Tools for Practice Outils pour la pratique

#362 Facing the Evidence in Acne, Part I: Oral contraceptives and spironolactone in females

How effective are combined oral contraceptives (COC) and spironolactone for treating acne of at least mild-moderate severity in females?

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.

CFPCLearn Logo

Reading Tools for Practice Article can earn you MainPro+ Credits

La lecture d'articles d'outils de pratique peut vous permettre de gagner des crédits MainPro+

Join Now S’inscrire maintenant

Already a CFPCLearn Member? Log in

Déjà abonné à CMFCApprendre? Ouvrir une session

  • 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.
  • 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.

  • 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

johannes malan April 3, 2024


gregory Stroh April 7, 2024


Elionora sofronova April 19, 2024


Latest Tools for Practice
Derniers outils pour la pratique

#363 Making a difference in indifference? Medications for apathy in dementia

In patients with dementia, how safe and effective are stimulants, antidepressants, and antipsychotics for treating apathy?
Read Lire 0.25 credits available Crédits disponibles

#362 Facing the Evidence in Acne, Part I: Oral contraceptives and spironolactone in females

How effective are combined oral contraceptives (COC) and spironolactone for treating acne of at least mild-moderate severity in females?
Read Lire 0.25 credits available Crédits disponibles

#361 Preventing RSV Infections in Infants

How safe and effective are monoclonal antibodies to prevent respiratory syncytial virus (RSV) infections in infants?
Read Lire 0.25 credits available Crédits disponibles

This content is certified for MainPro+ Credits, log in to access

Ce contenu est certifié pour les crédits MainPro+, Ouvrir une session

  • Sasha Katwaroo PharmD candidate
  • Brianne Desrochers PharmD candidate
  • Allison Paige MD CCFP
  • Jamie Falk PharmD

1. Williams Arowojolu AO, Gallo MF, Lopez LM, et al. Cochrane Database Syst Rev. 2012; 2012(7):CD004425.

2. Huang CY, Chant IJ, Bolick N, et al. Ann Fam Med. 2023; 21(4):358–69.

3. Santer M, Lawrence M, Renz S, et al. BMJ. 2023; 381:e074349.

4. McLeod LD, Fehnel SE, Brandman J, Symonds T. Pharmacoeconomics. 2003; 21(15):1069-79.

5. Patiyasikunt M, Chancheewa B, Asawanonda P, et al. J Derm. 2020; 47:1411–1416.

6. Zaenglein AL, Pathy AL, Schlosser BJ, et al. J Am Acad Dermatol. 2016; 74:945-73.

7. Asai Y, Baibergenova A, Dutil M, et al. CMAJ. 2016; 188(2):118-126.

8. National Institute for Health and Care Excellence (NICE). Acne vulgaris: management. Available at:; Updated Dec 2023. Accessed December 12, 2023.

Authors do not have any conflicts of interest to declare.