Role of topical spironolactone in the treatment of acne: A systematic review of clinical trials-Does this therapy open a path towards favorable outcomes?

Efficacy and safety of Spironolactone in treating patients with acne vulgaris: a systematic review and meta-analysis of 1,086 patients

Acne vulgaris affects 9% of the global population, particularly women, affecting their quality of life. Topical treatments are preferred for mild acne, while systemic management is necessary for moderate and severe cases. Spironolactone, an androgen receptor inhibitor, may be effective for severe acne, although no concrete evidence exists. A comprehensive literature search was conducted on five databases up until July 25th, 2024, to evaluate the effectiveness or safety of Spironolactone for acne vulgaris. A meta-analysis using R software was conducted to assess the total number of lesions, acne severity score, adverse events, mean count of comedones, papules, and pustules, and acne severity. Search process identified 14 studies (n = 1,086). Meta-analysis found that Spironolactone 5% was more effective than placebo in reducing total lesion count and acne severity index (ASI) (MD - 6.85, 95% CI [-10.94; -2.76], P < 0.01) and (MD - 6.33, 95% CI [- 8.89; -3.76], P < 0.01) respectively. The 100 mg group showed a significant improvement in ASI compared to the topical group. A meta-analysis of randomized controlled trials found no significant difference in comedones and pustules count over 6-8 weeks, while single-arm studies showed significant improvement after 8 weeks. Meta-analysis found that spironolactone 5% significantly reduced total lesion count and acne severity index after eight weeks, while also reducing comedones and papules. The safety profile is excellent. The limited number of eligible studies and evidence from single-arm studies indicates the need for more randomized controlled trials.

Oral and topical spironolactone in acne treatment: A meta-analysis of effectiveness and safety

Acne vulgaris (AV) is a common chronic inflammatory skin disorder that commonly lasts from adolescence to adulthood and has serious social and psychological consequences. Current treatments typically use antibacterial drugs, which contributes to the rise in antibacterial drug resistance. Spironolactone, a potassium-sparing diuretic with anti-androgen effects, has been used off-label to treat acne by lowering sebum production. This systematic review and meta-analysis aims to assess the safety and efficacy of oral and topical spironolactone in acne treatment. Following PRISMA guidelines, a complete search of five databases yielded seven eligible studies (643 individuals) that compared spironolactone to placebo in randomized controlled trials. The total lesion count (TLC), comedones and papule counts, acne severity index (ASI), and adverse events (AEs) were all measured. RevMan was used for statistical analysis, and effect estimates were presented as mean differences (MD) and relative risk (RR), as appropriate. The study found that spironolactone significantly reduced ASI (MD =  - 6.53, 95% CI: [- 10.83 to - 2.22], p = 0.003) and had a satisfactory safety profile, particularly in terms of menstruation symptoms. There were no statistically significant variations in TLC, comedone, or papule counts between the 4, 8, and 12-week intervals. Adverse events, including menstrual abnormalities, were similar across groups. Spironolactone, both oral and topical, demonstrated promise in lowering acne severity, particularly in female patients. While larger, long-term trials are required to demonstrate its efficacy and safety, spironolactone is a beneficial option to antibacterial drug therapies for dermatological and cardiovascular issues.

Hormonal Therapies for Acne: A Comprehensive Update for Dermatologists

INTRODUCTION

Acne impairs quality of life, often leads to permanent scars, and causes psychological distress. This review aims to update dermatologists on the Federal Drug Administration (FDA)-approved and off-label use of combined oral contraceptives (COC), clascoterone, spironolactone, and emerging hormonal therapies for acne treatment.

METHODS

We reviewed current literature on hormonal acne treatments and discussed common patient concerns, barriers to care, and individualized care needs.

RESULTS

Different brands and dosings of COC have generally similar efficacy in treating acne. Dermatologists should discuss contraceptive options and provide individualized shared decision-making with patients based on patient preferences, contraceptive needs, comorbidity profile, access, and cost. Spironolactone is an effective acne treatment with clinical trial data to support its use as a first-line acne treatment for women with acne. Potassium monitoring is of low value for patients on spironolactone unless patients have specific risk factors for hyperkalemia. Clascoterone is a safe and effective topical anti-androgen for the treatment of acne in men and women with limited systemic effects on reproductive hormones.

CONCLUSION

Hormonal therapies are essential strategies to treat acne. Clinicians should expand the use of existing and emerging hormone therapy as part of their acne treatment strategies.

A Systematic Review of Spironolactone Nano-Formulations for Topical Treatment of Skin Hyperandrogenic Disorders and Chronic Wounds

Background/Objectives: Spironolactone (SP), an aldosterone inhibitor widely used to treat androgen-dependent disorders such as acne, hirsutism, and alopecia, has demonstrated therapeutic potential in both oral and topical formulations. However, SP's low solubility and poor bioavailability in conventional formulations have driven the development of novel nanocarriers to enhance its efficacy. This review systematically examines recent advancements in SP-loaded nanocarriers, including lipid nanoparticles (LNPs), vesicular nanoparticles (VNPs), polymeric nanoparticles (PNPs), and nanofibers (NFs). Methods: A search strategy was developed, and the relevant literature was systematically searched using databases such as Scopus, PubMed, and Google Scholar. The review process, including screening, inclusion, and exclusion criteria, adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results: A comprehensive analysis of 13 eligible research articles, corresponding to 15 studies, highlights key aspects such as encapsulation efficiency, stability, particle size, and in vitro and in vivo efficacy. Six studies focused on lipid nanoparticles (LNPs), including solid lipid nanoparticles (SLNs) and nanostructured lipid carriers (NLCs), which were found to improve SP's bioavailability and skin permeation. Another six studies investigated vesicular nanoparticles (VNPs), such as ethosomes and niosomes, demonstrating superior skin targeting and penetration capabilities. Two studies on polymeric nanoparticles (PNPs) showed effectiveness in delivering SP to hair follicles for the treatment of alopecia and acne. Additionally, one study on SP-loaded nanofibers indicated significant potential for topical rosacea therapy. Conclusions: SP-loaded nanocarrier systems represent promising advancements in targeted topical therapy. However, further clinical studies are required to optimize their safety, efficacy, and delivery mechanisms.

The cutaneous effects of androgens and androgen-mediated sebum production and their pathophysiologic and therapeutic importance in acne vulgaris

Background: The recognition of an association between the development of acne vulgaris (AV) and pubertal hormonal changes during adolescence dates back almost 100 years. Since these formative observations, a significant role of circulating hormones in the pathophysiology of AV and other cutaneous disorders has been established.Aims: This review article aims to provide an overview of clinical and preclinical evidence supporting the influences of androgens on the skin and their therapeutic importance in AV pathophysiology.Results: The cutaneous effects of hormones are attributable, to a large extent, to the influence of steroid hormones, particularly androgens, on sebocyte development and sebum production in both sexes. Androgen-mediated excess sebum production is implicated as a necessary early step in AV pathophysiology and is therefore considered an important therapeutic target in AV treatment. Although the local production and/or activity of androgens within the skin is believed to be important in AV pathophysiology, it has received limited therapeutic attention.Conclusions: We have summarized the current evidence in support of the therapeutic benefits of targeted hormonal treatment to decrease androgen-stimulated sebum production for the effective and safe treatment of AV in both male and female patients.

Effects of spironolactone on skin biophysical properties in women with acne treated with oral spironolactone

BACKGROUND

Spironolactone (SPL) is an effective treatment for women acne, but other effects on skin biophysical properties remain to be investigated.

OBJECTIVES

The aim of the current study was to explore the effects of oral SPL used to treat women acne on skin biophysical properties, including hydration, transepidermal water loss (TEWL), skin surface lipid (SSL) levels, mechanical properties, color, pH, and pore size.

MATERIALS AND METHODS

Twenty-five Thai women with acne treated with oral SPL were followed for 6 months. Skin hydration, TEWL, SSL levels, mechanical properties, color, pH, and pore size of the forehead, chest, and inner arm were evaluated at baseline and 2, 4, and 6 months after treatment with oral SPL. Facial and upper back pore size were also assessed. Clinical outcomes were changes in these skin biophysical properties at each visit compared with baseline.

RESULTS

Skin hydration, TEWL, SSL levels, color, pH, and pore size remained stable throughout the study. Facial skin parameters at 6 months demonstrated the following changes: hydration levels, 7.60 (95% confidence interval [CI], -59.74 to 74.94); TEWL, -2.36 (95% CI, -5.77 to 1.06); L* value, 0.51 (95% CI, -0.70 to 1.72); individual typology angle, 1.65 (95% CI -2.27 to 5.57); pH, 0.01 (95% CI -0.43 to 0.46); pore size, -0.24 (95% CI, -1.21 to 0.73); and SSL levels, 7.60 (95% CI -59.74 to 74.94). Improvement of facial mechanical properties was observed. R0 (indicating skin tightness) and R1 (indicating elasticity) showed significant decreases (-0.076 [95% CI, -0.141 to -0.010] and -0.016 [95% CI, -0.033 to -0.001]). R3 and R4 (representing tiring effects) were also improved (-0.091 [95% CI, -0.158 to -0.025] and -0.022 [95% CI, -0.044 to -0.001]). Parameters in the truncal and inner arm areas remained stable, except for skin elasticity and tiring effects, which exhibited a similar trend of improvement as the facial area. The changes were notable as early as 4 months.

CONCLUSION

Oral SPL used for acne did not impair the skin barrier. Moreover, the skin mechanical properties were improved at 4 to 6 months.

Efficacy and safety of topical spironolactone versus topical dapsone in the treatment of acne vulgaris

Acne vulgaris is a common skin disease that greatly impacts the quality of life of affected individuals. Several treatment modalities are available for acne, with variable degrees of success. Our aim was to compare the safety and efficacy of topical spironolactone 5% gel and topical dapsone 5% gel as treatment modalities for acne vulgaris. The study included 28 patients with mild to moderate acne. They were randomly divided into two equal groups. Group I treated with topical spironolactone 5% gel, and group II treated with topical dapsone 5% gel. In both groups, the gel was applied twice daily for 12 weeks, and patients were evaluated using the acne severity index. Group I included 14 patients [11 (78.6%) females and 3 (21.4%) males]. More than one-half of this group (64.3%) had moderate acne severity. Group II included 14 patients [12 (85.7%) females and 2 (14.3%) males]. Half of patients had moderate acne severity. Therapeutic response was poor, moderate, good, and excellent (14.3%), (28.6%), (50%), (7.1%), respectively, in topical spironolactone group versus poor, moderate, and good (50%), (42.9%), (7.1%), respectively, in topical dapsone group. The therapeutic response between the studied groups was statistically significant in favor of the topical spironolactone group. Regarding adverse effects, burning sensation was evident after application of topical spironolactone while itching was significantly common with topical dapsone. The data provided by the current study support the use of topical spironolactone 5% gel in treating acne vulgaris in both male and female patients.

The Microbiome and Acne: Perspectives for Treatment

The skin microbiome consists of the microorganisms populating the human skin. Cutibacterium acnes (C. acnes, formerly named Propionibacterium acnes) is recognized as a key factor in acne development, regulating inflammatory and immune pathways. Dysbiosis has been described as the imbalance in skin microbiome homeostasis and may play a role in acne pathogenesis. Microbial interference has been shown to be a contributor to healthy skin homeostasis and staphylococcal strains may exclude acne-associated C. acnes phylotypes. In this review we present an update on the skin microbiome in acne and discuss how current acne treatments such as benzoyl peroxide, orally administered isotretinoin, and antibiotics may affect the skin microbiome homeostasis. We highlight the collateral damage of acne antibiotics on the skin microbiome, including the risk of antimicrobial resistance and the dysregulation of the microbiome equilibrium that may occur even with short-term antibiotic courses. Consequently, the interest is shifting towards new non-antibiotic pharmacological acne treatments. Orally administered spironolactone is an emerging off-label treatment for adult female patients and topical peroxisome proliferator-activated receptor gamma (PPARγ) modulation is being studied for patients with acne. The potential application of topical or oral probiotics, bacteriotherapy, and phage therapy for acne are further promising areas of future research.

Correlating the Gut Microbiota and Circulating Hormones with Acne Lesion Counts and Skin Biophysical Features

Acne vulgaris is a common inflammatory condition that is multi-factorial and impacted by both intrinsic and extrinsic features. Several previous studies have assessed for correlations between factors such as circulating hormones, stress, or the microbiome. However, there have not been any correlations specifically against lesion counts or differentiating correlations between inflammatory and non-inflammatory lesion counts. Here, we correlate several factors against acne lesions. Twenty men and women with mild to moderate acne were recruited, and their hormonal levels and their gut microbiome were collected and correlated against their inflammatory and non-inflammatory lesions of acne. Facial non-inflammatory lesions were weakly correlated to sebum excretion rate and weakly inversely correlated to forehead and cheek hydration. We examined stress through the use of a normalized peak-to-trough ratio (higher numbers indicated less stress), which correlated with skin hydration and inversely correlated with sebum excretion rate. Sebum excretion rate was weakly correlated to testosterone levels, and facial hydration correlated with estradiol levels. Correlations with the gut microbiome showed differential correlations with inflammatory and non-inflammatory lesions, with Clostridium sp AF 23-8 correlating to inflammatory lesion counts, while Actinomyces naeslundii str Howell 279 correlated to non-inflammatory lesions. Overall, measures of stress and circulating hormones correlate to skin biophysical properties and acne lesion counts. Also, different gut bacteria correlate with either inflammatory or non-inflammatory lesion counts. We hope that our findings stimulate further work on the gut-mind-stress-skin axis within acne.