Acne treatments. If you're reading this, you've likely already read about almost all of them in existence. You know about salicylic acid and benzoyl peroxide; you've heard about regulating your hormones with an oral contraceptive; you know that one option is always Accutane. (Read about one Fashionista editor's experience with that here.) But there still might be one treatment method you haven't tried — or even heard of — a magical (in our experience) little pill called spironolactone. Here's everything you need to know about it.
What it is
Spironolactone (or its brand name, Aldactone), is a diuretic pill that's FDA-approved to treat high blood pressure but has been increasingly prescribed off-label to treat acne, specifically the type caused by hormones and common in women. "Spironolactone is one of a dermatologist's best-kept secrets for adult acne," says New York-based dermatologist Dr. Doris Day. "In [high blood-pressure] cases, you typically take 200 mg a day as a recommended dose, but spironolactone tends to work well [for treating acne] at very low doses, as low as 25 mg." Another major plus about the drug: It's cheap! Prescription acne oral and topical medications can often cost upwards of a couple hundred dollars, but an informal office poll confirmed that filling a monthly spironolactone prescription can very easily clock in at less than what it costs to order in lunch on Seamless.
How it works
Although spironolactone is commonly prescribed for treating hormonal acne, it doesn't do so through changing the body's hormone levels themselves, as would be easy to assume. "Spironolactone blocks the effect of the hormones on oil glands," explains Dr. Joshua Zeichner, Director of Cosmetic & Clinical Research in Dermatology at Mount Sinai Hospital. "Less oil means fewer blockages within the pores, less shiny skin and less 'food' to feed acne-causing bacteria that promote inflammation."
Spironolactone works by specifically blocking androgen hormone receptors. (Androgens are colloquially referred to as "male hormones" since testosterone is the most widely known androgen, but it's a bit of a misnomer, since androgens are naturally present in both men and women, just at different levels.) "When the hormones bind to their receptors, it initiates different events that for some people, can lead to acne," says Day. "By blocking those receptors, your hormone levels don't change, but what is changing is how your body reacts to that hormone." (An interesting side note is that for this reason, spironolactone is also commonly prescribed for transgender women.)
A note on side effects
A common reason why more and more women are looking to spironolactone (and why derms feel comfortable and confident prescribing it) is that for the majority of patients, it has little to no adverse side effects and is incredibly effective at treating stubborn acne. Men, on the other hand, tend to react differently to the drug (side effects include breast swelling and/or tenderness) and generally are not prescribed spironolactone for acne-related purposes.
And though it's a diuretic, taking spironolactone at a dose as low as 25 or 50 mg likely won't be severe enough to significantly change your bathroom routine. But if your doctor writes you a spiro prescription, they'll also likely suggest periodic blood tests to make sure your potassium levels are in check (some patients even find that they need to stay away from potassium-rich foods, like bananas, tomato sauce and coconut water). Another important note is that you should avoid the drug if you are currently pregnant or trying to conceive, since it can affect the development of secondary sex organs, especially in males. At higher doses, spironolactone can also sometimes cause breast tenderness, irregular periods and dizziness (taking the pill after eating a full meal personally helps me manage that last one, although I haven't experienced any other side effects).
You're not going to see results right away, so be patient. No, really. It takes time, but it's totally worth it. For most patients, it'll be about three months before beginning to notice a decrease in breakouts. In my personal experience with a 50 mg dose, I went from dealing with pesky blemishes basically all the time to only a flareup, usually around my period. But if you've been taking it for that long and still aren't experiencing a clearer complexion, your doc may up your dosage or recommend a round of antibiotics to help spur results. (It took another Fashionista editor about four months and an even higher dosage to notice a true change in her skin). But when spiro does work, the results are impressive; it can mean the difference between a constant smattering of intense, painful blemishes and an I-barely-need-any-makeup complexion.
That's not to say that spironolactone is a "get out of jail free" card for poor skin-care habits — it's still important to maintain a good at-home regimen — and in certain cases, your derm will recommend using a prescription topical in addition to your daily dose of spironolactone. "Sometimes I combine it with other treatments; once [the patient] gets clearer skin, I'll do spironolactone plus something like Retin-A, which will keep you clear," says Day. And eventually, points out Day, you may even "outgrow" your acne and no longer need to take medication to ward off breakouts. Hormone levels can change, after all.
So while spironolactone still might not attract the kind of name recognition and attention that Accutane does, that's by no means a signal of its inefficacy; in fact, for many patients, it can be a more effective choice. "I know plenty of women who have done Accutane — like one course or two or three courses — and while it worked, the acne always came back in an adult pattern," says Day. "When I prescribe the spironolactone, they do so much better." All that considered, it's still not immediately clear why people aren't buzzing about the largely negative-side-effect-free, affordable and effective drug, and our experts are split on whether it'll remain relatively niche or become the next big-name prescription acne drug. "As its use is getting more attention, it is gaining popularity," says Zeichner; meanwhile, Day believes it'll remain relatively under-the-radar due to acne treatment's status as an off-label use of the medication. One thing, however, is certain: When spironolactone works, it works — multiple Fashionista editors are living proof. So consider this our own little acne-treatment PSA.