Spironolactone vs Winlevi for Acne
Often patients are interested in trying the “newest” thing. This is understandable, especially if they have been underwhelmed by their treatment options. Winlevi is one of the newest things available by prescription for acne. It was FDA approved for acne in 2021 and was the first in its class of medications. But how does it compare to one of our oldest options, spironolactone. Let’s dive in and take a look.
Both of these medications work to target the effect of androgens on the skin.
What are Androgens? Androgens are primarily male hormones mainly testosterone, but females have androgens as well. The two primary Androgens are Testosterone produced by the ovaries and DHEA made by the adrenal glands. When females have excess androgens it can lead to hirsutism (excessive growth of hair in unusual places), premenstrual acne flares, irregular menstrual cycles, and hair loss on the scalp. Women with Polycystic Ovarian Syndrome (PCOS) often have excess androgens and may find it helps with their symptoms as well. Androgens impact acne by causing increased production of oil or sebum. Androgens encourage sebum production which leads to clogged pores and inflammation, which are both critical portions of acne.
Winlevi is a newer topical medication, first in its class. It works to block binding of androgen hormones to androgen receptors primarily in the oil glands. By doing this, it decreases oil or sebum production which plays a role in acne. Winlevi is applied topical to the acne areas
To learn more about Winlevi, check out this video https://vimeo.com/842591914 ADD LINK PLEASE. I found it very informative! It is use twice a day as a preventive measure, NOT as a spot treatment. It can be used in both males and females because absorption in the blood stream is very limited. Adverse reactions are uncommon and seen in less than 10% of patients. On patients in our office, Winlevi is a game changer for only small portion of patients, but the main limitation is cost, as many insurances do not cover it. The company does have a coupon and discount program at https://www.winlevi-hcp.com/savings
Spironolactone isn’t new. It’s a very old drug. By class, it is a diuretic. However, it is rarely used for its diuretic effect. Why? It has a side effect. Spironolactone’s main side effect is that it antagonizes androgens leading to a feminizing effect. While this side effect is undesirable for men and harmful to the fetus in pregnant women, it is helpful for some patients. Add spironolactone to the list of medications in dermatology that we employ for their side effect – Rogaine and Latisse are a few others. Spironolactone is used primarily for women who have excess androgens.
How are these medications different from taking a birth control pill for acne? Birth control pills can be prescribed to help with hormonally induced acne. It is important to realize that not all birth control pills make acne better, and many make it worse. Here’s why. Most birth control pills contain both estrogen and a type of progesterone. Estrogen is the primary female hormone and has less of an effect on acne. The progesterone varies between each type of birth control pills. Some types of progesterone are highly androgenic (contain lots of the male hormone androgen properties), some are low androgenic, and others are anti-androgenic. I often recommend Yasmin or Yaz as a birth control pill of choice for women with hormonally induced acne or excess hair. The progesterone in Yasmin or Yaz is anti-androgenic and is very similar to spironolactone.
What are the negative side effects? The feminizing effect of spironolactone is undesirable for most men and harmful to the fetus in pregnant women. So, it is only recommended for females with no childbearing potential. Because spironolactone is a mild diuretic, it can impact potassium levels, so potassium needs to be monitored. Dr. Rosenberger usually checks after initiating or changing the dose and once stabilized once a year. Effects on potassium were less common with Winlevi and no bloodwork monitoring is required.
I hope the following chart will be helpful in comparison. But in my office, I usually only recommend spironolactone if a woman is not desiring pregnancy and she has multiple signs or symptoms of androgen excess. Winlevi is available to all acne patients, but its high cost greatly limit its practical use.
| Spironolactone | Winlevi | |
| FDA Approval | 1960 | 2020 |
| FDA Approved for Acne | NO | YES |
| Safe for Women | YES | YES |
| Safe for Men | NO | YES |
| Use | ORAL | TOPICAL |
| Blood Work Monitoring | YES | NO |
| Antiandrogen Effect | Multiple Mechanisms | |
