Spironolactone for Female Acne is Safe and Effective
by Jeffrey Dach MD
My patient, Rebecca lives in Shanghai so we do our follow up called via Skype video conference. On the last call, I asked Rebecca, “how are you doing?”, and she informed me , ” Oh, I’m OK except for these annoying acne breakouts.” We then launched into a discussion of acne prevention with vitamin B5 and L-carnitine as described in my previous article.
Afterwards, I realized I forgot to mention an old blood pressure drug called spironolactone which also serves as an anti-acne drug by inhibiting testosterone. We have many patients finding it is helpful in controlling acne. Usual dosage is 100 mg daily. Left Image Mona Lisa with Acne courtesy of Leonardo Da Vinci and Paris Louvre Museum..
Dr. Marchbein believes spironolactone should be first-line therapy and standard of care for adult women with acne. He says:
“even though spironolactone is not indicated as a first-line treatment in the newest acne guidelines. I think we are doing a disservice to our acne patients by not positioning spironolactone as first-line therapy.”(1)
Jeffrey Dach MD
Articles with Related Interest:
References:
1) Spironolactone safe and effective for adult female acne. Bob Kronemyer Jun 23, 2017 Dematology Times.
2)Layton, Alison M., et al. “Oral spirono-lactone for acne vulgaris in adult females: a hybrid systematic review.” American journal of clinical dermatology 18.2 (2017): 169-191.
3) Barbieri, J. S., et al. “Frequency of Treatment Switching for Spirono-lactone Compared to Oral Tetracycline-Class Antibiotics for Women With Acne: A Retrospective Cohort Study 2010-2016.” Journal of drugs in dermatology: JDD 17.6 (2018): 632-638.
4) Charny, J. W., J. K. Choi, and W. D. James. “Spirono-lactone for the treatment of acne in women, a retrospective study of 110 patients.” International journal of women’s dermatology 3.2 (2017): 111-115.
5) Kelidari, Hamid Reza, et al. “Spirono-lactone loaded nanostructured lipid carrier gel for effective treatment of mild and moderate acne vulgaris: A randomized, double-blind, prospective trial.” Colloids and Surfaces B: Biointerfaces 146 (2016): 47-53.
6) Grandhi, Radhika, and Ali Alikhan. “Spirono-lactone for the Treatment of Acne: A 4-Year Retrospective Study.” Dermatology 233.2-3 (2017): 141-144.
7) Layton, Alison M. “Top ten list of clinical pearls in the treatment of acne vulgaris.” Dermatologic clinics 34.2 (2016): 147-157.
8) ur Rehman, Habib, et al. “Treatment of Post Adolescent Female Acne with Spirono-lactone and Low Dose Isotretinoin.” National Editorial Advisory Board 29.5 (2018).
9) Carter, David. “Potassium Monitoring in Young Women Taking Spirono-lactone for Acne is Unnecessary.” AJN The American Journal of Nursing 115.6 (2015): 57.
10) Harper, Julie C., et al. “Treating Acne in Adult Women.” Dermatology News® (2018): 12.
11) Bagherani, Nooshin. “Efficacy of topical spirono-lactone in treatment of acne.” Dermatologic therapy 28.3 (2015): 176-176.
12) Schlosser, Bethanee J. “Hormonal Therapy for Acne: Pros and Controversies.” (2017).
13) Diri, Halit, et al. “Comparison of spirono-lactone and spirono-lactone plus metformin in the treatment of polycystic ovary syndrome.” Gynecological Endocrinology 32.1 (2016): 42-45.
14) Carol, R. “Hormonal therapies serve as key adjunct acne treatment.” Dermatol World. 2012 May (Acne suppl). 2-6.
15) Ebede TL, Arch EL, et al. “Hormonal treatment of acne in women.” J Clin Aesthet Dermatol. 2009; 2(12): 16–22.
16) Harper JC. “Use of oral contraceptives for management of acne vulgaris. Practical considerations in real world practice.” Dermatol Clin. 2016;34(2):159-65.
17) Kim GK, Del Rosso JQ. “Oral spironolactone in post-teenage female patients with acne vulgaris: Practical considerations for the clinician based on current data and clinical experience.” J Clin Aesthet Dermatol. 2012;5(3):37-50.
18) Plovanich M; Weng QY, et al. “Low usefulness of potassium monitoring among healthy young women taking spironolactone for acne.” JAMA Dermatol. 2015;151(9):941-4.
19) Reynolds RVS. ‘Hormonal treatment for acne.” Presented during the forum: Acne guidelines: Translating evidence into practice. 2017 Annual Meeting of the American Academy of Dermatology; 2017 March 3-7. Orlando, FL.
20) Zaenglein AL, Pathy AL et al. “Guidelines of care for the management of acne vulgaris.” J Am Acad Dermatol. 2016;74:945-73.
Spironolactone
21) Roberts, Erin E., et al. “Use of spironolactone to treat acne in adolescent females.” Pediatric dermatology 38.1 (2021): 72-76.
Background/objectives: Studies assessing the utility of spironolactone for treating acne in adolescent females are lacking. Thus, we sought to examine spironolactone’s role in treating this patient population.Methods: A retrospective review was performed to determine the efficacy of spironolactone treatment in adolescent females seen at Mayo Clinic in Rochester, Minnesota, from 2007 to 2017.
Results: In a cohort of 80 pediatric patients with a median age of 19 years (range, 14-20 years), 64 patients (80%) experienced improvement of acne on treatment with spironolactone (median dose, 100 mg daily) with a favorable side effect profile. Approximately a quarter of patients (22.5%) had a complete response; more than half (58.8%) had a complete response or a partial response greater than 50%. Initial and maximal responses were observed at a median of 3 months and 5 months, respectively. Patients received treatment with spironolactone for a median duration of 7 months (range, 3-45 months) with limited side effects.Conclusions: Spironolactone demonstrated efficacy in treating acne in adolescent females and is a safe long-term alternative to systemic antibiotics in these patients.
Garg, Vaibhav, et al. “Long-term use of spironolactone for acne in women: A case series of 403 patients.” Journal of the American Academy of Dermatology 84.5 (2021): 1348-1355.
Background: There are limited data regarding the long-term outcomes of spironolactone use for women with acne and its effect on truncal acne.
Objective: To comprehensively describe outcomes of patients treated with spironolactone in routine clinical practice, including long-term outcomes.
Methods: We performed a retrospective case series of 403 adult women treated for acne with spironolactone at an academic medical center between 2008 and 2019. Rates of objective, as assessed by Comprehensive Acne Severity Scale scores, and subjective acne clearance were evaluated, as well as rates of treatment discontinuation, dosage changes, and drug survival. Logistic regression was used to assess for association between incidence of menstrual adverse effects and combined oral contraceptive use.
Results: As evaluated by Comprehensive Acne Severity Scale scores, at the first follow-up, 75.5%, 84.0%, and 80.2% of patients with available data had reduction or complete clearance of acne on the face, chest, and back, respectively. The mean drug survival was 470.7 days. Menstrual adverse effects were less common among those using combined oral contraception (odds ratio, 0.23; 95% confidence interval, 0.11-0.50).
Limitations: This study was conducted at a single academic medical center.
Conclusions: Spironolactone improves clinical outcomes and is well tolerated for many adult women with acne using it for an extended duration.
Vitamin D
Ahmed Mohamed, Amal, et al. “The impact of active vitamin D administration on the clinical outcomes of acne vulgaris.” Journal of Dermatological Treatment 32.7 (2021): 756-761.
Acne vulgaris is one of the most common chronic inflammatory skin disorder affecting millions of people worldwide. Vitamin D deficiency has a role in various inflammatory skin diseases as acne. This study aimed to investigate the serum level of 25 hydroxy vitamin D in acne patients and to assess the efficacy and safety of active vitamin D in management of acne. This study was conducted on 100 patients with acne and 100 healthy controls, then the 100 acne patients were randomized to either the study group that received 0.25ug alfacalcidol daily or the placebo group that received oral placebo during the 3 months study period. Serum levels of 25-hydroxy-vitamin D were significantly lower in acne patients than in healthy control and were inversely correlated to the severity of acne. After alfacalcidol administration, the study group showed significant higher level of 25(OH) D levels (p < .05) compared to placebo group. In addition, median serum level of IL6 and TNFα significantly decreased (p < .05) in the study group in comparison to placebo group and as compared to their baseline results. Acne patients are more commonly to have vitamin D deficiency as compared to healthy people and hence, alfacalcidol might have a beneficial role in the acne management with no reported side effects.
Acne and Nutrition
Podgórska, Aleksandra, et al. “Acne Vulgaris and Intake of Selected Dietary Nutrients—A Summary of Information.” Healthcare. Vol. 9. No. 6. Multidisciplinary Digital Publishing Institute, 2021.
Abstract: Acne vulgaris (AV) A retrospective review of publications in PubMed regarding diet therapy and the impact of individual nutrient intake on the skin condition of patients was conducted. Ingestion of products with a high glycaemic index may indirectly lead to sebum overproduction, which promotes infection with Cutibacterium acnes and causes inflammation. Consumption of certain dairy products may result in skin deterioration caused by the presence of hormones in these products, i.e., progesterone and testosterone precursors. The beneficial effect of fatty acids on the skin is manifested by the reduction in inflammation. Of significance in AV treatment are vitamins A, C, D, E and B, as well as mineral elements zinc and selenium. Proper nutrition may not only prevent or alleviate AV but also increase treatment efficacy.
Nitric Oxide
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5022991/
J Clin Aesthet Dermatol. 2016 Aug; 9(8): 12–18.
Results of a Phase 2 Efficacy and Safety Study with SB204, an Investigational Topical Nitric Oxide-releasing Drug for the Treatment of Acne Vulgaris
Hilary Baldwin, MD,a Daisy Blanco, MD,b Charles McKeever, MD,c Nelly Paz, MD,d Ynca Nina Vasquez, MD,e John Quiring, PhD,f Carolyn Enloe, MPH,corresponding authorg Emily De León, MSCR,g and Nathan Stasko, PhDg
Both concentrations of SB204 were safe and well-tolerated. Conclusions: When compared to vehicle, both SB204 1% and SB204 4% significantly decreased the percentage of noninflammatory lesions and SB204 4% also significantly decreased the percentage of inflammatory lesions in subjects with acne vulgaris treated for 12 weeks. Treatment with SB204 1% and SB204 4% was safe and well-tolerated.
Acne Caused by Diet
https://www.skininc.com/treatment/wellness/article/21879873/the-diet-acne-connection?logout=true
The Diet-Acne Connection Sep 3rd, 2013 Elise May
Dairy and Acne
CA Adebamowo, et al, High school dietary dairy intake and teenage acne, J Am Acad Dermatol 52 2 207–214 (Feb 2005)
CA Adebamowo, et al, Milk consumption and acne in adolescent girls, Dermatol Online J 12 4 1 (May 2006)
Low Glycemic Diet
RN Smith, et al, A low-glycemic-load diet improves symptoms in acne vulgaris patients: a randomized controlled trial, Am J Clin Nutr 86 1 107–115 (Jul 2007)
Hyperinsulinemia causes hyperandrogenemia
full pdf
Cordain, Loren, et al. “Acne vulgaris: a disease of Western civilization.” Archives of dermatology 138.12 (2002): 1584-1590.
Melnik, Bodo C., and Gerd Schmitz. “Role of insulin, insulin-like growth factor-1, hyperglycaemic food and milk consumption in the pathogenesis of acne vulgaris.” Experimental dermatology 18.10 (2009): 833-841.
It is the purpose of this viewpoint article to delineate the regulatory network of growth hormone (GH), insulin, and insulin-like growth factor-1 (IGF-1) signalling during puberty, associated hormonal changes in adrenal and gonadal androgen metabolism, and the impact of dietary factors and smoking involved in the pathogenesis of acne. The key regulator IGF-1 rises during puberty by the action of increased GH secretion and correlates well with the clinical course of acne. In acne patients, associations between serum levels of IGF-1, dehydroepiandrosterone sulphate, dihydrotestosterone, acne lesion counts and facial sebum secretion rate have been reported. IGF-1 stimulates 5alpha-reductase, adrenal and gonadal androgen synthesis, androgen receptor signal transduction, sebocyte proliferation and lipogenesis. Milk consumption results in a significant increase in insulin and IGF-1 serum levels comparable with high glycaemic food. Insulin induces hepatic IGF-1 secretion, and both hormones amplify the stimulatory effect of GH on sebocytes and augment mitogenic downstream signalling pathways of insulin receptors, IGF-1 receptor and fibroblast growth factor receptor-2b. Acne is proposed to be an IGF-1-mediated disease, modified by diets and smoking increasing insulin/IGF1-signalling. Metformin treatment, and diets low in milk protein content and glycaemic index reduce increased IGF-1 signalling. Persistent acne in adulthood with high IGF-1 levels may be considered as an indicator for increased risk of cancer, which may require appropriate dietary intervention as well as treatment with insulin-sensitizing agents.
https://link.springer.com/article/10.1007/s40257-020-00542-y
Baldwin, Hilary, and Jerry Tan. “Effects of diet on acne and its response to treatment.” American journal of clinical dermatology 22.1 (2021): 55-65.
there is evidence that diet plays a role in acne and its treatment. There is strong support for the reduction of acne with regular consumption of omega-3 fatty acids and low-GI glycemic Index and low-GL Glycemic Load diets. Similarly, several studies demonstrate milk may worsen the number and severity of acne lesions. Specifically, acne flares in individuals consuming milk may be related to whey proteins and casein via insulinotropic and IGF-1 pathways, which may explain why other dairy products such as butter or cheese have not demonstrated the same associations with acne. Low glycemic diets have generally shown favorable improvements in acne outcomes, possibly because of their effects on insulin and IGF-1; however, because of inconsistent findings in studies of patients with acne on low glycemic diets, additional treatment may be necessary in combination with changes in diet to reduce acne. Administration of probiotics shows promise in reducing acne lesions. More investigation is necessary on the effects of vegetarian/vegan and ketogenic diets on acne, as research in this area is lacking.
Vitamin A E and Zinc and Acne
https://pubmed.ncbi.nlm.nih.gov/23826827/
Ozuguz, Pinar, et al. “Evaluation of serum vitamins A and E and zinc levels according to the severity of acne vulgaris.” Cutaneous and ocular toxicology 33.2 (2014): 99-102.
Background: Although hyperseborrhea, follicular hyperkeratinization, Propionibacterium acnes colonization and inflammation are found to be responsible in the pathogenesis of acne, the exact mechanisms are unknown. Vitamin A and E are basic antioxidants vital for health. Zinc is also an essential element for human. But these parameters of the effects on skin are not fully understood. We aimed to evaluate plasma levels of vitamin A, E and zinc in acne patients in relation to the severity of the disease.
Material and method: There were 94 acne patients who were referred to our clinic, all new diagnosed, and 56 age and sex matched healthy volunteers as control group. All patients are assessed according to Global Acne Grading System and grouped as mild, moderate, severe and very severe. Acne patients further grouped as group 1 consist of patients with mild to moderate disease; and group 2 consist of patients with severe to very severe acne. The patients with the controls and group 1 with group 2 was compared.
Results: The level of vitamin E, vitamin A and zinc were significantly lower than the control group (Table 1,p < 0.001). When the patient group is compared among each other there was no statistically significant difference for plasma vitamin A levels between group 1 and 2 whereas vitamin E and zinc levels were significantly low in group 2 than group 1. Thus there was a negative correlation between acne severity and vitamin E and zinc levels.
Conclusion: Our study marks the importance of diet in patients with acne. We offer supportive dietary measures with foods rich in vitamin A and E and zinc in the acne prophylaxis and treatment. Supportive treatment with these vitamins and zinc in severe acne may lead to satisfactory results.
https://www.acne.org/forums/topic/388757-1000-scars-cystic-acne-cured-with-low-carbohydrate-plant-based-diet/
Acne Cure = Keto Vegan Success Story: Severe Cystic Acne Cured with Low Carbohydrate, Plant Based Diet
clascoterone, the first topical androgen receptor antagonist.
Androgens and acne: perspectives on clascoterone, the first topical androgen receptor antagonist Leon H. Kircik
Introduction: Increased circulating androgens are key to the multifactorial pathogenesis of acne. Clascoterone is the first topical androgen antagonist developed to treat acne in both male and female patients and the first such agent to receive U.S. Food and Drug Administration (FDA) approval for treatment of acne. Androgens directly stimulate sebaceous gland growth and increased sebum production, creating a nourishing medium in which anaerobic Cutibacterium acnes (C. acnes) bacteria flourish. Androgens may directly contribute to inflammation in the sebaceous gland.
Areas covered: In this review, the author assesses clascoterone’s potential role in the management of acne. With a 4-ring backbone identical to dihydrotestosterone (DHT) and spironolactone, topically applied clascoterone binds androgen receptors (ARs) in the sebaceous glands and hair follicles, interfering with the pathogenesis of acne and reducing acne lesions with no reported systemic effects.
Expert opinion: Phase III study results confirmed the safety and efficacy of topical clascoterone for acne, with considerable reductions in absolute non-inflammatory and inflammatory lesion counts at week 12. The approval of a first-in-class topical androgen antagonist is indeed a ‘game-changer’ for acne management. This topical agent is expected to be quickly adopted in clinical practice, likely within combination regiments, yet to be formally evaluated.
Leave a Reply
You must be logged in to post a comment.