Spironolactone

Spironolactone is a diuretic and an antiandrogen. It can be considered in moderate to severe acne as an alternative to oral antibiotics in females with another indication for its use, or when acne may be related to hormonal changes (eg menstrual cycles), and if a COCP:

is contraindicated, not desired or not tolerated
is not sufficient as monotherapy.

Note: Spironolactone is contraindicated in pregnancy.

Spironolactone is contraindicated in pregnancy because of the risk of defective virilisation of the male fetus. Exclude pregnancy before starting treatment and ensure use of effective contraception during therapy. Stop spironolactone when planning pregnancy or when pregnancy is suspected or confirmed.

Adverse effects of spironolactone include irregular menstrual bleeding, postmenstrual spotting, and breast tenderness or lumpiness.

For moderate to severe acne in females, consider:

spironolactone 25 to 50 mg orally, once daily, increasing gradually to 50 to 100 mg once daily as tolerated. Review therapy after 6 months. spironolactone spironolactone spironolactone

If a COCP alone has not been sufficiently effective for acne, adding spironolactone can enhance the benefit. The COCP also provides reliable contraception and minimises adverse effects of spironolactone. Choose any well-tolerated COCP—the choice of progestogen does not matter in this situation. For COCP formulations available in Australia, see Formulations of combined hormonal contraception available in Australia in the Sexual and Reproductive Health guidelines.

If the response to spironolactone is insufficient after 6 months, consider adding an oral antibiotic (if this has not been trialled previously). Alternatively, refer to a dermatologist for consideration of oral isotretinoin.