Spironolactone For Acne: Your Guide to the Hormonal Treatment

I’ve been taking 100mg of Spironolactone for the greater part of 10 years to control my cystic, pus-filled acne. I have a deep-rooted love for the off-label drug, which has been used for nearly 30 years to safely treat hormonal female acne—but I’m far from alone. It’s a holy grail in nearly every dermatology practice and without a doubt a magic pill for women dealing with mild, moderate, or severe acne. “Spironolactone 100 percent should be the first-line therapy for adult female acne. When it’s used properly, in the right dose, in the right way, it’s a miracle medication,” says board-certified dermatologist and founder of Niche Dermatology Dr. Shari Marchbein. “I think we under-treat adult female acne and often people are using over-the-counter products for a while, but topicals don’t address the hormonal component of acne.” 

This all isn’t to say that you need to be on medication. A simple skincare routine for acne-prone skin may be enough to keep your skin happy. But if you haven’t been able to get breakouts under control or want to explore your options, it’s worth discussing Spironolactone with your doctor. For a pretty in-depth overview of the medication, read ahead. Top dermatologists are explaining everything you need to know about using Spironolactone for acne, including benefits, risks, and of course, when you’ll notice results. 

What Is Spironolactone?

Here’s the deal: Spironolactone is FDA approved—but not for anything remotely related to the skin. It was originally made to treat high blood pressure and some heart conditions. So, how’d we get here? Well, after the drug was in business for a few decades, doctors started to realize that it doubled as an anti-androgen medicine, which ushered in its era of off-label use. “It’s very effective to treat medical conditions where we’re trying to block hormones either at the skin level or the level of the hair follicle,” explains Dr. Marchbein. 

How Does Spironolactone Work for Acne?

Acne can pop up when hormones bind to oil glands. So think of Spironolactone as a little machine that interrupts the binding process, and as a result, prevents acne. “I like to compare it Pacman," says Dr. Marchbein. "It eats hormones at the level of the oil gland, so it doesn't allow hormones produced by the body, such as testosterone, to bite the oil glands.” As a result, testosterone, which contributes to excess sebum production and oil, is going to go down. Less testosterone means less oil, which, you guessed it, means less acne. 

It's particularly effective when treating nasty cysts—especially the ones that make a home on the lower third of your face. Dermatologist *think* (more studies need to be conducted for an official reasoning) that certain oil glands are hyper-responsive and reactive to hormones. “Spiro literally blocks those hormones from binding the receptors on the oil glands, or as I like to say, it’s like Pacman and just eats them up so they’re not available to bind.”

Am I a Candidate?

While this is a widely used medication in dermatology practices, you do need to meet certain criteria to be considered. 

Age

“The ideal candidate is a female with hormonal acne,” says board-certified dermatologist Dr. Anna Karp. “It is a medication we would start only after puberty.” But once a female has been visited by Mother Nature, Spironolactone gets the green light. Dr. Karp primarily prescribed the pill to women in their 20s and 30s, while Dr. Marchbein says that she has certain post-menopausal patients still refilling their prescription. 

Type of Acne

Large, painful cystic acne on the face, chest, or back is going to be the most receptive to Spiro. It’s also ideal for those who flare when they ovulate. “It works much less well for the smaller comedones,” explains Dr. Marchbein. Because those pimples are rooted in bacteria, inflammation, and hyperkeratinization of the hair follicle, they’ll require topicals like retinoids, benzoyl peroxide, or topical dapsone. “Once you get into any larger lesions, papules, or cysts, you need to be a bit more aggressive. Topicals typically are not going to be the thing that clears that up.” 

Pregnancy Status

“Anyone trying to get pregnant or who is pregnant should avoid Spironolactone,” says Dr. Karp. Reason being, it’s an anti-androgen and anti-hormonal medicine that blocks testosterone. Dr. Marchbein explains that if you were to take the medication while pregnant with a male fetus, it could result in feminization of the male fetus. That said, you can go back on the medication as soon as your baby is delivered—it’s safe to take while breastfeeding. “The American Academy of Pediatrics deems Spironolactone safe for breastfeeding,” says Dr. Marchbein. “It does not get secreted in breast milk. The one potential side effect that I warn everybody about during nursing is that it can decrease your breast milk production.” 

Gender

Sorry guys, but Spiro is not for you. “They’ve found that when used for male patients it caused gynecomastia, which is increased male breast tissue,” says Dr. Marchbein. “So this is completely contraindicated for men. 

How Much Should I Take?

While there’s no *right* answer, I want to be abundantly clear: Dosage is probably the most important factor when it comes to Spironolactone’s efficacy. But it’s a bit of a game to figure out the magic number. “There is not a standard dose, but I personally start patients on 100mg a day and increase in 50mg increments,” says Dr. Marchbein. “While 50mg per day may be fine for some, I’ve found that patients with polycystic ovarian syndrome (PCOS), hormonal imbalances, or a progesterone-secreting IUD require higher doses. Nevertheless, we would go slow and work our way up.” Most dermatologists will max out around 200mg, however because Spironolactone has been used to treat other medical conditions in higher doses (think: 300mg or 400mg), some doctors will prescribe more. 

Just remember: A difference of 50mg might be the difference between cystic breakouts and clear skin, so work with your dermatologist to find the most effective dosage. “If you are not clear, you're not on the right dose. Period. It's so rare to see a failure on Spironolactone. You just really need to titrate to the correct dose and that in and of itself can take six months.”  

How Does Spironolactone Fit Into a Routine?

While Spironolactone is amazing, it is just one piece of the acne puzzle. “No medication was ever meant to be used as monotherapy,” explains Dr. Marchbein. She, along with Dr. Karp, recommends taking Spiro in conjunction with a birth control bill—it’s the most effective way to target hormonal acne. If you also experience whiteheads and blackheads, chances are your doctor will recommend incorporating a benzoyl peroxide, retinoid, salicylic acid, or prescription topical into your routine.  

The medication doesn’t need to be taken with food (although it’s not a bad idea) and, depending how much you’re on, it will either be taken in the evening, or the mornings and the evenings. Just remember not to skip a day. “This is a pill that has to be taken every day or it does not work,” emphasizes Dr. Marchbein. “I have many, many patients who will skip a day by accident and they get a cyst. It is temporarily suppressing your hormones, it's not accumulating or building up in your system. So if you do not take it for a day or two, it doesn't work and you're probably going to break out.” 

Is Spironolactone Safe?

No drug comes without side effects (more on that below), but overall Spironolactone is a very safe drug with decades of research and studies behind it. “There is so much safety data on Spironolactone—it’s ridiculous. It’s been shown that there’s no increased risk of cancers, including breast cancer and cervical cancer, and it will not affect any sort of fertility at all,” says Dr. Marchbein. 

What Are the Side Effects?

Yes, it is safe (peep above), but there can be side effects.

Menstrual Changes

“Most commonly I see spotting between periods, especially if someone has a history of endometriosis or fibroids,” says Dr. Karp. General irregularity is also very common, however that should resolve within a month or two. Dr. Marchbein explains, “Some women won’t get their period at all on Spironolactone. Some women could spot, they could spot mid-cycle, they could spot the whole month. Their period could come a little early or it could be a little late.” That said, menstrual changes are typically side swept if you’re also on a birth control pill. 

Breast Tenderness

“It may also cause some breast tenderness and/or breast enlargement,” says Dr. Karp. While your breasts may feel different, it’s important to remember that there is no research indicating that Spironolactone increases your risk of breast cancer. 

Dehydration

This medicine is a diuretic, meaning it’s going to make you pee—a lot. That in mind, you’re going to want to amp up your water intake (hydrate people!) to avoid dizziness or light-headedness. 

Elevated Potassium

Spironolactone can cause spikes in potassium, but that’s not a concern for most people under the age of 45. However those over the age of 45, with a kidney issue, heart disease, diabetes, or on other medications that can affect potassium, will likely require a bit more monitoring on Spironolactone. “There is no standardized monitoring, but I’ll check potassium levels at baseline, a month after starting Spiro, and a month after any dose increase,” says Dr. Marchbein. “Then I check it once every six months.” 

When Will I See Results?

You’ll notice your skin clearing relatively quickly. “It’ll take one to two period cycles before major differences are noticed, but you may see less oiliness within a few weeks,” says Dr. Karp. But it’s important to remember that results won’t kick in at all until you’ve nailed down the right dose. “It’s not Oh, I took a hundred milligrams for two months and it didn't work,” says Dr. Marchbein. “That's just simply not true. There's almost nobody who I cannot get clear with a combination of topicals, Spironolactone, and birth control pills.”

Meet the Dermatologists

Dr. Shari Marchbein

Dr. Shari Marchbein is a board-certified dermatologist and a fellow of the American Academy of Dermatology. Dr. Marchbein’s academic and clinical interests include the treatment of acne, in particular adult female acne, acne scarring, and rosacea. She also specializes in various aesthetic procedures and laser surgery. Dr. Marchbein has been sought out as a leader in her field for the treatment of acne and rosacea and has published multiple articles on acne pathogenesis and treatment. She has presented at renowned national conferences on the topics of acne and rosacea, including the annual American Academy of Dermatology and Advances in Dermatology meetings. Dr. Marchbein earned her Bachelor of Science degree from the State University of New York at Binghamton where she graduated Summa Cum Laude and became a member of the Golden Key National Honor Society and Phi Beta Kappa National Honor Society.

Dr. Anna Karp

Anna Karp, DO, is a board-certified dermatologist at the Skin Institute of New York (SINY®). Dr. Karp specializes in medical, cosmetic, and surgical dermatology, and she treats adults and children at SINY’s® three offices in New York City’s West Village and Bay Ridge and Park Slope in Brooklyn, New York. Dr. Karp is a native New Yorker, growing up on the South Shore of Long Island. After graduating magna cum laude with her bachelor of arts degree in Biology from the State University of New York at Binghamton, she went on to earn her medical degree from Touro College of Osteopathic Medicine in New York City. She then completed dual residencies in Family Medicine and Dermatology at St. John’s Episcopal Hospital in Far Rockaway, New York. During her residency, Dr. Karp presented at a number of local and national conferences, and she published several articles in peer-reviewed journals. She also served as Chief Resident during the final year. Dr. Karp is an active fellow and member of the American Academy of Dermatology, American Osteopathic College of Dermatology, and the American Medical Association. As a highly skilled dermatologist, she focuses on providing the highest level of individualized and compassionate care to all her patients.