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.
Why Spironolactone? Spironolactone is used primarily for women who have excess androgens. Androgens are primarily male hormones, but we as 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.
How is this 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.
How does it help acne? Some portion of acne is driven by androgens. Androgens encourage sebum production which leads to clogged pores and inflammation, which are both critical portions of acne. For females with excess androgen, it helps reduce the “driver” of their acne. Spironolactone is not very effective when used alone and is best used in combination with other acne treatments.
Are there any other medications that help with androgens for acne? There is a new topical medication on the way that is designed to antagonize androgens, called CLASCOTERONE (generic) or WINLEVI (name brand). Because this is new and not commercially available yet, I cannot say exactly how well it will work. It is planned to be released at the end of 2021. While spironolactone is only for females, the new topical drug is safe for males and females.
Spironolactone can be helpful for patients. But, like most things in medicine, every patient is different. Perhaps Winlevi will be the answer to attacking those androgens in males and females. Time will tell.
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