The Ultimate Guide to Hormonal Acne
Treatments - Medications
Hormonal acne can be treated with birth control pills, antiandrogens and other pharmaceuticals. This page covers the pros and cons.
Pharmaceutical treatment options include birth control pills, antiandrogens, and insulin lowering drugs (Metformin). This post doesn’t cover antibiotics. They aren’t specific to hormonal acne and taking them for acne is a bad idea.
Birth control pills
Birth control pills, or combined oral contraceptives, contain a mixture of estrogen and progesterone. They reduce androgen production and increase the production of sex hormone binding globulin, which binds to testosterone and further reduces its bioactivity. All BC pills prescribed for acne include estrogen, which helps to offset the acne-causing effect of androgens. The net effect is a significant reduction in androgen levels and acne.
A 2014 paper analyzed 32 studies on the effect of birth control pills on acne. This graph shows the average reduction in acne after 3 months and 6 months of treatment.
It takes some time for the effects of birth control pills to kick in. Studies show a reasonable reduction in acne by the end of your 3rd cycle.
Keep in mind what while birth control pills reduce acne, the opposite is also true. Many women report a drastic increase in acne after stopping birth control pills. The post-pill acne can be much worse than acne before the pill.
Stopping the pills means there’s a lot less estrogen to balance androgens, and it may take several months to a year for your hormones to balance.
What is the best birth control pill for acne?
The short answer is they are all equally effective. 17 studies have compared the effectiveness or 2 or more birth control pills. None of the currently available BC pills emerged as a clear winner. Some studies showed one to perform better, other studies showed the opposite. These results show all the available birth control pills are, on average, equally effective against acne.
However, it’s entirely possible one pill works better than the others for you. But that’s something you have to discover through trial and error.
Are birth control pills safe?
Currently available evidence points to BC pills being by and large safe. Some women experience spotting or abnormal vaginal bleeding during the first two cycles on the pill. 10 to 20% of women also report slightly more headaches and moodiness while on the pill.
The pill is commonly blamed for reduction in sex drive and weight gain. However, a 2014 review of 49 studies showed women taking BC pills didn’t gain anymore weight than women who used other birth control methods.
Changes in sex drive and libido are reported in studies. However, a 2007 study of 1716 women taking BC pills showed that over 80% of the participants reported no change in sexual satisfaction. Furthermore, equally many women reported improvements in sexual satisfaction than did report reductions.
Studies have also shown 8 to 24% increase in breast cancer risk among women who take birth control pills. Increase in breast cancer risk is higher in younger women. However, the absolute risk of breast cancer in women under 40 is miniscule. The increase in risk declines after stopping the pill and disappears within 5 to 10 years. BC pills are also known to reduce the risk of other cancers.
There are also concerns that birth control pills increase the risk of blood clots. Again, the absolute risk in young women is miniscule.
Antiandrogens are another common class of medications prescribed for women with hormonal acne, the most common being spirinolactone (or spiro).
Spironolactone reduces acne by decreasing testosterone production and by blocking the action of testosterone and DHT in the skin. While spiro is an androgen blocker, it’s also effective against acne in women who have normal androgen levels.
A study published in the Journal of American Academy of Dermatology analyzed the change in acne in 85 women given low doses of spironolactone. 66% of the women either cleared completely or showed a marked improvement. This graph breaks down the results.
A Japanese study from 2006 also showed spironolactone is effective for women with acne. However, this study shows the potential harm in prescribing antiandrogens to men. The study included 23 men and had to be stopped before completion because three of the men developed gynecomastia (man boobs).
Antiandrogens can be very effective for women, but they aren’t recommended for men with acne
Aside from acne, spironolactone has also been shown to reduce sebum production by 30 to 50%. Studies show it takes about 3 months to get good results.
Guidelines for care for the management acne vulgaris published in The Journal of American Academy of Dermatology in 2016 states that spironolactone is well tolerated and side effects are rare.
Metformin is a diabetes drug derived from the French lilac plant. Given the central role of insulin in initiating acne, one would expect insulin lowering drugs to reduce it. And indeed, that’s what studies show.
Metformin has been shown to reduce acne in both men and women
Metformin has been studied on women with PCOS. Metformin can reduce acne and androgens even in women who aren’t insulin resistant. A 2007 study showed 64% reduction in acne in thin women with PCOS but who weren’t insulin resistant. Metformin hasn’t been studied in women with normal androgen levels.
A study published in the Clinical and Experimental Dermatology showed that the combination of metformin and low glycemic index diet reduced acne by 45% in men.
Don’t bother with DHT blockers
Many natural health books and websites promote DHT blockers as the solution for acne. DHT blockers, more specifically, 5-alpha reductase inhibitors, block the conversion of testosterone into DHT. Pharmaceutical DHT blockers include Finasteride and Dutasteride – natural options include green tea and saw palmetto.
Given the role these hormones play in acne, many people believe DHT blockers can clear acne. But, as we discussed above, the conversion of testosterone into DHT happens in the skin. Taking DHT blockers orally (drugs, supplements, food) probably has no effect on the conversion in the skin. Indeed, study published in 2004 showed that pharmaceutical DHT blockers had no effect on acne. That being said, topical DHT blockers can reduce sebum production and acne (see the discussion on topical treatments elsewhere in the guide).