Hormonal acne treatments: weighing the benefits and risks

Spironolactone and oral contraceptives are good for treating acne, but providers should be familiar with their side effects and risks, said Julie Harper, MD, in a presentation at Maui Derm for Dermatologists 2022, being held Jan. 24-28 in Maui, Hawaii.1

Julie Harper, a board-certified dermatologist in private practice at the Dermatology and Skin Care Center of Birmingham in Alabama, provided a roadmap with detailed recommendations for using these drugs to achieve optimal results and to assess their AEs and risks. Spironolactone is an antiandrogen that has been shown to be effective in treating acne, although it is not FDA approved for this purpose.1

Harper recommended a maximum dose of 100 mg once daily and suggested using it in conjunction with topical treatments such as retinoids, benzoyl peroxide, topical dapsone, and topical antibiotics. It can also be used with oral medications such as doxycycline, minocycline, sarecycline (Seysara; Almirall), oral contraceptives, and isotretinoin.1

“Using spironolactone in combination with oral contraceptives decreases irregular menstrual periods and prevents pregnancy, which is important because its antiandrogenic properties may increase the risk of feminization in late first trimester male fetuses,” Harper said.

The possible side effects of spironolactone increase with higher doses and include menstrual irregularities, breast tenderness and/or swelling, fatigue, headache, diuresis and orthostatic hypotension, she noted.1 It can be used long-term except when patients experience severe side effects or are pregnant , or acne goes away, Harper said.

As for the risks, she highlighted a study by Plovanich et al showing that spironolactone carries a low risk of hyperkalemia, so healthy patients’ potassium can be monitored while taking the drug.2 Elderly patients, those with a history of heart or kidney disease or impaired liver function, and those on high doses of potassium should be monitored, Harper said. In addition, patients taking ACE inhibitors, angiotensin II antagonists, aldosterone blockers, nonsteroidal anti-inflammatory drugs (NSAIDs) such as indomethacin, salt substitutes, potassium supplements, and rimethoprim/sulfamethoxazole require monitoring of potassium levels.1

Harper noted that spironolactone has a black box warning and is tumorigenic in chronic toxicity studies in rats, therefore it should only be used under certain conditions according to the Usage and Indications information. She said there was no evidence of an increased risk of breast, uterine or ovarian cancer with its use. It shouldn’t be used during pregnancy, but is found in small amounts in breast milk and is considered safe for breastfeeding, she added.1

Oral contraceptives can also be used to treat acne, including ethinylestradiol 10-50 mg and 1st-4th generation progestins.1 When using oral contraceptives to treat acne, providers should take a complete medical history to avoid serious side effects, Harper said. The FDA has approved Ortho-Tri-Cyclen (Janssen Pharmaceuticals), Estrostep FE (Warner Chilcottt Inc) and Yaz (Bayer) for treatment, it reported.

Risks of taking oral contraceptives include venous thromboembolism, stroke, myocardial infarction, and breast cancer.1 A thorough medical history is essential before prescribing oral contraceptives to treat acne, Harper said. She warned that patients who are pregnant, breastfeeding less than 6 weeks after childbirth, are older than 35 years and are heavy smokers (more than 15 cigarettes/day), high blood pressure, diabetes mellitus with nephropathy, retinopathy, neuropathy or vascular diseases have a history of deep vein thrombosis, heart disease, or stroke should not receive this treatment.

In addition, patients with migraine headaches (with focal neurological symptoms at any age or without focal neurological symptoms but older than 35 years) and/or patients with cirrhosis or liver tumor (benign or malignant) should also not be prescribed oral contraceptives for acne.1 Providers should note that some antibiotics interfere with contraceptive effectiveness and advise their patients of this.1 Patients should see improvement in acne after 3 pill cycles, Harper said.


1. Harper JC. Oral contraceptives and spironolactone for acne. Presented at: Maui Derm 2022; January 24-28, 2022; Wailea, Hawaii.

2. Plovanich M, Weng QY, Mostaghimi A. Little benefit of potassium monitoring in healthy young women taking spironolactone for acne. JAMA Dermatol. 2015;151(9):941-944. doi:10.1001/jamadermatol.2015.34.

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