June 4, 2023

Hormonal acne can be very difficult to treat and one of the most popular acne prescriptions you can get is spironolactone. And it’s available in both oral and topical forms. We chatted with board-certified dermatologist Dr. Sam Ellis to learn all about spironolactone to help you find out if it’s right for you.

If you deal with hormonal acne there is an ingredient called spironolactone you can get that either as an oral prescription or a topical prescription and i recently posted about it and realized there were so many people that had questions so i decided to have some of my followers on instagram submit questions and then i decided to bring on dr sam ellis she is

A board-certified dermatologist in danville california she also has a new youtube channel so i’m excited to have her join us for this hi dr ellis hi susan thanks for having me so this is a really interesting topic i posted about topical spironolactone recently and i realized that people didn’t necessarily know what it does so i think the first question is what

Is spironolactone and how does it work sure so spironolactone is a medication that initially came to market as a blood pressure medication so it’s actually a diuretic meaning that it makes you pee out a little bit of extra fluid but what we also found is that spironolactone is an anti-androgen so it basically inhibits the effects of the male hormone in the body

So when you take it orally you have less circulating testosterone and other androgens and we know that those hormones stimulate acne and when you use it topically or when you take it orally as well it also competitively inhibits testosterone and other androgens from binding to the oil glands in the skin so that those acne causing oils don’t build up in the skin

And don’t provide food for acne causing bacteria so that explains why it’s really only something that’s prescribed to women orally exactly you don’t want to competitively inhibit testosterone in males they’re usually not big fans of that but for women and especially for when they’re struggling with hormonal acne it’s a big win for them so tell us a little bit

About you know are there like side effects to it are there people that can’t use the oral version of it it is a diuretic and that’s why we it works well for people with high blood pressure because it does make you pee out a little extra fluid and for a lot of women that diuretic or extra pee production is not really noticeable especially if they take their pill

At night but that is certainly one of the most common side effects other things that can happen are like breast tenderness some people can get lightheaded when they stand up if they were to not be staying up on their fluids and then there are more rare side effects like headaches and tummy upset and things like that and because it’s blocking androgens is that one

Of the reasons why only women can take it right so men actually do take spironolactone they call it aldactone for men when they have high blood pressure but in much lower doses i would never give it to a guy orally to treat their acne because exactly it’s estrogenic so the main side effect for men is that they can develop breast tenderness and breast enlargement

And i would say the vast majority of my male patients that is not a side effect they’re seeking so then it’s exciting that we can also access it topically is this something that’s new or is this something that’s been available for a while so it has been available i think actually since like the early 90s they’ve had sprouted lactone in a topical formulation that

Occasionally would get compounded into certain acne topicals but it’s not something that ever came to the forefront and there’s not a ton of data to support that it’s as effective as oral but like you said for guys who might not tolerate other topical acne medications can’t be on certain oral things for various reasons it might be a good option to help decrease

Oil production and then decrease overall number of acne bumps all right so i actually thought that topical spronolactone was only newly available because i only just started to hear about it so tell me a little bit more about what we know i guess about what topical sprotolactone does yeah so it’s been around for at least a couple of decades and pharmaceutical

Compounding pharmacies around the us will often compound it into topicals to treat acne or to treat hair loss but it’s never come to like the forefront of the acne market and i think probably because there’s just not tons of clinical studies that study it compared to oral spironolactone but there is a study that shows that a form of topical five percent topical

Spironolactone did block androgens from binding the oil gland so in theory it does and can work there’s just not as much data to support it out there compared to oral spironolactone so who would be the right candidate for oral spironolactone or even topical spronoloctone at least in my practice the vast majority of the spironolactone i prescribe is for women

In their 20s or above but usually before menopause who are dealing with hormonal acne so typically that lower face jawline cystic acne neck acne or even my patients who have had good improvement of their acne on their birth control pill but need a little extra boost you can add oral spironolactone to continue to help with their acne so one of my worries about

Taking oral spronolactone is when i was on birth control i had perfect skin so i feel like i’m the like the best candidate for oral spronolactone but i guess i worry that then i’m committing myself to taking it forever because when i got off of birth control years ago i had major breakouts that i had to adjust to and i basically it was like the first time i

Had to start using tretinoin and everything just really commit to it because i had the worst hormonal breakouts yeah and that is so frustrating for people and that is a huge question i get from patients is like okay dr ellis if i go on this what’s what’s our end game here and really i try to explain to patients that hormonal acne is a chronic skin condition it’s

Like having high blood pressure it’s like having diabetes it’s something that you have for your lifetime or at least till you hit menopause and so you should treat it like that with medication and so my patients go on spironolactone with the expectation that they’ll probably be on it long term and if their acne bothers them to a significant degree it’s worth it

For them and i’ve had many patients on spironolactone for years and years and they’re super happy oh so you can stay on it just kind of indefinitely yeah it’s safe to be on very long term and we know that too from the patients who take it for high blood pressure they’re on it for decades and decades and they do great and i know you’re saying that you essentially

Don’t really prescribe topical spronolactone to anyone but if you did who would be the ideal candidate so if someone had been on a birth control pill or had tried spironolactone and maybe seen good results but couldn’t tolerate the side effects of the oral medication that would be someone who i think might do well also men can use topical spironolactone without

The risk of feminization so if there was a guy who was not responding to some of the other acne topicals and didn’t want to take oral medication i think spironolactone topically is an option for that type of patient can you use spronolactone whether topically or orally in conjunction with other treatments i guess for acne yeah you absolutely can so anytime

You add another prescription topical to your regimen there’s an increased risk of redness and irritation and things like that but spironolactone tends to be pretty well tolerated so i you could add it in i would talk with your dermatologist or your prescribing provider about how they’d want you to incorporate it but i definitely think it could be an adjunct

Treatment now that we’ve been talking i think i know the answer to this question but i got my topical spironolactone from apostrophe it’s one of those services online where you like sign up you tell them all your symptoms everything that you’re experiencing and then a dermatologist gets back to you and starts to prescribe you stuff so i was prescribed oral

Spronaloctone and then also a compound actually they gave me tretinoin 0.025 because i was like i’m sensitive and still very legit is that oh good i’m so glad and then they gave me the spironolactone 5 and tranexamic acid five percent is is this one of the only ways that you can get topical spronolactone or can somebody just go see their dermatologist yeah so

The way you would get it from a dermatologist is they would have to contact a compounding pharmacy and they would have to formulate it especially for that particular patient so it actually is probably easier to get topical spironolactone through a company like apostrophe but you’re saying that you’re not positive about the results yeah and i would say yeah i’ve

Been to a lot of meetings where there’s a lot of thought leaders and people who research acne all the time and spironolactone is a talk done by some amazing dermatologist every year at our academy meeting and topical spironolactone comes up a lot when you say that there aren’t a lot of studies about it you you’re not necessarily saying that people shouldn’t

Use it right because it’s more that you just can’t really guarantee anything totally it’s safe like there’s no problems with it it’s more about there’s just not as much data but there are plenty of things people use on their skin that people have great results from and there’s just not the clinical data to support it so i’m not anti-topical spironolactone but

I’m very pro-oral spironolactone okay so then let’s be clear who cannot take spironolactone let’s start orally who cannot do spironolactone okay so generally orally the people who should not take it i would say generally men but also people who have certain types of kidney disease because one of the side effects of oral spironolactone is elevated potassium

Levels and very high potassium levels can cause cardiac arrhythmia so irregular heartbeats that can be problematic and so if you have issues with your kidneys you are more prone to basically have elevated potassium and then there’s certain people who might be on other medications from their doctors that could interfere so it’s always important whenever you’re

Getting prescribed spironolactone to make sure who’s ever prescribing it knows what other medications you take on a regular basis which is just sound advice in general right yes absolutely okay so then when it comes to the topical spironolactone who is not okay to take it pretty much no one i guess if you are if you are pregnant i would talk to your ob gyn

About it because even though it’s topical it’s not studied in pregnant patients so you kind of want to get the go-ahead there maybe even if you’re trying to actively conceive i i consider not using it and then people who have super sensitive skin who might not be able to tolerate any prescription topicals but in general i think most people could use it the

Question that people ask the most was in reference to either breastfeeding or pregnancy and whether they can take it orally or even topically yeah so definitely not when pregnant and because it blocks androgens so male hormones the risk with taking it when pregnant is that it could feminize a male fetus now this has never actually happened to a human fetus

Before but it’s still a theoretical risk that we warn about so usually if you’re trying to conceive we’ll have you stop spronolactone orally and then if you’re breastfeeding i’m okay with my patients taking it when breastfeeding the world health organization recognizes that very scant amounts of spronolactone when taken orally actually make it into breast

Milk and they’re not worried that it causes any problems so it’s something you would definitely want to discuss with your ob gyn and your pediatrician but generally spironolactone is safe for breastfeeding moms and no matter what people shouldn’t freak out if they find that they’re pregnant they were taking it they just should stop talk to their doctor right

There’s actually a study that has a hint you know some women who that exact scenario happened to and all of their babies turned out just fine with no birth defects or any issues and then with topically i would recommend the same thing topicals bernalicton is just not as well studied so i would say the same in terms of guidelines this is actually a really good

Question so if you have low blood pressure can you use spronolactone either orally or topically yes you can so for my patients who have super low blood pressure and this is the concern here is that it makes you pee out extra fluid and so will that make you feel light-headed when you stand up will that drop your blood pressure it generally only drops people’s

Blood pressure about five percent so if you have super low blood pressure you might be sensitive to it so it’s something we keep an eye on but generally it’s not an issue if you have low blood pressure to take spironolactone or add it to your regimen all right so going back to topical spironolactone somebody was asking whether that can also essentially act as

A diuretic since you’re not actually taking it orally does it still act the same way i don’t know if there’s any study that shows this i would be shocked if the amount that gets absorbed systemically makes it to the kidneys increases urination is an issue so i would my feeling on this is no but i couldn’t say for certain yeah right that that’s a safe yeah if we

Don’t know we don’t know this is a really interesting question a lot of people don’t realize myself included i didn’t know this oral spironolactone can be prescribed if you have hair growth issues right so would topical spronolactone then cause hair growth or even oral spronolactone cause hair growth in other places where you don’t want it and i’m doing this

Right here because it’s you know this is the place i don’t want is like my mustache area yeah absolutely so actually for women who are have a condition called hirsutism so excess hair growth on the face or on the body usually in the setting of having excess male hormone floating around in their bloodstream we use bronolactone to treat excess hair growth so no

It should not cause any problems of increased hair growth on the face but we also prescribe it for women who have kind of female pattern hair loss on their scalp and it paradoxically increases hair growth on the scalp so yeah if you use it topically on your face i’d be surprised if it increased hair growth i’ve never heard of that happening but it’s i guess

It’s a possibility so with both oral spronolactone and topical spronolactone how long do you think people should wait before they generally start to see results so people can see results at least with oral spironolactone pretty quickly usually within one menstrual cycle so a month people will notice improvements a lot of the studies do 12 weeks so i usually

Recommend for my patients that they wait a full three months to get a sense of if things are working for them but anecdotally patients will tell me like oh yeah within my first period i could tell i had fewer like pre-menstrual breakouts so just in general i’d give spironolactone a few months to work if somebody were trying the topical spironolactone how long

Do you think they should wait to see results with that i’d also give that three months because first you have to decrease oil production and then you have to kind of see if how your acne lesions respond to that so i’d give that a few months as well this is actually another really good question is spironolactone safe for teenagers yeah it is i generally wait for

Prescribing it orally i generally wait for my girls to have their first period but once they start menstruating i’m totally fine with putting them on spironolactone usually i’ll try to put them on a birth control pill first but if there are certain reasons that they can’t go on a birth control pill like a very strong family history of breast cancer or something

Like that but they still have that very strong hormonal acne component i’ll use spronolactone instead actually so then do people actually pair birth control and bronolactone together is that possible yes it’s very possible so birth control pills but also other forms of birth control like hormonal iuds and things like that so with birth control pills you can

Get some improvement of your hormonal acne but spironolactone to me is like a birth control booster it doesn’t make your birth control in terms of not getting pregnant more effective but it does make the acne component better for some patients so if you’ve seen improvement with the birth control pill and you just need a little more oomph we can add spironolactone

But also a lot of patients will get flaring of their acne when they get like a mirena iud or other types of hormonal iuds and so i’ll use spronolactone in them to kind of counteract the hormonal acne that gets driven by the iud because a lot of the time when you’re getting on some type of birth control your hormones just kind of go get a little out of whack

Right completely and the iuds are very progesterone dominant and we know progesterone drives acne so sometimes you need that estrogen or those estrogenic effects of spironolactone to counterbalance that and then the last question is there a purging period no there generally shouldn’t be so purging happens usually when you start oral or topical medications that

Increase cell turnover so retinoids alpha hydroxy acids beta hydroxy acids those types of things with spronolactone the mechanism is really just to decrease oil production and decrease the circulating androgens in the bloodstream and in the skin so there really shouldn’t be this period where you’re noticing more pimples come up to the surface all right so that

Was spironolactone i feel like i learned a lot of stuff in this chat with you dr ellis it was very informational thank you i’m so happy i love spironolactone i am a spironolactone champion i prescribe it all day long in my practice so i’m glad we could talk a little bit more about it and hopefully some of the followers here learn something as well yeah definitely

Where can everybody find you on social media so i have an instagram which is at dr samantha ellis and i have a new youtube channel as well so you guys should come hang out with me and subscribe definitely i will make sure that it is linked in the description box you guys can also find me at susan yara on instagram and i’ll talk to you soon bye

Transcribed from video
Treat Hormonal Acne with Spironolactone: A Dermatologist Explains | DERM CHAT By Mixed Makeup