spironolactone in acne vulgaris

Last edited 05/2023 and last reviewed 05/2023

• spironolactone is widely used in the USA in the management of acne - however it is unlicensed for acne in the UK
• in the UK spironolactone may occasionally be used off-licence on the recommendation of specialists (1,2)
  • this is especially in women with hirsutism or polycystic ovarian syndrome
  • spironolactone has antiandrogenic properties (1)
    • administered either continuously or premenstrually for 7-10 days to prevent cyclical flares of acne
    • should not be taken during pregnancy and may cause intermenstrual bleeding
      
      
  • study evidence with respect to use of spironolactone in women showed (2):
    • spironolactone improved acne on all outcomes: not all outcomes were significant at 12 weeks, but all were significant at 24 weeks
    • spironolactone at doses of 50 mg and 100 mg were well tolerated with mild side effects similar to placebo
      • adverse effects were more common with spironolactone (20% vs. 12%, p=0.02)
    • spironolactone could provide a useful alternative to oral antibiotics for women with persistent acne where first line topical treatments have not worked
    • a commentary noted (3):
      • this study shows that, for women with acne that persists despite topical treatment, prescribing oral spironolactone alongside topical treatment has the potential to significantly reduce long term oral antibiotic prescribing

Reference:

1. Prescriber (September 5th 2006): 44-55.
2. Santer M, Lawrence M, Renz S, Eminton Z, Stuart B, Sach T H et al. Effectiveness of spironolactone for women with acne vulgaris (SAFA) in England and Wales: pragmatic, multicentre, phase 3, double blind, randomised controlled trial BMJ 2023; 381 :e074349 doi:10.1136/bmj-2022-074349
3. Santer M, Layton A. What do we know about prescribing spironolactone for acne? BMJ 2023; 381 :p1114 doi:10.1136/bmj.p1114