When I hit my late-20s, I learned that acne doesn't automatically stop when you graduate and sign a lease for your own apartment. Up until this point in my life, except for getting the odd pimple around the time of my period, I was that annoying person with clear skin even though my skincare routine was minimalist at best. But as soon as I turned 28, I started getting a few hormonal, cystic pimples on my chin and jawline, regardless of where I was in my monthly cycle. This quickly escalated into full-on breakouts that didn't respond to any acne treatment I tried.
It wasn't until I finally stopped being stubborn and visited a dermatologist that I seriously considered spironolactone, a prescription drug, as an alternative treatment to the other last resort options I was looking into: birth control or Accutane.
What Is Spironolactone?
If you haven’t heard of the pill, join the club. I only came across it during one of my early hypochondriac Google searches before my hormonal acne was at its worst.
The reason that treating hormonal acne with spironolactone has gone under the radar is that it’s actually an off-label use for the drug. “Spironolactone has been around for over 50 years,” Dr. Cybele Fishman, a board-certified dermatologist in New York City previously told InStyle. “It was originally used as a blood pressure medicine because it’s a diuretic and when you pee more your blood pressure goes down. Now, it’s not regularly used to lower blood pressure, but to treat hormonal acne, female pattern hair loss, and PCOS [polycystic ovary syndrome] due to its anti-androgen activity.”
How Does Spironolactone Work for Acne?
Spironolactone acts as a roadblock for androgen hormones in your body by preventing them from overstimulating the skin’s oil glands. “In women with hormonal acne, androgens appear to have a strong impact on sebaceous gland activity,” explains Dr. Fishman. “Spironolactone blocks the effect of those androgens. Testosterone and dihydrotestosterone are the main ones, but progesterones also have some androgen activity." This is why women often experience breakouts right before their period, as they get a spike in progesterone.
By the time I was first prescribed spironolactone, my hormonal acne was beginning to effect my mental health and my self esteem. I was desperate for a solution so I barely asked about any of the pill's side effects. So while spironolactone will drastically improve the appearance of your skin, it's not a miracle pill so do not expect perfection.
Here are eight things you should know before you start taking spironolactone for hormonal acne, from the aforementioned side effects to how long the pill takes to work.
1. Don't Expect Instant Results
Although I started seeing an improvement in the cystic acne on my chin and jawline after being on the pill for around a week, don't expect that spironolactone will work as quickly for you as it did for me. "It takes about three months at the right dose to get the full effect," says Dr. Joshua Zeichner, director of cosmetic and clinical research in dermatology at Mount Sinai Hospital in New York City. "If the dose is too low for an effect in you, you may need to increase the dose and need to wait a few months for that dose to kick in."
2. Spironolactone Might Not Work for You
If you've been taking the pill for over three months and your hormonal acne situation isn't any better, it might be time to try a new dose or another treatment option all together. "When using it to treat acne, spironolactone is only used in women and tends to work best for women with hormonal acne, menstrual flares, adult-onset acne, or conditions with hormone abnormalities and acne (e.g. PCOS)," explains Sejal Shah, cosmetic dermatologist and founder of Smarter Skin Dermatology in New York City "It is also often used in women whose acne is resistant to conventional therapies."
"At a high enough dose it has some effect on all women," adds Dr. Zeichner. "The issue is that at higher doses it may be associated with side effects like breast tenderness or irregular periods, which get in the way with using it."
3. You Will Pee — A Lot
The pill itself is a diuretic, so frequent urination is an expected side effect. Personally, I peed every 30 minutes the first week or so I was on spironolactone. (Yes, I counted.) The interval eventually tapered off, but I still pee more than I did before I started taking the medication.
4. Your Period Cramps May Get Worse
I've had borderline debilitating cramps every month since I started getting my period in middle school, and I didn't think it was possible for them to get worse until I experienced my first period on spironolactone. Dr. Shah says that it's possible that these intensified cramps could be caused by hormonal changes from taking the drug. My cycle also lasts longer, too. (Lucky me!). But what I haven't dealt with is spotting, which is a common side effect of spironolactone.
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5. You Can Feel More Tired Than Usual
When my body was still adjusting to spironolactone, I was so exhausted I could have easily fallen asleep standing up while in line at Whole Foods — even though I was taking a very small dose of the medicine. Since then, my energy levels are pretty much back to what they used to be before taking the pill. "Spironolactone blocks the hormone aldosterone, which can lead to fatigue," Dr. Shah explains. "In addition, it can lower the blood pressure, and if this drop is sudden, you may feel tired."
6. It Is Possible to Still Get Pimples While Taking Spironolactone
The first six months I was on spironolactone, my skin was completely blemish-free. Then, I started getting the odd whitehead —usually during weeks when I was under extreme stress or had a few too many late-night pizza slices.
When I asked Dr. Zeichner about this, he said that it's possible to experience mild breakouts after being on spironolactone for a year. "You are not the same person you were a year ago," Dr. Zeichner said. "The hormones and sensitivity to those hormones may change over time, which means you may need to adjust your dose."
7. Spironolactone Is Safe for Long-Term Use
Sure, the everyday side effects of spironolactone are minimal, but what about the long-term risks of being on it? Breathe a sigh of relief, because it falls under "very safe" on the spectrum of medications. Although it's not associated with cancers (including breast or ovarian) in humans, both Dr. Zeichner and Dr. Shah note that spironolactone does have a black box warning because high doses have caused tumors in rats.
However, if you are planning on getting pregnant, you shouldn't take spironolactone. "Theoretically it can cause birth defects, so you should use contraception if you are on it," says Dr. Zeichner.
8. Your Acne Can Come Back If You Stop Taking Spironolactone
The reality is that spironolactone only works when you're on it. If you do stop taking it, it's possible that your hormonal acne will come back. "The effect of the body's hormones will go back to what it was before you started," says Dr. Zeichner.
Spironolactone may sound too good to be true, but if you’ve struggled with hormonal acne and have exhausted other treatment options, this pill may finally be the exception you’ve been searching for. My skin drastically improved once I started taking spironolactone, and even though everything's not perfect, I'm happy I made the decision to go on it.