#362 Facing the Evidence in Acne, Part I: Oral contraceptives and spironolactone in females
CLINICAL QUESTION
How effective are combined oral contraceptives (COC) and spironolactone for treating acne of at least mild-moderate severity in females?
BOTTOM LINE
At ~24 weeks, ~80-90% of females report improvement in their acne with COCs, compared to 50-80% placebo, and 30-50% will have clear-almost clear skin versus 10-40% on placebo. Efficacy appears similar between individual COCs. Spironolactone, typically added to topical agents, has similar outcomes. Discontinuations due to adverse events appear comparable to placebo.
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EVIDENCE
- COC: Two systematic reviews1,2 (19-31 randomized controlled trials [RCTs]; 6199-12,579 patients, 11 different COC combinations) in females aged 14-49 with at least mild to moderate acne. At ~24 weeks:
- Versus placebo:
- Patient-assessed improvement: ~80-90% versus 50-80% (placebo).1 Number needed to treat (NNT)=4-7.
- Clinician assessed clear-almost clear skin: 30-50% versus 10-40% (placebo), NNT=6-9.
- Adverse event discontinuations:1 Usually similar to placebo. When different, number needed to harm (NNH)=25-50
- Versus COC:1
- No consistent statistical differences in 17 comparisons.
- Adverse event discontinuations: Usually not different.
- Versus placebo:
- Spironolactone: One double-blind RCT (410 females, mean age 29),3 spironolactone 100mg daily versus placebo (~70% using topicals concurrently) for 24 weeks:
- Patient-assessed improvement: 82% versus 63% (placebo) (NNT=6).
- Patient-assessed clear-almost clear skin: 32% versus 11% (placebo) (NNT=5).
- Quality of life (30-point scale, higher=better, baseline=13): Increased 8.0 versus 4.5 points (placebo), difference likely clinically meaningful.4
- Any adverse events: 64% versus 51% (placebo); example: headache 20% versus 12% (placebo).
- Adverse event discontinuations: No difference.
- Other RCT added spironolactone to topical benzoyl peroxide found slightly greater benefit, but benefits possibly exaggerated as smaller, shorter RCT (63 patients, 12 weeks).5
- Limitations: Most COC RCTs unblinded, many COC RCTs prohibited concurrent topical agents, no RCTs comparing COCs to topical agents, many industry-funded.
CONTEXT
- Guidelines support adding COC if hormonal contraception desired, or when standard treatments (example: topical benzoyl peroxide or retinoid) inadequate. No clear recommendations for spironolactone (all published prior to recent RCT).6-8
- Two small RCTs (170 patients) found no statistical difference between COC and oral antibiotics.1,2
- Potassium monitoring with spironolactone generally unnecessary unless patient otherwise at risk (example: on angiotensin-converting enzyme inhibitors).6
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helpfull
Informative
informative
Another in the armed of acne
Useful Information! Thank you
Good to know spironolactone as good as COC for women who may be older and smoker, or other risks of blood clots
Great talk
Good information. I have never used Spironolactone for acne treatment.