Among my closest group of girlfriends from college, four out of the five of us have taken spironolactone at some point in our lives. When I first mentioned that I was going on it, the resounding response from my friends was, "It's the best!" This made this wonder if I was the last person to learn about this magical acne-zapping pill.
I've been on spironolactone since 2018 and can't imagine going off of it unless I decide to become pregnant. Like many people with uteruses, I was first prescribed spironolactone after getting an IUD (Mirena) implanted in 2018.
Right before my OBGYN shoved a piece of plastic into my cervix, she said to let her know if I started breaking out. Lo and behold, angry cysts cropped up on my face six weeks later, leaving me self-conscious in a way that I hadn't felt since high school. My OBGYN wrote me a prescription for spironolactone and within a few months, my skin was clearer than it had been before the IUD.
"Spironolactone is one of my favorite systemic treatments for female acne," shares Kimberly Shao, MD, a board-certified dermatologist in Dayton, Ohio. "Females with moderate to severe inflammatory acne of any skin tone would be good candidates."
With a huge increase in people with uteruses seeking long lasting birth control in the wake of the Roe reversal, demand for IUDs has gone up. A survey conducted by the Harris Poll on behalf of TIME magazine in July found that 21 percent of women "reported changing their primary contraception method" since the June 24 ruling. Seventeen percent of those surveyed said their primary method of birth control was an IUD or implant.
So it's not hard to imagine an increased demand for spironolactone, either. That's because "hormonal IUDs like Mirena, Skyla, and Liletta have been associated with worsening acne, particularly for those who breakout before their period," Dr. Shao adds. "Some suggest that this occurs mostly in patients who have switched from a birth control pill to an IUD (since the birth control pill had been helping to control acne symptoms). Others suggest that the IUD itself may worsen acne due to the hormone progestin that is released."
- Kimberly Shao, MD, a board-certified dermatologist at Dayton Skin Care in Dayton, Ohio
- Sejal Shah, MD, a board-certified dermatologist at SmarterSkin Dermatology in New York City
- John S. Barbieri, MD, board-certified dermatologist and director of the Advanced Acne Therapeutics Clinic in the Department of Dermatology at the Brigham and Women's Hospital (formerly the dermatology chief resident at the Perelman School of Medicine at the University of Pennsylvania).
What is spironolactone?
Spironolactone was approved by the Food and Drug Administration (FDA) in 1960 to treat high blood pressure and heart failure. For the past two decades, it's also been prescribed as a treatment for hormonal acne in women. You know the type: it flares up in cadence with your menstrual cycle, often along the jawline. Spironolactone works by blocking androgen hormones from overstimulating your oil glands, leaving your pores unclogged and your face clearer as a result.
Who is spironolactone for?
While most women can tolerate spironolactone well, it's not for everyone. "It does have a number of potential side effects, including fatigue, increased urination, irregular periods, and breast tenderness," says Sejal Shah, MD, a board-certified dermatologist in New York City.
While side effects like increased urination are more common, spironolactone can also cause muscle pain, irregular heartbeat, and confusion, and since the drug is technically a blood pressure medication, your doctor will want to know if you have low blood pressure already.
Despite its high rates of success — a 2017 study of 110 women taking spironolactone had only 11 not see any improvement in their acne — Dr. Shao says that not everyone is a candidate to take spironolactone. Those with "chronic adrenal insufficiency (Addison's disease), high potassium levels, impaired kidney function, [or] low blood pressure" should not take it, nor should anyone who is pregnant or trying to become pregnant. Spironolactone has been linked to serious birth defects in fetuses, and The American Academy of Dermatology says "you'll need to use birth control while taking spironolactone."
Lynnae, a 38-year-old in Brookline, Massachusetts, has used spironolactone to manage painful cystic acne for the past decade. "It made a marked difference within two months, and I've been free of widespread breakouts ever since," she says. "I almost always see a few zits come back if I don't go back to it." But even she deals with a (slightly) negative side effect: period irregularly.
Males with acne should not take spironolactone as it suppresses testosterone, which can lead to side effects, such as breast growth. Patients who are or have transitioned from female to male should not take spironolactone for the same reason. Many transgender women, on the other hand, are prescribed spironolactone to suppress testosterone as a part of their hormone replacement therapy.
Should I take spironolactone or antibiotics for acne?
Unlike the antibiotics also commonly used to treat acne, spironolactone is considered safe for long-term use. A 2021 study published in the American Journal of Dermatology concluded that "Spironolactone improves clinical outcomes and is well tolerated for many adult women with acne using it for an extended duration."
Though antibiotics are effective at fighting acne, "prolonged antibiotic use can result in antibiotic resistance," John S. Barbieri, former dermatology chief resident at the Perelman School of Medicine at the University of Pennsylvania, says. "It may even be associated with the development of inflammatory bowel disease, breast cancer, and colon cancer," he says. For this reason, the American Academy of Dermatology recommended using acne antibiotics only for "the shortest possible duration" — ideally less than three months — in a separate 2016 report on acne guidelines.
Translation? Dermatologists need a drug alternative for treating acne. And they have a very good one in spironolactone. In Barbieri's 2018 study published in the Journal of Drugs in Dermatology, he and his team compared tetracycline antibiotics with spironolactone; both options had been prescribed for treating acne. They analyzed data on more than 6,600 women and girls taking spironolactone to over 31,000 taking antibiotics.
To determine "effectiveness," the researchers then looked at how many women in each group had switched to another type of treatment within a year — a sign their first treatment wasn't working. The found just over 14 percent of spironolactone patients made a swap compared to just over 13 percent of patients on acne antibiotics.
The 1 percent difference suggests spironolactone is basically as effective at treating acne, without the risk of overloading on antibiotics. Anecdotally, the two drugs appear to work equally as well in her practice, Dr. Shah tells Allure. "It's really a case by case basis. Some patients respond better to antibiotics, whereas, others do better with spironolactone," she says. "However, we do need more data comparing the two options directly."
Is there a topical version of spironolactone?
For those unable to take spironolactone orally due to their gender or health risks such as low blood pressure or high potassium, there is an antiandrogen medication called clascoterone — also known by the brand name Winlevi and referred to as a topical form of spironolactone — that can be applied twice a day to the whole face.
Although larger comparative studies have yet to be released, a 2021 study of 78 people showed that 5 percent topical spironolactone is just as effective at preventing acne as oral medication. Clascoterone is FDA-approved for people of all genders 12 years or older, opening up antiandrogen acne treatments to a much wider audience.
As someone who loves to spread the good word of spironolactone, I'll definitely cheers to that.
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