Spironolactone, a medication initially developed to treat high blood pressure, has become an increasingly popular treatment for hormonal acne. Although primarily used for women experiencing hormonal acne, it has also shown promising results in other forms of acne treatment. In this comprehensive guide, we will explore the benefits and effectiveness of spironolactone for acne, how it works, the time it takes to see results, and potential side effects.

Spironolactone is a potassium-sparing diuretic, initially prescribed for treating high blood pressure, heart failure, and conditions causing excess fluid retention. Over time, dermatologists and researchers discovered its androgen-blocking capabilities, which are beneficial for treating acne caused by hormonal imbalances.

The Role of Androgens in Acne

Androgens are a class of hormones that include testosterone and dihydrotestosterone. While they are commonly referred to as "male hormones," they are also present in women. Androgens can stimulate oil production in the skin, leading to clogged pores and acne breakouts. Spironolactone's androgen-blocking properties help regulate hormone production and prevent excessive oil secretion, making it an effective acne treatment.

Benefits of Spironolactone for Acne

Spironolactone helps address various skin and hair conditions caused by androgens, including:

• Hormonal acne in women in their 20s and 30s
• Acne during perimenopause
• Acne caused by hormone replacement therapy (HRT) or testosterone as part of HRT
• Female pattern hair loss
• Excessive body hair

Spironolactone can be used alone or in combination with other acne treatments, depending on the severity and cause of the acne.

How Spironolactone Helps Hormonal Acne

Spironolactone helps control hormonal acne by blocking the effects of androgens and progesterone on the skin. By reducing hormone activity on hair follicles and sebaceous glands, it provides several benefits:

• Fewer inflamed spots, especially nodules and cysts
• Fewer comedones (skin-colored bumps that can become inflamed spots)
• Less greasiness in the skin, resulting in a visibly less oily appearance

Effectiveness of Spironolactone for Acne in Women

Several medical reports and studies have demonstrated the effectiveness of spironolactone in treating hormonal acne in women. Overall, it has been found to help control hormonal acne in about 60 to 65% of women.

A study involving 400 women treated with spironolactone showed that 93% of those who had never received other acne treatments before experienced improvement. In the group of 253 women who had previously tried other acne treatments, 87% saw improvement when spironolactone was added.

Other studies have reported improvement rates of:

• 93% in 147 women who had never been treated for acne, and 87% in 253 women who had previous acne treatment (Gradhi et al)
• 71% in 70 women (Isvy et al)
• 55% in 110 women cleared completely with spironolactone, and another 30% improved significantly (Charney et al)

Important Considerations for Spironolactone Treatment

When considering spironolactone as a treatment for acne, it's essential to keep the following points in mind:

• Spironolactone does not work for everyone, but it helps approximately 65% of women with hormonal acne. It is not possible to predict who may benefit and who may not.
• Some women may experience complete clearance of acne with spironolactone, while others may only see a reduction in acne but not complete clearance. This means additional acne treatments may still be necessary while taking spironolactone.
• Spironolactone can take 3 to 6 months to have its full effects, and waiting for results can be frustrating.
• The medication only works while you are taking it, which means your acne may return when you stop. Women may need to be on spironolactone for 1 to 2 years or sometimes even several years.
• Spironolactone can cause side effects. Approximately 1 in 20 women may need to reduce or discontinue spironolactone due to side effects.

Risks and Side Effects of Spironolactone

As with any medication, it's important to weigh the risks and benefits of spironolactone. About 1 in 20 women may experience side effects that require them to reduce their dose or stop taking the medication. Some potential side effects include:

• Acne flare-ups in about 5% of people
• Increased urination frequency for the first few weeks (29%), which usually settles within a month
• Menstrual irregularities, including heavy or irregular cycles, spotting, discomfort, or amenorrhea (when periods stop altogether) - 22%
• Breast tenderness (17%)
• Breast swelling
• Bloating
• Headache
• Nausea
• Dryness of the skin
• Fatigue
• Reduced libido
• Elevated potassium levels in the blood - 0.75%-2% for those under 45 years of age, and up to 16% for women over 46 years of age
• Reduced kidney function
• Reduced sodium levels in the blood
• Feminization of a male baby - it is essential to avoid pregnancy while on spironolactone as it can cause a male baby to become feminized by blocking androgens
• Theoretical risk of cancers with very long-term use - At medicinal doses, spironolactone has not been associated with cancer. However, animal studies using 150 times the human dose found increased benign and malignant tumors. This does not appear to be relevant for doses used for acne treatment.

Low Potassium Diet

While taking spironolactone, you should avoid potassium supplements and limit your intake of high-potassium foods. Cooking potatoes and other vegetables in ways that reduce their potassium content can be helpful. A low potassium diet is especially important if you are over 45 years of age or have other kidney conditions or medications that could affect potassium levels in your body. Consultation with a private registered dietitian can be helpful in managing a low potassium diet.

Duration of Spironolactone Treatment

Spironolactone is typically required for as long as acne is a problem. Most women will be on treatment for a year or two, and some may need treatment for several years. It is possible to reduce the dose and try without medication after a year of treatment once acne has been fully controlled.

How Long Does Spironolactone Take to Work?

Spironolactone is usually started at doses of 25-100mg per day and increased every 6 to 8 weeks until a dose that improves acne is reached. There are many variations to this regimen. Improvement in acne can take 3 to 6 months to be seen, with the usual dose for skin concerns being 50-150mg per day.

Pregnancy and Breastfeeding

Pregnancy and breastfeeding must be avoided while taking spironolactone due to the risk of birth defects and potential harm to the baby.

Required Appointments and Monitoring

Regular consultations and blood tests are necessary if you choose to use spironolactone for acne treatment. Follow-up appointments are typically required every 6 to 8 weeks, with more frequent consultations if side effects occur. Once your skin and medications are stable, consultations are required every 4 months.

Blood tests are needed to monitor potassium levels and kidney function:

• A blood test is required 2 and 6 weeks after starting treatment and after any change in dose.
• Once the dose is stabilized, blood tests are required every 3 to 4 months while on treatment.
• For those under 45 years of age, it is reduced to every 6 months in the second year of treatment.
• For those over 45 years of age, blood tests may be required monthly in the first 3 to 6 months, especially if there are any changes.

Spironolactone's Unlicensed Status for Acne in the UK

It is important to note that spironolactone is not licensed for acne treatment in the UK. This means that if you choose spironolactone as a treatment, you cannot continue under the care of your general practitioner (GP). You should factor this in when considering the costs of private spironolactone treatment.

Despite its effectiveness, spironolactone is not included in the UK Guidelines for Acne Treatment due to the lack of high-quality evidence compared to other established acne treatments. Until larger and more statistically sophisticated studies are conducted, spironolactone will remain unlicensed in the UK.

You can only receive a prescription from a doctor experienced in using this medication for acne, who has assessed you to deem the benefits outweigh the risks. You must also take the time to read information on unlicensed medications and agree that you feel the benefits outweigh the risks.

Discussing Spironolactone as a Treatment Option

If you are interested in discussing spironolactone as a treatment for acne, consult with a dermatologist or healthcare provider experienced in using this medication for acne treatment. They can help you determine if spironolactone is suitable for your acne and guide you through the process of starting and monitoring the treatment.

In conclusion, spironolactone is a promising treatment option for women experiencing hormonal acne. Although it may take several months to see significant improvements, the benefits of this medication can be life-changing for those struggling with persistent acne. Consult with a dermatologist or healthcare provider to determine if spironolactone is the right treatment for your acne and to discuss any potential risks or concerns.