Spironolactone in the treatment of acne in adult women: Systematic review

Abstract

Acne, the eighth most prevalent disease globally, significantly impacts quality of life, particularly in adult women, where hormonal factors play a key role. Spironolactone, an androgen receptor antagonist, has emerged as a promising treatment for acne by reducing sebum production and inflammation. Despite its off-label use, spironolactone is increasingly recommended as an alternative to antibiotics, especially amid rising antimicrobial resistance. This systematic review synthesizes evidence from studies published between 2010 and 2024 to evaluate spironolactone's efficacy in treating adult female acne. High-quality, studies, such as the 2023 Santer/SAFA trial have provided robust evidence for spironolactone's efficacy at doses below 200 mg/day, resolving prior uncertainties identified in the 2017 review by Layton. Current findings indicate significant improvements in acne severity, particularly in moderate to severe cases, with doses near 100 mg/day. Despite these advancements, methodological limitations, including varied assessment tools and high follow-up loss, hinder definitive conclusions. Future research should prioritize standardized methodologies, long-term maintenance studies, and subgroup analyses, particularly in populations with polycystic ovary syndrome (PCOS) or cyclical acne. Spironolactone's unique profile as a hormonal and anti-inflammatory agent positions it as a first-line option for antibiotic-resistant or recurrent female acne. This review underscores its potential for on-label approval and highlights the need for further research to optimize its use in clinical practice.