What is spironolactone?
It is a diuretic drug – it favors the formation of urine in the kidney – classically used for the treatment of high blood pressure, especially in the context of heart failure, since it reduces the morbidity associated with this disease and increases survival. Its use has been approved since 1960.
Additionally, it has an antiandrogenic mechanism that allows it to be used in hormonal imbalances (hyperandrogenisms): it makes male hormones have less affinity for their receptors in the tissues (binding less to them), so they end up acting less. The result is that the cutaneous manifestations of hyperandrogenisms (seborrhea, acne, hirsutism, androgenic alopecia) are less noticeable or non-existent.
How useful can it be in managing acne in young women?
As we have commented in other posts (click here), androgens – male hormones – have a primary role in the origin and maintenance of acne, since it is these hormones that are responsible for stimulating the skin receptors that will favor the excessive production of sebum and produce acne.
Spironolactone, with its peripheral antiandrogenic mechanism, reduces the binding of androgens to skin receptors and consequently may improve seborrhea, acne, alopecia, and/or hirsutism.
Does it have an antibiotic mechanism and can it promote bacterial resistance or modify the bacterial flora?
Spironolactone does not act against any microorganisms and does not cause alterations in the intestinal or vaginal bacterial flora in women. Consequently, it is usually better tolerated than tetracyclines (doxycycline, minocycline) in this regard.
What mechanism of action does it have on acne in young women?
As we have mentioned, it is a non-contraceptive antiandrogenic drug. It has different actions on androgen metabolism:
· It inhibits the binding of testosterone and dihydrotestosterone to their tissue receptors.
· Inhibits the conversion of testosterone to dihydrotestosterone.
· Inhibits testosterone production.
· Increases sex hormone binding protein (SHBG), decreasing circulating free testosterone.
If it has a hormonal mechanism, is it a contraceptive?
No. Spironolactone has no contraceptive action, does not regulate the menstrual cycle or protect against sexually transmitted diseases.
Is it a fast-acting drug on acne?
No. All medications with mild antiandrogenic action, such as spironolactone, can take 4-6 months to work on acne. For this reason, your dermatólog@ may instruct you to combine this drug with other options to accelerate acne improvement.
Is it the treatment of choice in young women’s acne?
Depending on the clinical context. It is a very valid option when contraceptives, isotretinoin or oral tetracyclines are not desired or contraindicated. It is not uncommon for your dermatólog@ to recommend it as a single or combined treatment when acne does not respond to topical treatment or has enough potential to leave scars, as well as in the event of certain alterations in the blood androgen profile.
Like oral contraceptives, is it contraindicated over the age of 35, in smokers, overweight patients or patients with cardiovascular risk factors?
No. Spironolactone does not increase the risk of thromboembolic phenomena as combined oral contraceptives can. Therefore, it is not contraindicated even with a history of varicose veins, thromboembolic phenomena or coagulation diseases.
What side effects can spironolactone cause?
In general terms, the doses that spironolactone is administered in the management of acne in young women, it is usually particularly well tolerated. The most frequent “side effect” is the increase in the frequency and amount of diuresis (urination), since it has a diuretic action. For this reason, your dermatólog@ will usually prescribe it in the morning.
It is not uncommon that, during the first months, it can cause menstrual period imbalances in up to 20% of cases. In general, after 3-4 menstrual cycles, they usually disappear. Also during the first 2-4 months, an increase in the size of the breasts may be experienced with a sensation (or not) of discomfort on palpation. More rarely, dizziness and headache may appear.
Is it advisable to get pregnant if I take spironolactone?
No. It is a class C drug during pregnancy. It can cause fetal malformations if conceived while consuming spironolactone.
Can spironolactone increase the risk of cancer?
In the most recent systematic reviews, no increase in the incidence or prevalence of ovarian, breast, esophagus, urinary bladder, kidney, or stomach cancers has been found. In men, the incidence of prostate cancer has been shown to decrease.
Does spironolactone decrease fertility in women?
To date, there is no data to support this statement in women. In principle, hyperandrogenisms – which can be treated with spironolactone – are the disorders that can decrease fertility in young women. In this context, antiandrogenic treatments should be in favor of improving ovarian metabolism and, consequently, positively influencing fertility.
In men, antiandrogens can have deleterious effects on fertility, which is why they are not prescribed in a generalized way except in specific cases to treat certain underlying endocrinological disorders.
I’ve read that spironolactone can increase potassium levels in the blood and be dangerous for heart arrhythmias, is that true?
In people with kidney failure , spironolactone can, in fact, increase potassium levels in the blood and this favors some cardiac arrhythmias. However, in healthy people and at the doses of spironolactone used in acne (50 – 100 mg/day) it is not necessary to monitor potassium levels by blood tests, since the probability of hyperkalemia is negligible.
How long does acne treatment with spironolactone take?
Spironolactone is usually prescribed in the context of adult female acne, whose origin is functional or quantitative hyperandrogenism. In principle, hyperandrogenisms are chronic disorders during childbearing age, so the treatment of acne in this clinical context is usually also of indefinite duration. The recommended minimum is 2-3 months but it is exceptional to take such short courses.
REFERENCES
· Marson JW, Baldwin HE. An Overview of Acne Therapy, Part 2: Hormonal Therapy and Isotretinoin.Dermatol Clin. 2019 Apr; 37(2):195-203.
· Charny J et al. Spironolactone for the treatment of acne in women, a retrospective study of 110 patients. Int J Womens Dermatol 2017; 33:111–5.
· Bommareddy K, Hamade H, Lopez-Olivo MA, Wehner M, Tosh T, Barbieri JS. Association of Spironolactone Use With Risk of Cancer: A Systematic Review and Meta-analysis. JAMA Dermatol. 2022 Mar 1; 158(3):275-282.
· Plovanich M, Weng Q, Mostaghimi A. Low usefulness of potassium monitoring among healthy young women taking spironolactone for acne. JAMA Dermatol 2015; 151:941–4.
· Mackenzie I, Macdonald T, Thompson A, et al. Spironolactone and risk of incident breast cancer in women older than 55 years: retrospective, matched cohort study. BMJ 2012; 345:e4445.
