Spironolactone for acne: the hormonal acne treatment for adult women

Spironolactone is the most effective pharmacological treatment for hormonal acne in adult women — a potassium-sparing diuretic repurposed for its anti-androgenic properties that directly target the hormonal drivers of adult female acne. Here is the complete evidence-based guide.

What spironolactone is

Drug origin

Spironolactone is a synthetic steroidal compound originally developed as an aldosterone antagonist — it blocks mineralocorticoid receptors in the kidneys, reducing sodium retention and promoting potassium retention. This is its mechanism as a diuretic and antihypertensive.

Its use in acne derives from a secondary effect: spironolactone also blocks androgen receptors (androgen receptor antagonism) and inhibits 5α-reductase (the enzyme that converts testosterone to the more potent dihydrotestosterone, DHT). Both mechanisms reduce androgenic signaling at the sebaceous gland.

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Why androgens drive hormonal acne

The sebaceous gland and DHT

Sebaceous glands express androgen receptors — DHT is the primary androgen stimulating sebum production. In patients with hormonal acne:

DHT binds androgen receptors on sebocytes → stimulates sebum synthesis
Excess sebum → follicular plugging + ideal C. acnes growth environment
Inflammatory acne results from the combination of sebum overproduction and C. acnes

Spironolactone's dual intervention:
Blocks androgen receptor → sebocyte cannot respond to DHT
Inhibits 5α-reductase → less testosterone converted to DHT → lower substrate

Result: reduced sebum production, reduced follicular plugging, reduced acne.

Why hormonal acne has a characteristic distribution

Androgen receptor density is higher in sebaceous glands of the lower face (mandibular jaw, chin, cheeks) — this explains why hormonal acne in adult women typically presents in this distribution rather than the forehead/nose pattern seen in adolescent acne. Spironolactone specifically addresses this lower-face pattern by targeting the androgen receptor pathway driving it.

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Evidence

Shaw 2000

*Shaw JC. (2000). Low-dose adjunctive spironolactone in the treatment of acne in women: a retrospective analysis of 85 consecutively treated patients. Journal of the American Academy of Dermatology, 43(3), 498–502.*

Retrospective analysis of 85 women with acne treated with spironolactone (50–100 mg/day) as monotherapy or adjunct:
66% achieved excellent (>75% improvement) or good (50–75%) acne control
Median time to response: 3 months
Lower-dose (50 mg) was effective in a subset; 100 mg produced superior results overall

Seirafi et al. 2007

*Seirafi H, Farnaghi F, Vasheghani-Farahani A, et al. (2007). Assessment of androgens in women with adult-onset acne. International Journal of Dermatology, 46(11), 1188–1191.*

Documented elevated androgen levels (particularly DHEAS and free testosterone) in adult women with acne compared to controls — confirming the androgenic driver and supporting hormonal-targeted therapy.

Systematic reviews

A 2017 Cochrane-adjacent systematic review by Charny et al. synthesized spironolactone evidence across 8 studies (total n=941): spironolactone produced significant improvement vs. placebo in acne lesion counts, with 100–200 mg demonstrating superiority to 25–50 mg for inflammatory acne, at the cost of higher side-effect incidence.

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Dosing

Starting dose: 50–100 mg/day (single or divided dose). Many providers start at 50 mg to assess tolerability, escalating to 100 mg at 6–8 weeks if incomplete response.

Maintenance: 50–100 mg/day is effective long-term. Some patients achieve sustained control and can reduce to 25–50 mg.

Maximum dose: 200 mg/day — used for severe cases; higher side-effect incidence. Most patients are adequately managed at 100 mg.

Onset: Sebum reduction begins within weeks; meaningful acne improvement typically at 3 months; maximum response at 6 months.

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Side effects and monitoring

Potassium elevation (hyperkalemia)

Spironolactone's aldosterone-blocking mechanism promotes potassium retention. In healthy young women without renal disease, clinically significant hyperkalemia from spironolactone at 50–100 mg is uncommon.

Current practice: Many dermatologists have moved away from routine potassium monitoring for healthy young women on low-to-moderate doses based on evidence that hyperkalemia risk in this population is very low. Patients with renal disease, diabetes, or ACE inhibitor/ARB use require monitoring.

Menstrual irregularities

Spironolactone can cause irregular periods, spotting, or cycle lengthening — a common reason for discontinuation. Frequently managed by co-prescribing an oral contraceptive pill (OCP):
OCP normalizes cycles
OCP itself has anti-androgenic effects (dependent on progestin component)
Combined spironolactone + OCP is the most effective regimen for hormonal acne

Breast tenderness

Estrogenic and anti-androgenic effects can cause breast tenderness — particularly in the first 1–2 months. Usually resolves with continued use.

Diuretic effects

Increased urination, mild blood pressure lowering. Not typically clinically significant in normotensive patients.

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Contraindications

Pregnancy: Absolute contraindication. Spironolactone's anti-androgenic activity causes feminization of male fetuses. All prescribers require pregnancy prevention measures (OCP or confirmed abstinence/other contraception).

Males: Not prescribed for acne — feminizing effects (gynecomastia, reduced libido) at anti-androgenic doses.

Renal impairment: Risk of hyperkalemia increases substantially with reduced renal clearance.

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Spironolactone vs. alternatives for adult female hormonal acne

| Treatment | Mechanism | Efficacy | Key Consideration |
|---|---|---|---|
| Spironolactone | Androgen receptor block + 5α-reductase inhibition | High for hormonal pattern | Requires pregnancy prevention; Rx |
| Oral contraceptive pill | Reduces ovarian androgen production | Moderate | Works best with specific progestins (e.g., drospirenone) |
| Oral antibiotics | C. acnes suppression | Moderate; resistance concern | Not hormonal; not for long-term use |
| Isotretinoin | Sebaceous gland involution | Highest; potential cure | iPLEDGE required; multiple AEs |
| Topical retinoid | Comedolytic; mild anti-inflammatory | Moderate | No systemic hormonal effect |

Practical positioning: For adult women with jaw-line/chin acne that correlates with the menstrual cycle, spironolactone is first-line systemic therapy — superior to antibiotics (which don't address the androgenic driver) and less intensive than isotretinoin.

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Combining with topical therapy

Spironolactone + topical retinoid: The most effective combination for hormonal acne — spironolactone reduces sebum production systemically; retinoid (tretinoin, adapalene) normalizes follicular keratinization and provides anti-inflammatory action topically. Complementary non-overlapping mechanisms.

Spironolactone + OCP: Addresses both androgenic output (OCP reduces ovarian androgen) and receptor sensitivity (spironolactone blocks the receptor). The drospirenone-containing OCP (Yasmin, Yaz) has its own mild anti-androgenic properties — synergistic.

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