if balancing hormones like estrogen or progesterone fall below normal levels, the body starts producing more sebum. Excess sebum can cause acne is several ways. It can clog pores, leading to blackheads and whiteheads, but it can also lead to pimples because it is the main food source for p. acnes. With more sebum comes more bacteria, which means if your skin becomes inflamed, as it often does, the sebum and bacteria get trapped under the skin and create an infection—and a pimple.
Usually we can’t do much to control our hormones. Most acne treatment solutions revolve around fighting acne after it’s formed, rather than preventing the cause. But the reason dermatologists started prescribing spironolactone for acne is because it can help control hormones. Spironolactone is an anti-androgen, meaning it can suppress androgen production. If your body is producing more androgens than usual or producing less estrogen than usual, you can take an anti-androgen to even things out. Restoring balance stops the body from producing too much sebum, and prevents acne.
Is “Off-Label” Safe?
Currently, the United States’ Food and Drug Administration (FDA) approves spironolactone to treat several conditions, but acne is not one of them. This means whenever a dermatologist prescribes spironolactone for acne, they’re doing so “off-label.” Even though this sounds bad, it is largely due to bureaucracy. The FDA is a huge organization, so things move very slowly there. It takes time to conduct enough studies and write enough reports and double-check everything for the FDA to add a use for any particular drug. Doctors and researchers often work together to ensure that a drug can safely be used for different conditions, to provide their patients with the best available treatment.
“Off-label” does not mean untested or experimental. There are countless studies on the effects of spironolactone for acne, in rats and humans, which find it to be an effective and safe treatment option for most people. “Off-label” just means not official.
There is one FDA warning that you may want to be concerned about though. Currently, spironolactone has a “black box warning” label, meaning it is only supposed to be prescribed when absolutely necessary because some studies have shown that it can cause tumors or cancer. This is a much scarier warning that should be taken seriously. Many sources state that the warning is based on old studies from when it was first developed in the ‘50s and ‘60s and given at doses nearly 500 times what’s prescribed now. Studies conducted in the last 10 years have not found any tumors or cancer, and it’s possible that the label simply hasn’t been removed because of the red tape involved, but this is a warning to take much more seriously than the relatively normal “off-label” warning.
Although many people experience hormonal acne4 at some point in their lives, those who menstruate often experience more frequent and intense hormonal fluctuations. Hormones spike and drop at various points throughout the menstrual cycle, and when menstruation ends and menopause begins, hormones continue to fluctuate, just differently. Additionally, some people with ovaries have a serious condition known as polycystic ovarian syndrome (PCOS), which can increase the likelihood of hormonal acne issues. Finally, being a teenager (of any sex or gender) typically means increased hormones and increased acne.
If you notice that the severity of your acne seems to depend on your menstrual cycle, you aren’t alone. For most people, acne will spike at the beginning of the menstrual cycle and continue through the first half. In this case, there is not a spike in androgens—there’s a drop in estrogen and progesterone. Because these hormones drop, there is a relative increase in androgens like testosterone, and the body starts to produce more sebum (and cause more acne).
Menopause and Perimenopause
If you’re menstrual cycle is becoming irregular and menopause is beginning, a similar occurrence may be happening. Estrogen and progesterone levels drop during menopause and perimenopause, a time before menopause that could last anywhere from several months to a few years and usually entails irregular periods and hormone fluctuations. The disparity between your androgens and your other hormones causes the body to produce more sebum, but you can control that disparity by taking spironolactone. According to this study in the Journal of Medicine, spironolactone is a cost-effective way to decrease menopausal acne and other less desirable side effects.
Polycystic Ovarian Syndrome
Spironolactone for acne could also be effective for those with polycystic ovarian syndrome (PCOS). PCOS is a condition that primarily affects the ovaries and the hormones they produce, however, it can be difficult to diagnose. Insufficient research has been conducted, and symptoms vary widely—for instance, despite the name, many people with PCOS do not have ovarian cysts. A relatively common symptom, however, is the overproduction of testosterone and other androgens, usually due to non-diabetic insulin resistance. This can lead to increased acne, especially when eating a particularly sugary diet. Spironolactone may be helpful in reducing PCOS-related acne, but it likely won’t help with some of the more significant symptoms, like irregular periods or painful cysts, and it could actually make periods more irregular or cause breakthrough bleeding (bleeding in the middle of your menstrual cycle).
Around 80% of people between ages 11 and 30 experience acne, and the teenage years can be especially rough. Hormones often play a key role, and some studies show that taking spironolactone for acne could help. Androgen levels rise for almost all teenagers, whether they are male, female, intersex, or nonbinary. This spike leads to more oil production which can clog pores and contribute to pimples.
Even though most teenagers experience this, spironolactone often works best when prescribed to those who present as female. Spironolactone can have feminizing effects, because it suppresses the production of the predominantly male hormones. Many people who take spironolactone, regardless of sex or gender, often report enlarged breast tissue, which may be undesirable for some teenagers.
Spironolactone Isn’t the Right Choice for Everyone
Spironolactone is a hormonal treatment, perfect for treating the root cause of hormonal acne. But there are some situations where it may not be the best solution. A few of the exceptions are outlined above, but there are also some situations where spironolactone will be ineffective at best and actively bad for you at worst. For example, if your acne is tied to hormones, but they’re primarily stress hormones, spironolactone probably won’t help very much. If you are undergoing testosterone therapy or have a kidney condition, then spironolactone could be bad for your health and it is not advised for you to take spironolactone for acne treatment.
Acne that is triggered by stress hormones is different from acne that is triggered by androgen hormones. Although being stressed can cause an increase in androgen levels, the hormones primarily associated with stress are cortisol and adrenaline, and they can cause acne5 because they are preparing your body for a fight. When you are stressed, your brain interprets the stressor as a literal, physical threat, so it prepares your body to respond in one of three ways: fight, flight, or freeze. Unfortunately, many things we are stressed about can’t be resolved through fist fights or marathons or standing still and waiting for it to go away. Instead of helping us, all these stress preparations tend to take a toll on our bodies. One form of this is acne.
At normal levels, cortisol actually reduces inflammation, but when the body is in danger, cortisol levels spike and induce inflammation to protect the body from any external threats. This closes the pores and traps sebum and dead skin cells beneath the surface, almost always leading to more acne.
Men undergo testosterone therapy for a variety of reasons, from gender transitioning to helping replace naturally declining testosterone levels. However, the influx of testosterone can cause your body to produce more sebum, and generate more acne. Most hormonal acne can be straightened out by restoring balance to the hormones, like you would with spironolactone for acne treatment. However, in these situations, you are trying to increase your testosterone levels, so taking an anti-androgen like spironolactone would defeat the entire purpose. Although it may be more frustrating, in these cases we recommend non-hormonal treatments, like those outlined below.
Spironolactone was originally developed to treat hypertension, and later on, congestive heart failure as well. It is still primarily prescribed for those purposes, because of the way it allows the body to retain potassium. Spironolactone is a potassium-sparing diuretic, meaning it helps reduce the amount of salt you absorb without getting rid of all your potassium too. This is usually a good thing, but many kidney conditions prevent the body from removing excess potassium, and spironolactone makes it more likely for you to develop a buildup of potassium. If you have a kidney condition, be sure to discuss it with your doctor before taking spironolactone.
This could potentially be avoided through topical spironolactone. This is a relatively new product, so few studies have been conducted, but you can find two here. It seems to produce fewer side effects, but you should still discuss with your doctor before trying anything that retains potassium.
If you have hormonal acne but don’t want to use hormonal treatments like spironolactone for acne, there are non-hormonal treatment options. Although they don’t treat the source of the issue, they can still clear skin if used consistently.
The best way to clear up any kind of acne is through a full treatment system, one that cleanses your skin, treats it, and keeps it moisturized (without adding to any oil buildup, of course). There are a lot of acne systems on the market right now, but the one we feel most comfortable promoting is Exposed Skincare. Their ingredients include scientific ones, like benzoyl peroxide and salicylic acid, and natural ones, like green tea extract and aloe vera. Combined, these treat your skin gently but still make sure your skin is clear and acne-free.
Retinoids are a popular acne treatment option6, especially for hormonal acne, because they are essentially concentrated forms of vitamin A, which has the ability to slow down retention keratosis. This is a process in which a pore is shedding dead skin cells much too quickly, and they clog the pore. This is only made worse with the excessive sebum production often brought on by hormone fluctuations. Vitamin A can break up these clogs and prevent the pore from shedding quite so many cells so quickly.
Most retinoids are only available as prescriptions, like Retin-A, Tazorac, or Avita, but a few are now available over-the-counter, like Differin. Retinoids are known to be harsher for the skin than some other options, so if you have sensitive skin this may not be the best answer for you. However, they can effectively cut through the thick layer of oil often produced by hormone fluctuations.
One of the most popular over-the-counter acne treatments7 available is benzoyl peroxide. Its primary function is to kill acne-causing bacteria, making it a decent solution for most kinds of acne, and it comes in all kinds of concentrations, from 0.5% to 10%, so it’s good for all skin types too, although we don’t recommend ever going over 5%, even with the oiliest of skin, as you will likely only cause irritation and more acne. Even though excess sebum is the primary concern when it comes to hormonal acne, bacteria can quickly become a problem too. The extra sebum gives the bacteria an even greater food source, so they can grow to a problematic number and contribute to more acne as well. Because of this, benzoyl peroxide could be a good option for hormonal acne.
This is a relatively gentle acne-fighting ingredient8, so if your skin is sensitive you’ll want to look for products with salicylic acid. It helps exfoliate the skin and remove excess oil without irritating it, as long as it’s used in concentrations of 2% or lower. Many over-the-counter products contain salicylic acid, but it’s also available at prescription strength if you speak with your dermatologist. Remember it’s always best to start with the lowest concentration and work your way up if it doesn’t provide the results you’re looking for.
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