It has been a long, awful journey for me when it comes to my skin. No, not the skin on my face; I’ve been struggling with cystic acne on my back for over a decade.
After years and years of emotional and physical pain, I’ve finally found a treatment that has kept my back clear for over 6 months now.
I wrote up everything about my experience with using spironolactone to treat cystic acne on Reddit a few months ago but thought I would expand upon it even more. Spiro is an off-label, lesser-known treatment for hormonal acne and I’ve realized most people haven’t even heard of as an option so I would love to get the word out.
Disclaimer: I am not a doctor. Please consult your GP or dermatologist if you have medical questions. This is just my experience.
My back acne story
The severity of my condition
From what I can remember, I started getting cystic acne on my body when I was about 16 years old. It was always the worst on my back, but I had periods of getting it on my neck and chest as well. I got deep, inflamed cysts that would sometimes come to a head but other times not, and would take weeks and even months to clear. I also had smaller pimples on my back in addition – comedonal and noncomedonal.
I don’t have any photos from when it was at its worst because the last thing I wanted to do was take pictures of my acne at the time. I have a few photos from less severe times though. So please don’t fixate on these photos as they truly aren’t representative of my acne when it was at its worst (which was in late 2017-early 2018).
For most of my life, it would come and go in waves. Sun and sea helped, so summer was usually a good skin period, while winter was a bad one. At its worst in 2017 and 2018, I would wake up each morning with 2 or so new cysts, alongside the ones I already had that were healing.
At its most severe, thoughts about it consumed me. I was in deep physical and emotional distress. I didn’t want anyone to see or touch my back. Some mornings I didn’t even want to leave my room and face the world because I felt so hideous…was in so much pain…felt so betrayed by my body…
(Reminder: things were way worse than in these photos at that time)
I know other severe acne sufferers can relate.
Treatments I tried for cystic back acne
I tried maaaaaany different treatments over the years, including topicals, oral antibiotics, retinoids, oral birth control, and diet changes.
The only thing I never tried was Accutane. The side effects always scared me, especially because I am prone to depression. For me, Accutane is an absolute last resort.
Here’s the full list of what I tried before spiro and how each treatment affected me:
Made acne worse
- Ortho tri cyclen
- Cutting out dairy
- Tea tree oil
- Apple cider vinegar (as a toner)
- Salicylic acid
- Zinc supplements
- Magnesium supplements
- A dandruff shampoo as body wash
- A sulfur-based body wash
- L-lysine supplements
- Breaking open Advil Liqui-gels and applying to cysts
- Making sure to not get conditioner on my back in the shower
- Changing my detergent
- Antibiotics, but the acne would come back when I got off them and I didn’t want to be on antibiotics long-term
- Birth control. Specifically, Ocella (generic version of Yaz I believe) which I was on for 3 years and my skin was amazing but eventually got off due to negative side effects.
- Cutting out sugar. This helped only very slightly but denying myself foods I loved made me so miserable, the slight improvement wasn’t worth it for me.
- NSAIDs like ibuprofen. Helped slightly but not preventive (also something I don’t want to take long term)
- Applying ice. Again helps with swelling but was not preventive.
Spironolactone to the rescue
Getting off birth control ushered in my most recent and most severe bout of cystic back acne at the end of 2017 and I started looking for more treatments I hadn’t tried yet. I was in therapy (the mental health kind, through Talkspace) at the time and my therapist said she used a drug called spironolactone to treat cystic acne on her face and it had really helped her.
I looked into it online and it sounded promising. I got a script from my derm.
I started spiro in December of 2017 and it worked pretty quickly to clear my face and chest within the first month or so, but the inflamed and painful cysts remained on my jawline/neck and back. I continued taking the medication because many people had said in online reviews that it took 3, 4, 5, or even more months before the medication fully cleared them of their acne.
In terms of dosage, I started on 25 mg/day and slowly went up to 50, then 75, then 100, then I even tried 150 mg to see if that would help but the side effects were too strong for me at that dosage. I was lightheaded and felt extremely fatigued, so I went back down to 100 mg/day.
I was losing hope when I was 6 months in and still had cysts on my back.
I gave spiro one last try and decided to combine it with antibiotics (doxycycline) for a month and see if that would clear the existing inflammation, with the reasoning being I could then stay clear because I would continue the spiro after stopping the antibiotics.
I continued with 100 mg/day of spiro after finishing the month-long doxycycline regimen. After five months of this post-getting clear, I decided to try lowering my dose to 50 mg/day and see if I could maintain clear skin at the lower dosage. I was seeing my potassium levels slowly creep up and also preferred to be on the lowest effective dose possible.
It’s been 8 months since the doxy stint and I’ve remained clear. I was on 50 mg/day for about 2 months and went back up to 100 mg/day recently after noticing I was getting a few cysts again.
**Hot tip: if you’ve been on spiro for a few months and it’s still not working, I recommend doing a month of doxy at the same time and seeing if that kickstarts you getting cleared up.
FAQs about spironolactone for cystic acne
What is spironolactone?
Spironolactone is an aldosterone antagonist typically prescribed to lower blood pressure. It has anti-androgen effects at higher doses. It’s not FDA-approved for acne treatment but has been prescribed “off-label” by dermatologists to women with hormonal acne or acne related to PCOS. The usual dose for acne is 50-200 mg a day.
How does it work to treat acne?
When taken for acne, spiro is a form of hormone therapy. Spironolactone works not by changing your hormone levels as oral contraceptives do but by reducing the delivery of your sex hormones to your tissues.
Specifically, it increases your sexual hormone binding globulin (SHBG) levels. This is a glycoprotein that binds to estrogen, dihydrotestosterone (DHT), and testosterone. Once bound to SHBG, these hormones are biounavailable to your tissues.
Here’s a direct quote from a 2012 study explaining the intricacies of the therapeutic pathway:
“So where does spironolactone fit into this puzzle of acne lesion formation, especially in the post-teen female patient? Spironolactone decreases 5 alpha-reductase activity via increased clearance of testosterone secondary to augmented liver hydroxylase activity. In addition, it increases the level of steroid hormone binding globulin (SHBG), thus providing a sink that reduces circulating free testosterone as more is bound by the increased quantity of SHBG. The resultant effect of reducing free testosterone in circulation is an increased estrogenic state, which can lead to gynecomastia or decreased libido, especially when higher doses of oral spironolactone are used. Spironolactone also acts locally by competing with dihydrotestosterone (DHT) for cutaneous androgen receptors, thereby inhibiting testosterone and DHT binding.”
Is spironolactone efficacious in treating acne?
From a brief and informal lit review of the academic journal articles reporting on spironolactone and acne, it looks like yes it is efficacious. However, do note there haven’t been any large-scale randomized control trials – I’m mainly seeing retrospective studies.
Here are some peer-reviewed articles for your reference:
Is spiro safe to take for acne?
Yes, it appears to be safe, according to the American Academy of Dermatology and Dermatology Times. In my opinion, I think it’s similar to the Pill in that we don’t know (and can’t show due to few longitudinal studies and too many variables) if there are long term negative effects.
Sorry boys but this treatment is for girls only! It has been known to cause enlarged breasts in men.
You also should not take it if you’re pregnant, have hyperkalemia (high potassium), renal insufficiency, or undiagnosed abnormal uterine bleeding.
What are the side effects of spironolactone for acne?
Peeing a lot and potassium levels
Spiro is a potassium-sparing diuretic so potential side effects are an increase in urination (and potential to become dehydrated) and increased potassium levels. I’ve noticed both side effects. The increased urination doesn’t bother me that much, and a plus is I never feel bloated these days!
For potassium, it can be dangerous if your levels get too high so you have to get your blood tested within the first 6 weeks of starting the spiro regiment and then every 6 months or so thereafter if you stay on it. They say you should eat foods high in potassium, like tomatoes, coconuts, and bananas, sparingly while on this drug.
However, a 2015 study found rates of hyperkalemia (high potassium) in women taking spironolactone for acne were the same as baseline rates for this condition, making monitoring potassium levels unnecessary while on spiro for acne.
Menstruation and reproductive system effects
Spiro can affect your period as well. For me, I didn’t get my period for the entire first year I was on it. I made sure to check with my derm if this was safe and she said it was fine. Honestly, it was kinda nice not having a period! I mean slightly weird but also nice. Now that I’ve lowered the dose to 50 mg/day instead of 100, I do get my period but it’s quite light and short and I don’t get terrible cramps like I used to.
I did have a weird scare when I was adjusting the dosage from 100 to 50 mg: I started having pain in one of my ovaries. I saw the doctor and had an ultrasound and it was an ovarian cyst. These are quite common for many women and often resolve themselves without intervention. I still have pain sometimes in one of my ovaries and this does concern me. Though there is nothing in the list of side effects about this, I see from others posting online that I am not alone (here and here). Not sure how I’ll handle this moving forward.
Lastly, do note you should not get pregnant while on spiro! If you’re planning to conceive, you need to get off this drug.
Lower blood pressure
Spiro is a blood pressure medication. It will lower your blood pressure! I already had pretty low blood pressure so was worried about this side effect. However the only time I felt lightheaded, dizzy, and/or faint was when I upped the dosage to 150 mg/day for a couple weeks. So I backed off and went back down to 100 and felt way better.
Other people have written about weight changes while on spiro but I haven’t noticed anything like this in either direction.
How long does it take for spironolactone to work for acne?
The million dollar question! I remember desperately Googling this 5 months in, hoping to find evidence of someone else with cystic back acne who didn’t get clear from spiro until 6 months or more of treatment…
The answer, for me, was 6 months but with the caveat that I intervened by taking a month of doxycycline alongside spiro. I chose to do this as a last resort before giving up on spiro completely. It’s hard to say if I would have had the same effects without the month of doxy; I truly don’t know.
What I can say is, the pattern seems to be that it takes upwards of 3 months to see results. I know it sucks, but patience is key. Give the drug time to work, and in the meantime, if you’re as emotionally affected as I was, I recommend working on accepting and loving yourself the way you are. (Easier said than done, yeah I know.) I worked on this with a therapist simultaneously.
Pros and cons of using spironolactone for acne
- Typically fewer side effects than taking oral contraceptives
- You have control over the dose and can increase or decrease as needed depending on how it affects you (can’t do this with birth control)
- Affordable even if you don’t have health insurance (Google search to find an affordable pharmacy in your area! For example, I found that Publix fills this prescription for $7 without insurance)
- May take a very long time to clear acne – it’s a hormonal treatment and can take months for your hormones to recalibrate
- May need to couple with other treatments to get clear skin (like topicals or antibiotics)
- May have unsavory side effects – irregular menstruation and breast tenderness seem to be the most common
- I honestly don’t know how safe it is to just stay on spironolactone for years at a time