Spironolactone is a blood pressure medication that dermatologists prescribe off-label for hormonal acne in women. A 2023 trial found it improved acne more than placebo by 24 weeks. Pregnancy must be avoided, and potassium matters for some people.
Spironolactone is an oral medication approved by the FDA for conditions such as heart failure and high blood pressure, and dermatologists have prescribed it for years, off-label, to treat hormonal acne in women. It works by dampening the effect of androgen hormones on the skin's oil glands. The American Academy of Dermatology's 2024 acne guidelines conditionally recommend it, and a large 2023 trial in the BMJ found it improved acne more than placebo, with the clearest difference at 24 weeks. Because it can affect a developing fetus, pregnancy must be avoided while taking it, and some people need potassium checks.
According to its prescribing information, spironolactone (brand name Aldactone) is an aldosterone blocker approved for heart failure, add-on treatment of high blood pressure, certain kinds of fluid retention and primary hyperaldosteronism. It is not approved for acne, and the 2024 AAD guidelines state this plainly.
The guidelines explain its acne effect: spironolactone lowers testosterone production and blocks testosterone and DHT from binding to androgen receptors in the skin. It may also inhibit the enzyme that makes DHT. Androgens stimulate oil glands, so dialing down their effect can mean less oil and fewer breakouts.
The AAD's patient page on hormonal therapy describes the typical candidate as a woman with acne along the lower face, jawline and neck, often deep and tender, that has not responded well to other treatments. It can be prescribed with or without a birth control pill; combining the two can increase effectiveness and also provides contraception. The AAD notes spironolactone is not prescribed for acne in men because of side effects, including breast development.
Hormonal swings are a common reason for adult acne. The AAD lists fluctuations around periods, during pregnancy, perimenopause and menopause, and after starting or stopping birth control pills as common triggers, and notes that adult-onset acne is most common among women going through menopause.
SAFA randomly assigned 410 women aged 18 or older with persistent facial acne to spironolactone or a matching placebo for 24 weeks, with doses increased partway through. Participants could keep using topical treatments. Key results:
| Measure | Spironolactone | Placebo |
|---|---|---|
| Acne quality-of-life symptom score at week 24 (higher is better) | 21.2 | 17.4 |
| Women reporting acne improvement at week 12 | 72% | 68% |
| Women reporting acne improvement at week 24 | 82% | 63% |
| Investigator-rated treatment success at week 12 | 19% | 6% |
| Headache | 20% | 12% |
The difference at 12 weeks was modest and the self-reported improvement at that point was not statistically significant, while the gap was larger and significant at 24 weeks. No serious adverse reactions were reported. The authors concluded spironolactone is a useful alternative to oral antibiotics for women with acne. As with all trials, these are group averages, and individual results vary.
The guidelines conditionally recommend spironolactone based on moderate-certainty evidence from eight studies. They note that SAFA was published after their literature search was complete, so its results add to that evidence. The AAD patient page also describes a review of 85 women's records in which about one third had complete clearing, one third had noticeably less acne and 7 percent saw no improvement.
The AAD patient page says women may notice fewer breakouts and less oiliness within a few weeks. SAFA suggests the full effect builds over months, with the strongest results at 24 weeks. Your prescriber sets the dose and adjusts it over time.
The 2024 guidelines report that irregular menstrual bleeding is common (40.6 percent versus 0 percent in pooled small trials), may depend on dose and is less common in women also taking a combined birth control pill. Other common effects include increased urination, breast tenderness or enlargement, fatigue, headache and dizziness. The AAD notes that fatigue, headache and dizziness rarely lead women to stop, and describes spironolactone as generally considered safe for healthy women.
The prescribing information lists additional warnings, including high potassium, low blood pressure and kidney effects from excess fluid loss, and other electrolyte changes.
The AAD notes that you may see a breast cancer warning in information about spironolactone, and explains that it came from studies in which animals received very high doses. It reports that available human evidence has not shown an increased breast cancer risk; in one study of 1,475 patients followed for 3 to 7 years, 9 cases occurred where about 8 would have been expected without the drug.
Spironolactone causes the body to hold on to potassium. Its prescribing information warns that potassium can rise too high, especially with kidney problems, potassium supplements, potassium-based salt substitutes or medications such as ACE inhibitors and ARBs, and it advises avoiding potassium supplements and high-potassium salt substitutes. The AAD patient page suggests skipping potassium supplements and coconut water.
For healthy young women taking it for acne, the data are reassuring. A 2015 JAMA Dermatology study of 974 women found a mild high-potassium rate of 0.72 percent, essentially the same as the 0.76 percent baseline rate in similar women, and none had symptoms. The 2024 AAD guidelines conclude that routine potassium monitoring is of low usefulness in healthy patients, but should be considered for older patients, people with conditions such as high blood pressure, diabetes or kidney disease, and people taking medications that affect the kidneys or potassium. Your prescriber decides whether lab work is needed for you.
The prescribing information states that, based on animal studies and its anti-androgen action, spironolactone may affect the development of a male fetus and should be avoided during pregnancy. The AAD stresses that it is essential to use birth control while taking it if you could become pregnant. For breastfeeding, the label notes that a small amount of a breakdown product was found in breast milk in one case and that long-term effects on an infant are unknown, so discuss it with your prescriber.
The AAD patient page says long-term hormonal therapy appears to be safe for women who respond, and many stay on it for a long time while stopping other acne treatments. Follow-up with your prescriber helps track side effects and any needed labs.
Yes, in many cases. The AAD notes the combination can increase effectiveness, and the 2024 guidelines report that irregular bleeding is less common when a combined pill is also used. Your prescriber will check whether the pill is safe for you.
The sources reviewed here do not report what typically happens after stopping. The AAD notes that women who respond often stay on hormonal therapy for a long time, so talk with your prescriber about a plan before making a change.
The AAD notes that dermatologists have prescribed spironolactone for many years for both acne and excess hair growth in women, both off-label uses. Its use for thinning scalp hair is covered in our article on hair thinning in women.
A licensed provider can review your acne history, menstrual cycle, blood pressure, kidney health, other medications and pregnancy plans to decide whether spironolactone is appropriate. Spironolactone is available through NewDay Wellness as an oral tablet when a provider determines it fits, and the prescriber sets the dose. Learn more on the spironolactone product page. This article is educational and does not determine eligibility for any treatment.
Written by the NewDay Wellness editorial team from the sources above and checked against them before publication, and medically reviewed by Dr. Sean Arora and Dr. Shannon Arora of Arora Health & Aesthetics; see our editorial standards. This article is educational and does not diagnose conditions, establish eligibility for any medication, or replace care from a licensed provider. Compounded medications are not FDA-approved.
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