Spironolactone Or Accutane: Which One Is Right For You?

Illustrated by Elliot Salazar.
If you have painful cystic acne or stubborn hormonal flares, you know the struggle to find the right treatment. It’s a bit like the search for a swimsuit — there are plenty of good options, but it also takes a ton of frustrating trial-and-error to find one that makes you feel comfortable in your own skin. After trying what feels like every over-the-counter cream, liquid, and mask your drugstore and Sephora have to offer, that battle brings many of us to the dermatologist’s office.
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Lately, two drugs have been gaining popularity and stealing the acne-treatment spotlight: isotretinoin (formerly known as Accutane) and spironolactone. These medicines are the big guns that dermatologists turn to when nothing else has worked. To help you learn the difference — and figure out which one is right for you — we talked to skin doctors to learn the must-know details of each. Read on for a crash course in acne drugs, and how these sometimes life-changing pills can make you feel confident to show some skin.

How They Work
The drugs have very different mechanisms of action, but yield similar results. First used as a diuretic to treat high blood pressure, spironolactone (spiro for short) has been prescribed off-label as an acne treatment.

“Spiro acts like a roadblock to androgen hormones in your body, preventing them from stimulating your oil glands,” says acne researcher Josh Zeichner, MD, an assistant professor of dermatology at Mount Sinai Hospital in New York. With the hormones shut off and oil production reduced, there’s very little sebum for bacteria to feed on or clog pores. The catch is that spiro only works as long as you’re taking it — once you stop, the breakouts will likely return.

Isotretinoin is a form of vitamin A now sold as Absorica, Claravis, Myorisan, and Zenatane. It addresses all the major causes of acne, Dr. Zeichner says. Isotretinoin essentially shuts down the oil gland, decreasing the amount of sebum available for inflammation-causing bacteria to eat. In addition, isotretinoin prevents skin cells from sticking together and clogging follicles. “Isotretinoin is very effective for acne, and is the closest we have to magic in dermatology,” says Katherine Holcomb, MD, a clinical assistant professor of dermatology at Tulane University School of Medicine in New Orleans. “It’s very safe when used correctly and has been around for 35 years.” Taking isotretinoin often has long-term results.
Who Should Take Them
“Spironolactone is one of the easiest, most reliable drugs for adult-pattern acne,” says Doris Day, MD, a clinical associate professor of dermatology at New York University. Dermatologists tend to go for spiro when breakouts occur before your period or are focused on the chin, jawline, and upper back. “This type of acne is due to a hormonal imbalance and is hard to clear with other options,” Dr. Day explains. “Blocking the androgen receptors helps restore balance.”

Women are the only candidates for spiro, Dr. Day says. The androgen-blocking effects can cause erectile dysfunction and gynecomastia in men. Due to the impact on hormones, doctors also avoid prescribing the drug to pre-menstrual teens.

But there is a caveat with spiro: “I wouldn’t prescribe spiro for anyone planning pregnancy soon,” Dr. Day says. “You don’t want to block hormone receptors in a developing child.”
Illustrated by Elliot Salazar.
“I prescribe isotretinoin for many types of severe acne,” Dr. Zeichner says. A course of treatment can also be effective for hormonal acne, but dermatologists tend to save this option for those with severe, cystic acne that is focused on the center of the face. In some cases, hormonal acne recurs after taking isotretinoin. For those patients, spiro can keep skin clear when isotretinoin cannot, Dr. Zeichner says. And there are no issues with men or women taking the drug. (More on the side effects in a minute.)

Dr. Zeichner says that he often prefers isotretinoin for those with sensitive skin because they won’t need to apply potentially irritating topicals during treatment. But those with very dry skin and eczema may have a harder time tolerating the drying effects of the drug.
“For women who’ve been on isotretinoin and still have recurring acne, I tell them spiro is the way to go,” Dr. Day says. “They’ll see better, longer lasting results. I often encourage women to do so.”
The Side Effects
If you’ve heard of Accutane, it’s likely because of the publicity around the worst-case-scenario side effects. If you become pregnant while taking the drug, there is a high probability the baby will develop severe birth defects. So during your treatment, you’ll be required to use two forms of birth control. In some cases, suicidal thoughts and depression have been reported, so it’s important that you check in with your doctor and report any changes in mood.

“The major side effect is very dry skin and chapped lips,” Dr. Holcomb says. “Some people experience joint pain, but as long as you follow the doctor’s instructions and moisturize, you’ll likely do great.” Your skin and hair will also feel dramatically less oily, which can be a nice perk.

With spiro, you could see increased potassium levels, at which point doctors will advise you to reduce your intake. “Some women report breast tenderness on spiro, but more often I hear that they’ve lost a couple pounds and feel less bloated,” Dr. Day says. Since it’s a diuretic, you’ll likely have to pee more often: Dr. Day suggests taking the med during the day so you won’t wake up to go at night. And, doctors advise patients on spiro to avoid pregnancy as well since the hormonal side effects can also cause birth defects.

On the upside, some women with thinning hair see an improvement in hair thickness — and oil production may also be reduced, Dr. Holcomb says.

What Treatment Is Like
The main consideration with either treatment is what protocol you’re willing to follow — a short, high-maintenance procedure or an indefinite option with fewer requirements.

“With spiro, you usually just need a low dose of 25 to 50 milligrams a day to maintain clearance,” Dr. Day says. You might need to come in for blood work on occasion to ensure your potassium is at a safe level, but the drug doesn’t require much monitoring.

“Spiro is a long-term commitment,” says Karen Chernoff, MD, a dermatologist at Weill Cornell Medicine and New York-Presbyterian Hospital in New York. “Acne will come back once you stop taking it, but you can take it indefinitely.”

You may not see results from spiro for three months, so dermatologists will often give patients a three-month course of antibiotics like doxycycline and stop it as soon as the spiro starts working.
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Illustrated by Elliot Salazar.
Doctors often like to combine spiro with another medication to attack acne on all fronts. “One of the best studies I’ve seen shows an excellent response when women take spiro and Yaz [the birth-control pill],” Dr. Chernoff says. Your doctor might also suggest a topical retinoid, like Retin-A, or a benzoyl peroxide treatment, she explains.

The counterpoint is the intense, but short-treatment period with isotretinoin. Treatment tends to last four to six months and requires monthly visits to your dermatologist, blood work (to test for liver function, cholesterol levels, and pregnancy), and compliance with the iPledge program, which involves taking monthly quizzes that prove you understand the side effects of the drug. Plus, doctors often advise avoiding alcohol during treatment.

Doctors have seen some instances in which the first dose of isotretinoin causes an acne flare-up, Dr. Chernoff says. To avoid that, you might take a low dose for the first month and then increase to a full dose after that. And depending on your results, your dermatologist might extend your treatment to nine months. “There has been some newer data that says using the treatment longer extends the length of time before a relapse may occur,” she says.

While you're taking isotretinoin, your doctor won’t use any other topicals or prescription treatments since the drug addresses all the acne-causing variables. You’ll just need to moisturize more than you ever have in your life and spend lots of quality time with your doctor.

How Your Doctor Decides Which To Prescribe
The decision is about the type of acne the patient has and how likely they are to follow the prescribed treatment, Dr. Holcomb says. “I really base my choice on whether a patient wants to take a pill every day for an indefinite amount of time or a finite amount of time,” she says. Again, spiro is a long-term solution, while isotretinoin requires a few months of treatment.

“A lot of the decision is patient preference,” Dr. Chernoff says. “Many women are worried about the side effects of isotretinoin, and spiro is easier to tolerate.”

For acne that’s focused on the center of the face, or appears as large cysts that have the potential to scar, dermatologists tend to prefer isotretinoin. “I find isotretinoin can be a lifesaver [for those at risk for] severe scarring — we want to stop the cycle as soon as possible.”

Either way, these proven treatments offer a way to escape the frustrating breakout cycle. “Spironolactone and isotretinoin are two of the most important drugs we have to treat acne, particularly in women unresponsive to topical treatments,” Dr. Zeichner says. So if you've tried it all and still aren't seeing results, maybe it's time to give one of these take-no-prisoners treatments a shot.
The grown-up guide to dealing with acne. Read more from The Acne Diaries here.
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