The statistics are staggering for adult female acne: 1 in 2 women in their 20s, 1 in 3 in their 30s and 1in 4 in their 40s.
“However, we have a paucity of treatment options for these patients,”
Shari Marchbein, M.D., an assistant clinical professor of dermatology at New York University of Medicine, tells Dermatology Times.
Furthermore, these patients are treated the same as for a teenage boy, even though adult female acne is a completely different population subset “that I do not think has yet to be well categorized or characterized,” Dr. Marchbein says. “We do not know exactly why these patients are affected and why traditional treatments like isotretinoin do no work as well in this patient population.”
As an alternative, Dr. Marchbein and many other dermatologists use spironolactone as a “wonderful adjuvant treatment” in conjunction with traditional therapies, birth control and other hormonal modalities to help with the hormonal component of acne.
Nonetheless, a lot of dermatologists are not comfortable using spironolactone because they are uncertain of the correct dosing, according to Dr. Marchbein. There is also a lack of literature, and most of the literature is at least 10 years old.
In addition, spironolactone is not FDA approved for any skin-related conditions, even though it has been used to treat acne for over 30 years now.
Adult female acne is typically characterized by larger, painful and more cystic breakouts on the lower third of the face. Women also tend to flare with their period or ovulation (mid-cycle).
“Spironolactone, at an appropriate dose, can help with these cystic flares, in particular the ones that women develop with their hormonal changes during the month,” says Dr. Marchbein, in an interview prior to her June presentation entitled “Spironolactone 101” at the 37th Annual Advances in Dermatology meeting at NYU Langone Medical Center.
Two working theories that have been published as to why adult women have acne are that there is more local skin production of the hormones that affect the oil glands and that the oil glands are more responsive to hormones in adult women than in other patients.
A 2015 published study found that potassium levels did not need to be monitored in young, healthy women under the age of 45 who were on spironolactone and did not have any known kidney disease. “The risk of these women having high potassium is the same as in the general population,” Dr. Marchbein reports.
Depending on the severity of their acne, Dr. Marchbein starts females on spironolactone on either 50 mg/day or 100 mg/day (once or twice a day).
“Sometimes taking the medication twice a day helps with any symptoms,” says Dr. Marchbein, noting that the most common side effect is dizziness or lightheadedness, followed by irregular menses, breast tenderness and diuresis. “However, these are all fairly low percentages and overall very well tolerated, so they should not deter patients from taking the drug.”
Patients who are on concomitant birth control pills often have less hormonal symptoms. “You also do not want to become pregnant while on spironolactone,” Dr. Marchbein says.
Dr. Marchbein has patients return to the office 1 month after starting the oral medication. If patients are still breaking out, she will increase the dosage each month by 50 mg/day, until the patient is clear.
“Over 3 months, if necessary, patients can escalate to 200 mg/day,” Dr. Marchbein says.
The maximum dose that has been reported for acne in the literature is also 200 mg/day, “which is considered a high dose,” says Dr. Marchbein, who is currently testing even higher doses because the drug is used at higher doses for other conditions.
If patients are on the correct dose for the first month, they should notice fewer and smaller cysts. “However, 12 weeks is the typical amount of time to see clearance,” Dr. Marchbein says.
Duration of treatment is until the patient wants to become pregnant. “Acne is a chronic disease, so I cannot predict when it will stop,” Dr. Marchbein. “Spironolactone simply controls acne.”
For patients who experience a side effect, the drug dosage can be reduced and/or the addition of a birth control pill.
In fact, Dr. Marchbein recommends that spironolactone be used in conjunction with birth control pills, not only to help with any hormonal symptoms, but to prevent feminization of the male fetus and pregnancy itself.
“It is extremely rare that I see a patient who cannot tolerate spironolactone and needs to discontinue the drug,” Dr. Marchbein says.
Published data out to 8 years indicate spironolactone “is an incredibly safe medication,” Dr. Marchbein says. “The reports of it being associated with breast cancer and other cancers like uterine and ovarian have been completely debunked.”
Dr. Marchbein believes spironolactone should be first-line therapy and standard of care for adult women with acne, “even though spironolactone is not indicated as a first-line treatment in the newest acne guidelines. I think we are doing a disservice to our acne patients by not positioning spironolactone as first-line therapy.”
Disclosure: Dr. Marchbein reports no relevant financial disclosures.