Should I take spironolactone for acne?

What is spironolactone?

Spironolactone is an oral prescription medication used to treat high blood pressure and fluid retention, but it is frequently prescribed off-label for the treatment of acne. It’s usually sold under the brand name Aldactone. 

“Spironolactone is perhaps one of the most commonly prescribed medications in dermatology and has been used safely for over 60 years to treat acne in adult women,” says Joshua Zeichner, MD, director of cosmetic and clinical research at The Mount Sinai Hospital. The drug is a diuretic, a water pill, which triggers your kidneys to filter out excess water from your body through increased urine production. Spironolactone belongs to a class of diuretics, called potassium-sparing diuretics, that prevents the loss of potassium during this filtering process; for a patient with high blood pressure, spironolactone can be effective at flushing out excess sodium, a common source of hypertension, without lowering potassium levels.

How does spironolactone work for acne?

Though spironolactone has been approved by the Food and Drug Administration (FDA) for treatment of blood pressure, Dr. Zeichner says it does not affect blood pressure when given at a low dose. Instead, its side effects make it a good off-label use for acne: It is an anti-androgen medication. Meaning, it blocks androgens, a type of sex hormone, from binding to oil glands (androgen receptors), reduces the secretion of androgen hormones from the adrenal gland, and prevents stimulation of oil production, which can lead to pimples. 

It’s also often prescribed for female patients who experience cystic acne, a type of pimple that sits deep in the surface of the skin rather than on top of it. Cystic acne happens when skin pores become clogged, then infected. It’s common along the jawline and on the chin.

However, spironolactone can also block testosterone and cause breast development in men, which is why it’s only prescribed to women. Spironolactone might not be the right treatment for all women with acne. According to Dr. Zeichner, it can be a good fit for women who:

• experience hormonal acne or breakouts related to their menstrual cycle;
• need systemic acne treatment to address severe acne or acne affecting large parts of the body;
• have acne that is not well-controlled by topical treatments alone;
• want to avoid treating their acne with hormonal birth control;
• and have recurrent acne once oral antibiotics have been discontinued.

Spironolactone is often prescribed to teenagers and young adult females, though women who are pregnant, or who may become pregnant, should not take spironolactone. Its feminizing effects could affect the fetus, so the testosterone levels of a male fetus could be impacted by the mother’s spironolactone use during pregnancy. 

How long does spironolactone take to work for acne?

It can take about three months for the drug to have a noticeable effect on acne, and it’s not a one-time treatment, says Dr. Zeichner. According to the American Academy of Dermatologists (AAD), spironolactone can be effective in the treatment of deep, tender acne that is located on the jawline, neck, and lower face. Among 85 women who took the drug, one third had a total clearing of their acne, and one third experienced noticeable results. Only 7% of the individuals observed saw no improvement in the severity of their acne. And when combined with certain hormonal therapies like oral contraceptive pills, spironolactone may be even more effective. 

How long do you stay on spironolactone for acne?

“If you discontinue spironolactone, the skin slowly will return back to what it’s genetically programmed to do,” he explains. “Acne typically returns within a few months [after stopping the drug].”

Spironolactone dosage for acne

The typical dose of spironolactone for acne is 25 to 200 milligrams per day; according to a 2012 study published in the Journal of Clinical and Aesthetic Dermatology, patients should start with the lowest dose and increase slowly over time if needed. Patients often experience improvement of acne, as well as fewer side effects, at lower doses. 

Is it safe to take spironolactone for acne?

As with any drug, spironolactone may cause side effects in some patients and not in others. It’s important to discuss these possible side effects with your doctor—and inform them of any other medications you’re taking—before taking it. 

Spironolactone for acne side effects

Potential side effects of spironolactone include:

• Breast tenderness
• Irregular periods
• Increased potassium levels
• Lightheadedness 
• Nausea and vomiting
• Fatigue
• Increased urination

Dr. Zeichner says many of these side effects are more likely when the medication is given at higher doses. It’s worth noting that there is a black box warning on the drug, but it may not be a cause for genuine concern if you are an otherwise healthy female.

“In one study in rats spironolactone caused solid organ tumors, however it has not been shown to be a problem in humans,” advises Dr. Zeichner. The amount of the drug given to rats in the study was significantly higher than the one prescribed to women.

Spironolactone does not typically cause depression or mood changes. If you do notice changes in mood while taking it, let your healthcare provider know. Sometimes, spironolactone is prescribed to promote hair growth in women because it’s an antiandrogen—that means it blocks the male hormones that may lead to hair loss in women.

Because the drug decreases fluid retention, you may lose a small amount of weight while taking it. There isn’t any evidence that spironolactone works as a weight loss medication, but it may help with premenstrual bloating and is often prescribed to treat symptoms of PMS and premenstrual dysphoric disorder (PMDD). 

When it comes to actually taking spironolactone, Dr. Zeichner recommends taking it with food for better absorption. Because sodium and potassium levels are impacted by the drug, you should monitor your intake of both. There is a chance that your potassium levels could become fatally high while taking spironolactone (known as hyperkalemia), so you should avoid eating large amounts of potassium-containing foods such as bananas, avocados, and spinach.

Diuretics like spironolactone are processed through the renal system, so patients with kidney disease should avoid taking this drug. Patients who take potassium supplements, other drugs containing spironolactone or diuretics (especially triamterene and eplerenone), and other blood pressure medications should also avoid taking spironolactone. Patients should also avoid potassium supplements as well as salt substitutes that contain potassium while taking spironolactone. The following drug interactions, with serious side effects, are possible:

• Drugs and supplements that increase potassium: These include ACE inhibitors, angiotensin receptor blockers, heparin, and trimethoprim.
• Lithium: Spironolactone makes it harder for the kidneys to clear lithium from the body, increasing the chances of lithium toxicity. 
• Nonsteroidal anti-inflammatory drugs (NSAIDs): NSAIDs can reduce the diuretic effect of spironolactone. 
• Digoxin: Spironolactone may increase blood levels of digoxin, potentially causing digoxin toxicity, a life-threatening condition that causes nausea, vomiting, and an irregular heartbeat.
• Cholestyramine: Combining the two drugs may decrease the effectiveness of the  diuretic-effect of spironolactone.
• Acetyl salicylic acid: This drug can reduce the effectiveness of spironolactone. 

How much does spironolactone for acne cost?

For a one-month supply of 25 milligram generic Aldactone tablets, the average patient pays about $28. With a SingleCare discount card, you might be able to pay less than $7.

What are some alternatives to spironolactone for acne?

Other popular prescription topical antibiotics like clindamycin, topical retinoids such as tazarotene, and oral medications like doxycycline or Accutane (Accutane users cannot be pregnant or become pregnant, and must follow a strict protocol through a program called ipledge). Some dermatologists recommend birth control pills, especially if your breakouts are cyclical, like your menstrual cycle. Oral contraceptives can regulate the flow of hormones that affect oil production in your skin; it’s often helpful for women with polycystic ovary syndrome, or PCOS, which usually causes a relative overabundance of male hormone levels.

There are a few over-the-counter acne medications, too, like benzoyl peroxide (cleansers, creams, or gel), Differin Gel, and salicylic acid cleanser or moisturizer. Most prescription acne treatments come with some side effects and not all are compatible with every person’s lifestyle. If you’re struggling to win the war against acne, make an appointment with your primary care provider or dermatologist for advice on which treatment option might be best for you. 

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The bottom line

As a potassium-sparing diuretic, spironolactone is typically used to treat high blood pressure, heart failure, and hypokalemia (a condition marked by low levels of potassium in the blood). It may also be used in people who produce too much aldosterone, a hormone that regulates the balance of water and sodium in your body. And spironolactone is often used off-label in women with stubborn acne to help clear skin. Though it’s an effective acne treatment in women, spironolactone is not recommended as an acne treatment for men, because it may cause the unwanted side effect of breast growth.