Acne did not take over JJ Boparai's skin in his adolescence, until he was in his 20s.
“I've never had acne like that, my face was just covered,” said the 31-year-old from Metuchen, New Jersey, adding that experiencing this was “horrible psychologically.”
Boparai's breakouts — which she described as “very cystic, many under the skin, large, painful, several on her chin and cheeks” — were persistent. After a year of trying various washes, chemicals and creams, she went to a dermatologist who prescribed oral antibiotics and medicine.
The acne persisted.
It wasn't until the doctor prescribed spironolactone — a blood pressure medication approved in 1960 — that Boparai noticed a difference in her skin.
She's far from the only one: According to a study published in JAMA Dermatology, prescription rates of spironolactone for acne in women increased nearly 300% from 2017 to 2020. By 2020, dermatologists were prescribing the blood pressure drug at rates similar to those of antibiotics.
What is spironolactone and why does it treat acne?
Spironolactone works by blocking a hormone in the body called aldosterone, which retains sodium; By blocking it, it helps the kidneys eliminate salt and water from the body to reduce blood pressure.
As explained by Dr. John Barbieri, a dermatologist and epidemiologist at Brigham and Women's Hospital in Boston and author of the study in JAMA Dermatology, the drug also alters similar hormones in the body, including those that cause acne.
These hormones are called androgens and include testosterone.
“Testosterone increases oil production in the skin, and when there is a lot of oil, it clogs pores and causes acne,” explained Dr. Ayman Grada, a dermatologist and associate professor at Case Western Reserve University School of Medicine in Cleveland. . Spironolactone blocks these effects on the skin.
After small studies in the 1980s showed the drug was effective against acne, some dermatologists began prescribing it to women. Men can also get acne in adulthood, but it is only prescribed for women.
“Its use has increased over time,” according to Barbieri.
Spironolactone is one of the acne treatments included in the American Academy of Dermatology's treatment guidelines.
The drug is not usually used as a first-time treatment for acne. It is considered an option for women if other medications, such as creams or oral antibiotics, do not work.
“I prescribe it more often than before and have felt more comfortable with it,” said Dr. Jessica Krant, a dermatologist at the Laser and Skin Surgery Center in New York, who noted that she usually only gives it when other treatments don't work.
Oral antibiotics are the most common treatment for women with adult acne, but Barbieri hopes spironolactone will soon surpass that.
“There is more and more high-quality data supporting the use of spironolactone for acne, which I think has made more people aware of it and comfortable prescribing it,” he said.
The American Academy of Dermatology, which publishes prescribing guidelines for the treatment of acne, has asked dermatologists to limit the use of antibiotics whenever possible.
“If we could use more spironolactone, that could help us use less antibiotics,” added Barbieri, who also co-chairs the group's acne guidelines working group. “That will create less resistance to antibiotics in the community, and fewer complications associated with them for patients, such as alteration of the microbiome.”
Is spironolactone safe for acne treatment?
Spironolactone is not approved by the Food and Drug Administration (FDA) for the treatment of acne and is prescribed off-label.
Barbieri noted that since the drug is generic — and has been for many years — it is unlikely that a drugmaker would spend the money on the clinical trials that would be necessary to seek approval for its use for acne. . “It's not clear who would want to make that effort,” he explained.
As a blood pressure medication, spironolactone is usually prescribed at a dose of 25 milligrams per day.
For acne, the dose is higher: usually starting with 50 mg and then increasing to 100 mg and, in some cases, 200 mg.
These doses have not been studied in large long-term clinical trials. Additionally, the original studies on the drug were conducted primarily in older white men, not young women.
It should not be prescribed to men for acne, because at these high doses, it can cause gynecomastia, or enlargement of breast tissue in men, Barbieri added.
As the use of spironolactone for acne has increased, a handful of small studies have been conducted on the drug's short-term safety and effectiveness.
“It has been used for a long time, but clinical trials are limited,” Grada said. He feels comfortable prescribing the drug, but would like to see long-term studies.
“The side effects are very mild, comparable to those of other drugs, but there is no long-term safety data,” he added.
A phase 3 clinical trial, published in The BMJ last year, followed 400 women taking spironolactone or placebo for 24 weeks. Side effects were slightly more common in women who received the drug compared to placebo but were generally mild.
Like other blood pressure drugs, it can cause side effects such as dizziness, lightheadedness, and headaches. In older women who take it, or in those who suffer from certain diseases, potassium levels should be monitored.
Krant says some women have stopped taking the medication because of breast tenderness or decreased sexual desire. She also said it can disrupt the menstrual cycle and cause irregular bleeding.
According to the American Academy of Dermatology, the drug should not be used during pregnancy because it can cross the placenta and potentially affect the fetus.
Spironolactone is the subject of an FDA warning based on a study that showed that at extremely high levels—up to 150 times human doses—it caused cancer in rats. A recent meta-analysis found no increased risk of cancer in humans, although the researchers noted that “the certainty of the evidence was low and future studies are needed.”
“Overall, spironolactone is a safe medication based on the data we know,” said Dr. Christopher Bunick, a dermatologist and associate professor at Yale University School of Medicine.
However, “more high-quality studies are needed to really understand the correlation between spironolactone use and cancer,” he said. “It would be foolish to try to ignore it.”
