Female patients with hormonal acne that typically flares before or after menstrual cycles may be ideal candidates for spironolactone, said Emmy M. Graber, M.D., president of the Dermatology Institute of Boston who spoke on the use of spironolactone for acne on Friday at the American Academy of Dermatology (AAD) annual meeting in San Diego.
Spironolactone is one of four hormonal agents recommended by the AAD in its 2016 treatment guidelines for acne vulgaris. The recommendation was rated a B due to inconsistent or limited-quality patient-oriented evidence. By comparison, combined oral contraceptives received an A rating; flutamide, a C rating; and oral corticosteroids, a B rating.
Women who have failed other therapies — such as antibiotic treatment — may be good candidates for spironolactone, as might patients with recurrent acne after a course of isotretinoin, Dr. Graber said. In addition, women who take progesterone only contraception might also benefit from the anti-androgen effects of spironolactone.
Spironolactone can work well for some patients, but it can take several months to see positive results and dose adjustment may be needed, Dr. Graber said.
“The dosing varies greatly from patient to patient. Some patients might come back in three months with only slight improvement, which would be an indication that they might need a higher dosage,” she said.
Patients with polycystic ovarian syndrome (PCOS) or hirsutism may also benefit from treatment with spironolactone. “Some PCOS patients have irregular cycles, but there are also patients with irregular menstrual cycles who don't have PCOS, that might be good candidates for spironolactone,” she said.
Spironolactone is approved in the United States for primary hyperaldosteronism, congestive heart failure, cirrhosis of the liver accompanied by edema and/or ascites, nephrotic syndrome, essential hypertension, and hypokalemia. Although it can be effective in treating acne, there is insufficient data to support use for acne treatment, said Dr. Graber who was a member of the work group that prepared the 2016 guidelines.
Some of the most common side effects of spironolactone are diuresis, menstrual irregularities, and breast tenderness. It is a pregnancy category C, so concomitant use of a combined oral contraceptive is recommended to prevent pregnancy and in many patients, regulate menses, the AAD guidelines state.
Although hyperkalemia is a rare and potentially serious side effect of spironolactone, regular potassium monitoring is no longer thought to be needed in young, otherwise healthy women taking the drug, Dr. Graber said.
A 2015 study published in JAMA Dermatology reported a hyperkalemia rate of 0.72% among 974 healthy young women taking spironolactone for acne, compared to an equivalent 0.76% baseline rate among women not taking the drug. Researchers concluded that routine potassium monitoring was not necessary for healthy women taking the spironolactone for acne.
“As a result of that study, a lot of people have changed the way they've practiced. Many people used to check potassium levels routinely, which was a big barrier to getting patients to take spironolactone, whereas now, myself included, many of us don't check potassium levels routinely in patients on spironolactone,” she said.
Dr. Graber reported disclosures with 3Derm Systems, Allergan, Inc., Almirall, Castle Creek Pharmaceuticals, and Sol-Gel Technologies.
“F015- Practical Guidelines for Using Spironolactone in Acne Patients,” Emmy M. Graber, M.D. 3 p.m., Friday, Feb. 16, 2018. American Academy of Dermatology 2018 annual meeting, San Diego.