Another class of medications that can be used to manage acne are hormonal treatments. These are medications that are primarily used to treat other medical conditions but have also been found to be beneficial in acne.
The oral contraceptive pill, spironolactone and cyproterone acetate are options that a doctor may consider for use in non-pregnant females to help manage acne. Oral corticosteroids may be used in males and females with severe inflammatory acne and can be started with oral isotretinoin.
Contraceptive agents (the pill)
Many people think about ‘the pill’ as a contraceptive (to prevent pregnancy) but it can also help some women to control their acne.
It’s well known that androgens (male hormones) have a significant role to play in acne and this is how the pill helps to treat acne - by interfering and ultimately blocking the stimulatory effect that androgens have on the skin.
The progestogen component of a combined oral contraceptive pill is considered the most important factor in determining whether an oral contraceptive pill is likely to improve or worsen your acne.
In women over 25 years old or those experiencing premenstrual flare-ups of acne, the pill may be particularly useful.
Various combined oral contraceptive pills can be considered in the management of acne. We’ve provided some regularly used and recommended combinations which your doctor may consider, depending on your specific situation.
Generally, improvement is expected to be seen within three months of starting these contraceptive type hormonal agents with the full effect usually seen within about six months. Some women may require a change in medication dose or the introduction of another therapy before results are seen.
Very low dose pills
Low oestrogen dose pills containing 20mcg ethinyloestradiol along with the following progesterones are acne treatment options:
- Low dose levonorgestrel (100mcg), such as Femme-Tab ED 20/100, Loette and Microlevlen ED (pills containing higher doses of levonorgestrel, e.g. 150mcg have been shown to be less useful and in some cases, worsen acne). Note: Femme-Tab ED is listed on the Pharmaceutical Benefits Scheme for contraceptive use.
- Drospirenone (3mg) – such as Yaz and Yaz Flex
Low dose pills
These pills contain more oestrogen (30mcg) along with the following progesterones:
- Dienogest (2mg) such as Valette. This type of pill has also been shown to be of particular benefit for woman with hormonal imbalances related to PCOS and menstrual irregularities
- Drospirenone (3mg) – such as Isabelle, Petibelle and Yasmin
- Norethindrone acetate (1mg) - none currently listed in Australia
Other oral contraceptive pills
Combined oral contraceptive pills contain higher oestrogen (35mcg ethyloestradiol) and another progesterone/anti-androgen cyproterone acetate (2mg). These include Brenda-35 ED, Estelle-35 ED, Diane-35 ED, Juliet-35 ED.
Other contraceptive pills that have been shown to improve acne include those containing the progestogens gestodene (e.g. Minulet). Results for this combination are limited.
Implantable contraceptive devices such as Implanon and Mirena are likely going to cause a flare of your acne given the active ingredients (etonogestrel in Implanon; levonorgestrel in Mirena). If this is the best contraceptive for you, alternative acne treatment should be considered.
Potential side effects
Generally, there are fewer side effects with lower dose pills and these still provide good contraceptive protection. It’s important to remember though - very low dose pills must be taken at about the same time every day.
If contraception is the primary goal, there is evidence to show improved benefit of contraception in higher oestrogen containing pills. These higher dose pills should still be taken daily but with less emphasis on regular dose-timing.
Breakthrough bleeding is a more common problem for females taking a very low dose pill compared to those taking one with a higher dose of oestrogen. Pills containing higher oestrogen are also more likely to be associated with nausea, breast tenderness, bloating and headache.
Pills containing drospirenone have been shown to have a higher risk of venous thromboembolism/DVT in retrospective studies. Recent prospective studies have challenged the evidence but at this stage, we believe there is insufficient evidence to support this and therefore the risk remains.
Pills containing dienogest have higher risk for causing mood changes, depression, weight gain and changes in libido. They also carry a higher risk of developing venous thromboembolism/DVT.
For both drospirenone and dienogest, the risk of venous thromboembolism/DVT is increased further if you are a smoker and/or have a BMI >30 (obese, not just overweight).
Complete details of known side effects can be found in the consumer product information relevant to your pill. These can also be easily found online by including “CMI” or “consumer product information” along with the brand name of your pill. Consult your doctor for more complete information.
Reduce the risks
The general principle of medication applies - the smallest dose of medication should be used to achieve the desired effect without causing harm. Reducing side effects from the pill can generally be achieved by choosing the lowest dose pill which has the intended result for you.
In many cases, particularly for moderate or severe acne, higher doses of medication are needed to achieve the desired effect. If side effects outweigh your intended treatment goal you should speak with your doctor immediately to seek alternatives.
Likewise, given contraception is also often the desired outcome, it is important to take your pill as directed. Very low dose pills must be taken at around the same time every day to reduce the chance of falling pregnant.
Non-contraceptive hormonal agents
Spironolactone is effectively a potent anti-androgen. It decreases overall testosterone production and competes with the remaining testosterone and other androgens - stopping them from binding and acting on the skin. Some studies suggest it may also increase the production of a key binding molecule made in the liver (SHBG) which binds to and therefore decreases the action of testosterone (an androgen) circulating in the blood.
Effective doses range from 50-200mg. Spironolactone may be particularly useful in females with excessive body hair (hirsutism) or androgenic alopecia (hair loss in females).
Spironolactone can often be used in combination with another therapy, particularly the combined oral contraceptive pill.
Improvement is generally expected within 2-3 months of starting spironolactone. Some women may require a change in medication dose or the introduction of another therapy before results are seen.
Potential side effects
Spironolactone is primarily used as a diuretic, interfering with the re-absorption of water in the kidneys. While the effects often go un-noticed in young women, it will be carefully considered by your doctor.
Spironolactone can produce birth defects and therefore should not be used in pregnancy or if you’re intending to become pregnant. It’s often advised to use contraception concurrently with this medication.
If you’re taking non-steroidal, anti-inflammatory medication such as ibuprofen or certain blood pressure medications (ACEi and ARBs), spironolactone should be carefully considered. If possible, these medications should not be taken together.
Reduce the risks
Reducing side effects from spironolactone can generally be achieved by starting at a low dose and carefully increasing until the desired effect is seen. In many cases, particularly for moderate or severe acne higher doses of medication are needed to achieve the desired effect. If side-effects outweigh your intended treatment goal you should speak with your doctor immediately to seek alternatives.
If you are sexually active, spironolactone alone may not be the best choice given it may harm a developing baby. Contraception is advised. If appropriate, your doctor may consider oral contraception as it may have additional effect in treating your acne. If you cannot take the pill, have a discussion with your doctor regarding other contraceptive options.
Maintaining a well-rounded diet and sufficient hydration when on this medication is also advised.
This is an anti-androgen and progestin which is present in some pills. In Australia, cyproterone acetate is also available in a tablet on its own. Like spironolactone, it is particularly useful in females with excessive body hair (hirsutism) or androgenic alopecia (hair loss in females).
When used on its own, this medication is usually taken on days 1 to 10 of your menstrual cycle only.
Before commencing this medication, your doctor will ensure you are not already pregnant by performing a blood or urine test.
Your doctor will likely perform regular blood tests to monitor for signs of toxicity and is also likely to request baseline blood tests which are carried out before starting this medication.
Potential side effects
Side-effects of cyproterone acetate include complications of pregnancy and feminisation of a male foetus. Therefore, strict contraceptive measures are indicated.
This medication should be completely avoided if intending to fall pregnant, actively breastfeeding or if you have a history of certain liver diseases.
If you have diabetes, you may need to alter your diabetes management.
Brain tumours have been reported in patients who have used this medication for years. Headaches, vomiting, visual changes, dizziness or tinnitus (ringing of the ears) should be reported to your doctor immediately for further investigation.
Reduce the risks
The general principle of medication applies. The smallest dose of medication should be used to achieve the desired effect without causing harm. Reducing side effects from cyproterone acetate can generally be achieved by starting at a low dose and only increasing the dose if no effect is seen. In many cases, particularly for moderate or severe acne this medication will need to be used in combination with other therapies OR higher doses of the medication may be needed to achieve the desired effect. If side-effects outweigh your intended treatment goal you should speak with your doctor immediately to seek alternatives.
Given the potential side effects in pregnancy, it is often recommended that this medication be taken WITH oral contraception – which is available as a combined preparation. At the very least, it is recommended that some form of contraception be strictly adhered to.
Corticosteroids are a very short-term measure that may be recommended in very severe cases of acne to immediately reduce inflammation. This treatment aims to reduce the scarring of a violent eruption and provide immediate relief from severe inflammation. Corticosteroids can be injected into the skin for treatment of single lesions, applied topically as an ointment/cream or given as a tablet if there is a wide area of involvement.
Potential side effects
Side-effects of corticosteroids include inducing acne, insomnia, weight gain and high blood pressure. Your doctor will likely use these medications for a very short time and can provide advice on when and how to take corticosteroids to reduce the chance of side effects. Injecting corticosteroids can be a painful procedure and in some cases, can induce atrophy (wasting) at the injection site.
Reduce the risks
Corticosteroids are used only in severe cases of acne. Your doctor will keep the course duration to a minimum to help reduce the potential of many of the above side effects. To reduce the chance of insomnia, oral corticosteroids should be taken first thing in the morning, with food. Once again, the smaller dose of medication used will help prevent/reduce any side effects.