Spironolactone for acne: uses and side effects

Spironolactone is a prescription pill that dermatologists use to treat hormonal acne in women. It was first made to treat high blood pressure and fluid build-up, and it is still sold for those uses. The American Academy of Dermatology (AAD) says dermatologists have prescribed it for many years to treat acne and extra hair growth in women. Acne is an off-label use, which means the FDA label does not list acne, and doctors prescribe it based on studies and experience. This guide covers who it is for, how well it works, how long it takes, side effects, potassium, and pregnancy. For the wider plan, see the hormonal acne treatment guide.

Skinli gives general education and is not a doctor. Spironolactone is a prescription medicine. Only a prescriber can decide whether it is safe for you and how to take it.

Who spironolactone is for

The AAD says spironolactone can effectively treat deep, tender acne on the lower face, jawline or neck when other acne treatments do not work. Its treatment page adds that it can treat acne on the face, chest and back in women with stubborn hormonal acne, and names two signs of that: stubborn acne on the lower face, chin and jawline, and breakouts that come predictably during a period.

It is a treatment for women. The AAD says it is not prescribed to men for acne, because men have developed breasts while taking it, and it lists erectile problems as another possible side effect in men. The hormonal acne in men guide covers options for men.

The AAD also says spironolactone may be prescribed alone, without a birth control pill, for women aged 35 or older or with health conditions that make the pill unsafe, such as a past blood clot or stroke. A 2019 review of acne around menopause calls it the first choice when women in that age group need a hormone-blocking pill. See menopause acne.

Its use has grown. A 2023 study of US dermatology visits found a rise in spironolactone prescriptions for women with acne beginning in 2012.

How well it works

Evidence	What it found
AAD's 2024 acne guideline	A conditional recommendation for spironolactone, a weaker grade than the strong recommendations it gives benzoyl peroxide and retinoids on the skin
SAFA trial, BMJ, 2023	410 women with long-lasting facial acne in England and Wales. At week 24, 82% on spironolactone reported improvement against 63% on a dummy pill. At week 12, 19% on spironolactone were rated clear or almost clear by a doctor against 6% on the dummy pill
Records of 85 women, cited by the AAD	One third had complete clearing, one third had noticeably less acne, and 7% saw no improvement

The SAFA authors concluded that spironolactone is a useful alternative to antibiotic pills for women with acne. The women in the trial could keep using creams and gels on their skin, and the AAD also says to keep using everything on your treatment plan.

How long it takes

The AAD says women notice fewer breakouts and less oil within a few weeks of starting spironolactone. The full result takes longer. In the SAFA trial, the difference between spironolactone and the dummy pill was larger at week 24 than at week 12.

The AAD says the dose is raised in steps at the start, so patients see their dermatologist every 4 to 6 weeks early on. It says taking spironolactone at the same time every day gives the best results. When it works, the AAD says patients may stay on it for a long time, and it can be used alone to prevent new breakouts.

Side effects

The AAD lists these as the most common side effects when spironolactone is taken without a birth control pill:

• Painful periods and cramping
• Irregular periods
• Breast tenderness
• Breast enlargement

It says these may lessen when women also take the pill. Other possible side effects it lists are tiredness, headache and dizziness, which it says rarely cause a woman to stop. Spironolactone is a diuretic, which means it makes you pass more urine, so you will urinate more often. In the SAFA trial, 20% of women on spironolactone reported headaches, against 12% on the dummy pill, and there were no serious side effects.

The NHS and MedlinePlus list more side effects, including feeling sick, leg cramps, and breast pain and growth in men. Both list rare serious side effects, such as severe allergic reactions, liver and kidney problems and high potassium. Call a doctor at once for any of the warning signs on your medicine leaflet.

The breast cancer warning

The AAD says you may see a warning about breast cancer in the information that comes with spironolactone. It explains that the warning came from studies in which animals were given high doses, and some developed breast cancer. The current FDA label describes tumors in rats given the drug in their food for 18 to 24 months. The AAD says evidence that spironolactone raises breast cancer risk in women is lacking, and cites a study of 1,475 patients followed for 3 to 7 years: 9 cases of breast cancer were reported, where 8 would have been expected without the drug.

Potassium and blood tests

Spironolactone makes the kidneys hold on to potassium. The FDA label warns that it can cause hyperkalemia, which means too much potassium in the blood, and that the risk rises with kidney problems, potassium supplements, salt substitutes that contain potassium, and some blood pressure drugs. The label advises checking potassium within one week of starting and regularly after. The label is written for its approved uses, such as heart failure.

For healthy young women taking it for acne, a 2015 study in JAMA Dermatology found a low rate of high potassium: 0.72% of 1,802 blood tests in 974 women, against a 0.76% rate in similar women. The authors called routine testing of low usefulness in this group. The AAD says you will need some blood tests before a dermatologist prescribes spironolactone. Your prescriber decides which tests you need and when, based on your health.

Food and medicines to ask about

• Potassium. The AAD says to skip coconut water and supplements that contain potassium. The NHS says bananas, avocados and salt substitutes can raise potassium further, and to ask a doctor or dietitian.
• Pain relievers. MedlinePlus and the NHS list anti-inflammatory pain relievers such as ibuprofen among medicines that may interact.
• Alcohol. MedlinePlus says alcohol with spironolactone can cause dizziness and fainting when you stand up quickly.

Tell your prescriber about every medicine, vitamin and herbal product you take. The supplements guide covers products sold for hormonal acne.

Pregnancy and breastfeeding

The AAD lists spironolactone among acne medicines to stop immediately in pregnancy, because it can cause serious birth defects. The FDA label says studies in rats showed feminization of male fetuses, and advises avoiding it in pregnancy. The AAD says it is essential to use birth control while taking it if you can get pregnant, and that taking it with a birth control pill has this added advantage. See birth control for acne and pregnancy acne.

On breastfeeding, the label says small amounts of a breakdown product reach breast milk and long-term effects on the baby are unknown. The NHS says you may be able to take it while breastfeeding after checking with a doctor.

Spironolactone compared with other options

• Birth control pills treat acne through hormones too, and the AAD says taking both can increase how well they work.
• Antibiotics of the tetracycline group were the most prescribed acne treatment for adult women in the 2023 study of US visits. The SAFA authors call spironolactone a useful alternative to antibiotic pills.
• Isotretinoin is for severe or scarring acne. The AAD's 2024 guideline gives it a strong recommendation. See the Accutane guide.

Questions to ask before you start

• Which blood tests do I need before starting, and do I need any later?
• What birth control should I use while I take it?
• Which of my other medicines or supplements could raise my potassium?
• Should I keep using my acne cream or gel?
• How long should I take it before we decide whether it works?
• What should I do if my periods change?

Before your visit, the AAD suggests listing your medical conditions, medicines, supplements, past surgeries and conditions in close relatives. Skinli's free acne plan gives you a first-line routine to use alongside any prescription.