Spironolactone for Acne: Oral vs. Topical Treatment

Spironolactone isn’t a typical acne drug. You won’t find it in the same aisle as benzoyl peroxide or retinoids. But for women with stubborn hormonal acne-especially around the jawline, chin, and lower face-it’s become one of the most effective options doctors reach for. The big question? Should you take it by mouth or apply it straight to your skin? The answer isn’t simple, and it depends on what your body needs, not just what’s trendy.

Why Spironolactone Works for Acne

Acne isn’t always about dirty skin or too much oil. For many women, it’s driven by androgens-male hormones like testosterone that spike during puberty, menstrual cycles, or due to conditions like PCOS. These hormones tell your sebaceous glands to overproduce oil, clog pores, and trigger inflammation. Spironolactone blocks androgen receptors in the skin and reduces the amount of free testosterone circulating in your blood. It doesn’t kill bacteria or dry out your skin like other acne meds. It goes after the root cause.

Studies show that about 70% of women with hormonal acne see noticeable improvement after 3 to 6 months of oral spironolactone. One 2021 review in the Journal of the American Academy of Dermatology found that doses between 50mg and 200mg daily led to a 50% or greater reduction in acne lesions in most patients. That’s comparable to isotretinoin in some cases-without the same level of side effects.

Oral Spironolactone: The Gold Standard

Oral spironolactone has been used off-label for acne since the 1980s. It’s not FDA-approved for this use, but it’s widely accepted in dermatology. Doctors usually start at 25mg to 50mg per day and increase slowly, depending on how you respond and tolerate it.

Here’s what you can expect:

• Timeline: It takes at least 2 to 3 months to see results. Don’t give up if your skin looks worse at first-it’s common.
• Effectiveness: Works best for adult female acne, especially if it flares before your period. It also helps reduce excess facial hair in some cases.
• Side effects: Frequent urination (it’s a diuretic), breast tenderness, menstrual irregularities, dizziness, and low blood pressure. Rarely, it can raise potassium levels, so your doctor will likely check your bloodwork every few months.

It’s not safe during pregnancy. If you’re sexually active, you must use reliable birth control. Spironolactone can cause serious birth defects in male fetuses. Even if you’re not planning to get pregnant, it’s a non-negotiable safety step.

Topical Spironolactone: The New Kid on the Block

Topical spironolactone is newer, less studied, and not yet available as a standard prescription in most countries. But compounding pharmacies in the U.S., Canada, Australia, and New Zealand can make custom creams or gels with spironolactone concentrations between 1% and 5%.

Here’s how it stacks up:

• How it works: Applied directly to acne-prone areas, it blocks androgens right where they’re causing trouble-without affecting your whole body.
• Benefits: No systemic side effects. No need to worry about potassium levels, dizziness, or menstrual changes. Great for people who can’t take oral meds due to kidney issues, low blood pressure, or pregnancy concerns.
• Limits: It only treats the areas you apply it to. If your acne is widespread, it won’t help much. It’s also not as potent as oral. Studies show about 30-40% improvement in lesions after 3 months, compared to 70% with oral.

One 2023 pilot study in Clinical, Cosmetic and Investigational Dermatology tested a 5% topical spironolactone gel on 42 women with mild-to-moderate facial acne. After 12 weeks, 76% reported less redness and fewer breakouts. But 20% saw no change at all. It’s promising, but not a magic bullet.

Oral vs. Topical: The Real Comparison

Here’s how the two forms compare side by side:

Oral wins for severe or widespread acne. Topical is better if you’re looking for a gentler option, have mild acne localized to your chin and jaw, or can’t tolerate oral meds. Some dermatologists even combine both-oral for internal control, topical for spot treatment.

Who Should Avoid Spironolactone Altogether

Not everyone is a candidate. Avoid spironolactone if you:

• Have kidney disease or are on dialysis
• Have Addison’s disease
• Are pregnant or planning to become pregnant
• Have high potassium levels (hyperkalemia)
• Are taking NSAIDs like ibuprofen long-term (can raise potassium further)
• Are male (it can cause breast growth and sexual side effects)

Men with acne should look elsewhere. Spironolactone isn’t effective for male-pattern acne and carries too many risks.

What to Do If It Doesn’t Work

Spironolactone isn’t a cure-all. If you’ve tried it for 6 months with no improvement, talk to your doctor about:

• Switching to a higher oral dose (up to 200mg/day, under supervision)
• Adding a topical retinoid like tretinoin
• Trying a different hormonal therapy like combined oral contraceptives (e.g., Yaz, Estrostep)
• Considering isotretinoin for severe, scarring acne

Some women need a combo approach. One patient I worked with took 100mg oral spironolactone and used a 2% topical retinoid nightly. Her acne cleared by month 5. She still gets occasional breakouts, but nothing like before.

Real Talk: Managing Expectations

Spironolactone won’t give you perfect skin overnight. It’s not a quick fix. It’s a long-term management tool-like wearing glasses for vision. You take it because it works, not because it’s easy.

Also, don’t stop suddenly. If you discontinue oral spironolactone, your acne can come back hard and fast. Many women need to stay on a low dose (25-50mg) indefinitely to keep breakouts under control.

And yes, you’ll still need to use gentle cleansers, sunscreen, and non-comedogenic moisturizers. Spironolactone helps from the inside, but your skincare routine still matters.

Where to Get It

Oral spironolactone is easy. Ask your GP or dermatologist. They’ll write a prescription, and your local pharmacy can fill it. In New Zealand, it’s available as a generic under the brand name Aldactone or just as spironolactone.

Topical spironolactone is trickier. You’ll need a compounding pharmacy. In Wellington, places like Pharmacy 2000 or Healthcare Compounding can make it. Bring your prescription and ask for a 1-5% cream or gel. Don’t try to make your own-it won’t be safe or effective.

Final Thoughts

Oral spironolactone is the proven, powerful choice for hormonal acne. Topical is a promising alternative for those who can’t handle the side effects or only have localized breakouts. Neither is perfect. But for many women, they’re the best shot at clear skin without the harshness of isotretinoin or the frustration of endless spot treatments.

Start with oral if your acne is moderate to severe. Try topical if you’re sensitive to side effects or have mild, chin-focused breakouts. Either way, work with a doctor who understands hormonal acne. Don’t self-prescribe. Don’t skip blood tests. And don’t give up too soon.

Clear skin isn’t about luck. It’s about matching the right tool to the right problem-and spironolactone, in either form, is one of the most reliable tools we have.