Oral spironolactone for acne vulgaris in females: Evidence review and practical recommendations

Acne vulgaris is a common condition, and in females, often persists into adulthood. In this review, we evaluate the evidence for the efficacy and safety of oral spironolactone in females with acne vulgaris and provide practical recommendations for prescribing. Medline, Embase, Web of Science, and Cochrane Central Register of Controlled Trials were searched from inception until February 2025, and 16 randomized controlled trials and 52 nonrandomized studies evaluating spironolactone for acne vulgaris in females were identified. Two randomized placebo-controlled trials were of good quality and demonstrated that spironolactone was effective in treating acne at doses of 50 to 100 mg daily. The efficacy of spironolactone appears to be dose dependent, with some evidence that doses above 100 mg daily confer higher benefit. There is evidence from nonrandomized studies that spironolactone is effective for truncal acne and that it is effective in adolescents, although these studies were all found to have either a serious or critical risk of bias using the ROBINS-I tool. Spironolactone is generally well tolerated and at doses of up to 100 mg daily the adverse effect profile is similar to placebo. The most common adverse effects are menstrual irregularities, polyuria, headache, and dizziness.