SAN ANTONIO — The diuretic spironolactone is inexpensive, well tolerated, and effective for most women with acne vulgaris, Dr. Steven A. Davis said at a meeting of Skin Disease Education Foundation.
“This is one of the better products” for treating acne, Dr. Davis said. “It really gets to the heart of the acne problem, at least as well as or better than antibiotics.”
Hormones can play a major role in manifesting acne, as evidenced by premenstrual flare in women, acne changes with oral contraceptive and pregnancy, and exercise- and stress-induced acne flares in women and men. Spironolactone can clear acne in these patients by blunting the androgen response, he said.
“All of my patients are women—spironolactone can cause gynecomastia in men,” said Dr. Davis of the University of Texas, San Antonio. “We ask them if their acne occurs right before their period and clears up after. We noticed that a lot of adolescent girls will get acne during a sport season and clear up afterward, pointing to a testosterone effect of heavy exercise.”
This off-label use of spironolactone, however, is primarily indicated for women over 18 years and up to 70 years old, he said. “One of the great things is that the response is usually very fast. If someone is given 75 mg/day and there is no response in 7–10 days, it's unlikely to work.” In a study at the university, treatment for a median of 15 months was considered effective for 79% of 53 consecutive female patients.
Dr. Davis' standard dosing protocol is 75 mg/day taken as two 25-mg pills in the morning and one 25-mg pill in the evening. Diuretic side effects vary widely from patient to patient and tend to occur at daily doses of 100 mg/day or greater. With this in mind, he doses higher in the morning. “I would rather they urinate frequently during the day if it occurs,” he said. SDEF and this newspaper are wholly owned subsidiaries of Elsevier.
The dose can be increased to 100 mg/day, given as two 25-mg pills in the morning and two 25-mg pills in the evening if there is no response within a week, but the doses should not exceed 200 mg/day in divided doses, Dr. Davis said.
Spironolactone is available as a generic and costs $10–$20 for a bottle of 100 pills. Dr. Davis has no financial relationship with any manufacturer of spironolactone.
“It's a very safe and very clean product. I feel very comfortable giving it to a woman taking oral contraceptives,” he said. “I've probably treated at least 1,000 patients with spironolactone, and it requires little or no blood testing. I don't think it's necessary to follow potassium levels in most healthy adults.”
The most common side effects are menstrual irregularities, which occurred in 5 participants in the 53-patient series, “but I tend not to see this at 75 mg. As you start going up the line to 100 mg and 125 mg, the menstrual irregularities start to kick in.”
In response to a question from the audience, Dr. Davis said lithium and digoxin can interact with spironolactone, so if patients taking a psychoactive drug should check with their psychiatrist about potential interactions.
“The patient satisfaction rate is very, very high. Some patients are treated for 10 or more years without side effects.”