The Definitive Guide to Spironolactone

Spironolactone is a prescription-only medicine with many actions and uses. It was originally developed to treat high blood pressure and heart failure. However, it also blocks androgen hormones, which has made it a useful treatment for hormonal acne and androgenetic (patter) hair loss. Spironolactone comes in two forms. The oral tablets are already licensed for heart and blood pressure conditions but used off-label for skin and hair. Spironolactone is also available in topical compounded formulas which you apply directly to the skin or scalp. These are unlicensed and formulated individually for each patient.

Regardless of form, you can only use spironlactone under the guidance of a registered doctor or medical prescriber. This guide explains how spironolactone works to treat acne and hair loss and the differences between the oral and topical forms. We will also review the side effects and how to get it safely in the UK if it is appropriate for you.

What is Spironolactone?

The main function of spironolactone is as a potassium-sparing diuretic. It is an aldosterone (mineralocorticoid) receptor antagonist, meaning it blocks the hormone aldosterone in the kidneys. This helps the body clear excess water and salt whilst holding on to potassium. For this reason, spironolactone has been popular for decades to treat heart failure, resistant high blood pressure and a condition called primary hyperaldosteronism (where your body makes excess steroids).

Spironolactone also blocks the effect of androgens. This is the group of hormones, including testosterone and DHT, responsible for so-called “male” characteristics. Despite the name, both males and females have these hormones. Androgens drive oil production in the skin and contribute to hair follicle miniaturisation on the scalp. In some people this can lead to acne and hair loss. Interestingly, this is rarely due to an excess of androgens. Instead, some people’s skin and hair follicle cells are just more sensitive to androgen activity. By blocking androgen receptors and reducing the effect of these hormones, spironolactone can help reduce oil production and potentially reduce hormonal acne breakouts. It can also help reduce DHT-driven hair loss. Spironolactone is not licensed for use on the skin and hair. However, dermatologists have been using it off-label for over 30 years as both oral tablets and compounded topical forms.

What Does Spironolactone Treat?

Broadly speaking, oral spironolactone has a set of licensed and unlicensed uses. It is licensed by the MHRA in the UK for heart failure, resistant hypertension and primary hyperaldosteronism. In dermatology, spironolactone is used off-label in oral or topical form for patients if their doctor or medical prescriber deems it appropriate. The main uses of spironolactone for skin and hair are:

• Hormonal acne: By reducing androgen-driven oil production, spironolactone can treat the inflammatory and cystic breakouts along the lower face and neck which are typical of adult female hormonal acne. It is increasingly useful where standard acne treatments and antibiotics have not worked. Both oral and topical forms of spironolactone are used to treat hormonal acne in the UK.
• Androgenetic hair loss: Oral spironolactone has been a long-standing off-label treatment for androgenetic alopecia in women. By reducing the androgen effect on the follicle, it can slow shedding and, in some women, support regrowth. It has been particularly useful in hormonally-driven hair loss such as that linked to polycystic ovary syndrome (PCOS). Topical spironolactone is also used to treat androgenetic hair loss in both women and men in the UK.
• Hirsutism and other androgen-excess concerns: Because it lowers androgen activity, oral spironolactone is also has off-label use for treating hirsutism (excessive hair growth in women) and other signs of androgen excess.

At City Skin Clinic, we use topical spironolactone in our personalised acne and hair loss treatments where suitable. It is often compounded alongside other actives where the doctor believes it will help.

Oral vs Topical Spironolactone

Possibly the most important thing to understand about spironolactone is the difference between the oral and topical forms. They are not interchangeable and they suit different people and different problems.

Oral spironolactone is a tablet that works systemically to lower androgen activity throughout the whole body. It has by far the largest evidence base of the two forms. Your prescriber will determine the best dose and frequency for you, but common protocols involve:

• Acne: Doses typically range from 50mg to 100mg daily, titrated up over several weeks. Meaningful improvement usually takes 3-6 months.
• Hair loss: Doses may range from 50mg to 200mg daily, again titrated up gradually. Results can require 6-12 months of consistent use.

Working systemically carries a higher risk of side effects (which we cover later) and requires blood tests to monitor potassium and kidney function, particularly at higher doses. Because of its potential feminising effects, oral spironolactone is also not suitable for men.

Topical spironolactone usually comes as a compounded serum, though it can also be formulated as a cream or lotion. It is generally available at 1% for the hair and 5% for the skin, though the prescriber will set this based on each patient’s medical background and needs. You apply it directly to acne-prone skin or the scalp. Compared with oral, the key differences are:

• Advantages: There is minimal systemic absorption. By delivering the drug straight to where you need it, topical spironolactone minimises the systemic side effects. It also does not usually need the blood test monitoring that come with the oral form. The most common side effect is local irritation. This lower systemic side effects profile is also why it is sometimes useful for treating androgenetic hair loss in men.
• Disadvantage: It has a smaller evidence base. Early studies suggest topical spironolactone can be effective for both acne and hair loss. Whilst it has fewer side effects than oral, the research is less robust and larger trials are necessary.
• Availability: This is far more limited than oral. Topical spironolactone is only available in compounded formulas, so you can only get it through specialist clinics. Additionally, only compounding pharmacies can formulate it. By contrast, any suitable suitable medical provider can prescribe and regular pharmacies can dispense oral Spironolactone.

Because each topical formula is compounded individually to a doctor’s prescription, the strength, base and any added actives can all be tailored to you. This targets the problem from several angles in a way fixed, off-the-shelf products cannot. The trade-off, as with all compounded medicines, is that they are unlicensed and made freshly for each patient. As such, they have a shorter shelf life and need an experienced prescriber to get the formula right.

Ultimately both are prescription medicines, available as unlicensed treatment only if a doctor or other medical provider feels they are appropriate and safe for you. The right choice depends on the severity of the problem, your overall health, your tolerance for side effects and your preferences.

What Other Treatments Work Best with Spironolactone?

Both acne and androgenetic hair loss are multi-causal conditions. Whilst spironolactone tackles the hormonal driver, it is rarely enough on its own. It works best as part of a combination that addresses all of the drivers at once.

In acne, the main drivers are excess oil production, abnormal pore lining, clogged pores, acne-causing bacteria and inflammation. Androgen hormones cause oil production. Spironolactone only addresses the hormonal driver, so it usually best to pair it with treatments that tackle the other causes such as:

• Tretinoin: This topical prescription retinoid unclogs pores, speeds up cell turnover and treats acne, scarring and hyperpigmentation. Pairing it with spironolactone can help targets both the hormonal driver and the pores themselves. Tretinoin is available either as a stand-alone product or in compound formulas containing Spironolactone in a cream or gel.
• Azelaic acid: This is a topical agent that reduces inflammation, kills acne-causing bacteria and helps fade the post-inflammatory hyperpigmentation that often follows breakouts. Azelaic acid is available over the counter in lower strengths of up to 10% in serums, lotions, creams or gels. It is also available by prescription in up to 20% strength either as a standalone product or compounded with other acne treating actives.
• Antibiotics: These target acne-causing bacteria but their main function is to reduce inflammation. Topical antibiotics like clindamycin are available as standalone treatments, in pre-made products like Treclin or added to a compounded acne formula. Oral antibiotics such as doxycycline are sometimes useful in courses of 3-6 months for more widespread or inflammatory acne. Both oral and topical antibiotics are available by prescription only.
• Benzoyl peroxide: This over-the-counter topical treatment is available in cleansers, creams and gels. It kills acne-causing bacteria and reduces inflammation. You normally apply it at a separate time to other topical actives like Tretinoin or Spironolactone to avoid irritation.

In androgenetic hair loss, the key drivers are genetics and sensitivity to androgens (particularly DHT) at the follicle leading to the gradual shrinking of those follicles over time. Spironolactone blunts the androgen signal to stop hair shedding but it is not enough by itself to boost regrowth. It is usually best to combine it with treatments that stimulate hair growth or block DHT more directly:

• Minoxidil: This is the first-line treatment for hair loss. Minoxidil increases blood flow to the follicle and prolongs the growth phase of the hair cycle. It comes as an over the counter topical treatment in strengths of 2% and 5% as well as by prescription for compounded topical treatments or as an oral tablet. Combining Minoxidil with spironolactone can help tackle hair loss by preventing DHT follicle destruction and stimulating regrowth.
• DHT Blockers: Very rarely, some doctors may prescribe Finasteride or Dutasteride in addition to Spironolactone for poor responders with severe hair loss as a last resort. These are both prescription medicines that block the conversion of testosterone to DHT. Whilst these two medicines are available orally, combination with Spironolactone is usually in the form of compounded topical formulas. This is because all three of these medicines block androgens and hence can cause a number of systemic side effects. Even then, mixing them topically is still rare (also for safety reasons).
• Supportive ingredients: Topical agents like Melatonin, Tretinoin & Caffeine can help support hair growth by protecting and stimulating hair follicles. They are not usually effective by themselves and are only available by prescription in compounded treatments.

One important note of caution is that you can not combine Spironolactone with other medicines or conditions that raise potassium unless a doctor specifically directs it. This is one of several reasons it needs cautious prescribing and careful monitoring.

How to Use Spironolactone

How you use spironolactone depends entirely on the form and in both cases your prescriber will give you clear instructions regarding how to use it safely and effectively. You normally apply topical spironolactone to the affected skin for acne or scalp for hair loss. Frequency is usually once or twice daily as directed and the general approach is:

• Cleanse and dry the area first, as spironolactone absorbs best into clean and dry skin.
• Apply a thin layer of the cream, gel, lotion or serum, following your prescriber’s instructions on amount and frequency.
• Wash your hands afterwards and avoid contact with the eyes, lips and other mucous membranes. Keep away from children, pets and pregnant women (more on this later).
• Be patient and consistent as results build over months rather than weeks.

Oral spironolactone is normally available in tablet form. Doctors usually titrate the dose up gradually by your prescriber. It is usually taken with food. As it works systemically, it requires blood tests to monitor potassium and kidney function, particularly when starting or increasing the dose.

Whichever form you use, the timeline is similar to other hair and acne treatments. Acne tends to respond within 3-6 months, whilst hair loss can take 6-12 months before you see changes. Continued use is necessary to maintain the benefit.

What are the Side Effects of Spironolactone?

The side effect profile differs significantly between the two forms. Because it works throughout the body, oral spironolactone carries the greater risk. In the impressive SAFA acne trial it was generally well tolerated. However, possible side effects or oral Spironolactone include:

• Common: headaches, dizziness or light-headedness, breast tenderness, increased urination and changes to the menstrual cycle.
• Less common but serious: high potassium levels (hyperkalaemia), low blood pressure and effects on kidney function. These are the reason blood test monitoring is usually necessary before and during treatment.
• Feminising effects in men: because it is an anti-androgen, oral spironolactone can cause breast tenderness, breast enlargement (gynaecomastia) and reduced libido in men. This is why it is not generally suitable for acne or hair loss in men.

Topical spironolactone has minimal systemic absorption, so its side effect profile is very different and much gentler. This is one of the main reasons the topical form is used even though it is not licensed. However, there are still possible risks of topical Spironolactone use including:

• Common and expected: Local skin reactions where you apply it, such as mild irritation, redness, itching, dryness or contact dermatitis. In acne, there may also be an initial flare-up.
• Possible but rare: Because you may absorb a small amount through the skin, the systemic side effects listed above are still possible. However, they are uncommon with topical use and far less likely than with the tablets.

This is why any form of Spironolactone is only available by prescription and requires careful evaluation of risks and benefits before starting. With either form, stop and seek medical advice if you have a severe reaction, signs of an allergic reaction, or any side effect.

Who Can & Cannot Use Spironolactone?

Spironolactone needs careful patient selection to ensure it is appropriate, safe and effective. The main considerations doctors need to tthink about include:

• Women vs men: Spironolactone is primarily a treatment for women. Its anti-androgen action makes it well suited as an oral or topical treatment for female hormonal acne and androgenetic hair loss. However, in men it can cause feminising side effects especially in its oral form. Men with hair loss are usually better off with finasteride or dutasteride or topical spironolactone.
• Pregnancy & breastfeeding: Spironolactone in any form is not safe in pregnancy or for women trying to conceive. This is because its anti-androgen effect can interfere with the normal development of a male baby. You should also not use it whilst breastfeeding.
• Contraception: Premenopausal women using spironolactone should use effective contraception throughout treatment.
• Kidney or heart conditions & high potassium: Spironolactone affects potassium and kidney function. It should therefore needs use with extreme caution. Most doctors often prefer to avoid all together in people with kidney disease, certain heart conditions or already high potassium levels.
• Drug interactions: Spironolactone interacts with a number of medicines, including ACE inhibitors and other blood pressure drugs, potassium supplements, NSAIDs and trimethoprim. Always tell your prescriber about every medicine and supplement you take.

These considerations apply mostly to the oral form, but anyone considering spironolactone in any form should also think through them. This is precisely why it is a prescription-only medicine.

Alternatives to Spironolactone

Obviously, Spironolactone is not the only option for treating hormonal acne or androgenetic hair loss. Whichever you are dealing with, it is usually one of several treatments your prescriber will consider. More often than not a combination of treatments is necessary to tackle complex conditions like acne and pattern androgenetic hair loss.

For androgenetic hair loss, there are a couple of treatments that can serve as a suitable alternative to oral or topical Spironolactone. The main options are:

• Minoxidil: This is a hair growth treatment that is available in topical or oral forms. It can treat pattern hair loss in both men and women. Minoxidil doesn’t really block androgen hormones, it works through a different pathway to increase blood supply and nutrition to the hair follicles. This prolongs the growth phase of the hair cycle and encourages more follicles to enter it leading to regrowth.
• Finasteride or dutasteride: These are true alternatives to Spironolactone as they block hormones. However, rather than blocking androgen receptors, these medicines block the enzyme that converts testosterone to DHT. This makes them most effective for DHT-driven hair loss and principally used in men. Dutasteride is sometimes also useful for post-menopausal women. However, neither are usually used for pre-menopausal women. Both these androgen blockers are available by prescription only in both oral or topical form.

When it comes to treating acne in women, there are a few of treatments that can address the hormonal nature or the inflammation it causes. The main alternatives to Spironolactone for acne include:

• Antibiotics: Oral antibiotics like Doxycycline and topical ones like Clindamycin reduce inflammation which is common especially in the cystic type of adult hormonal acne. However you can only use them for a few months at a time and often the acne rebounds after stopping them. Spironolactone targets the underlying hormonal cause and can be used long-term if no side effects.
• Combined pill: Some combined oral contraceptives can also balance androgen activity and help with hormonal acne in women. They can be used in place of spironolactone or alongside it, depending on the individual.
• Winlevi (clascoterone): This is a newer topical anti-androgen that, unlike spironolactone, is licensed for acne. It works on a similar hormonal pathway and is suitable for both men and women.

As with everything in skin and hair, there is no single best treatment. The right choice, or the right combination, depends on the cause, your overall health and your individual circumstances. Your medical provider will shoudl help you find the best treatment options for you.

How to Get Spironolactone in the UK

Spironolactone is prescription-only in every form, so you cannot buy it over the counter. It is only available by prescription if a doctor or other medical provider deems it is appropriate, safe and most effective option for you. The main ways suitable people might be able to access Spironolactone for dermatology treatment in the UK are:

• Oral spironolactone is not usually available on the NHS for acne or hair loss, since these are off-label uses. That said, some GPs and dermatologists may prescribe it case by case for acne following the results of the SAFA trial we discussed earlier. Most people however need a private GP, dermatologist or specialist who is able to prescribe it off-label, counsel them on the risks, arrange any necessary blood tests and provide monitoring.
• Topical spironolactone is harder to find as it is unlicensed. You can only get it through specialist clinics and dermatologists who prescribe compounded formulas. A specialist compounding pharmacy then formulates the treatment for each patient.

At City Skin Clinic, we use topical spironolactone for suitable patients as part of personalised acne and hair loss treatments. The process works as follows:

• Consultation: You complete an online consultation form or book a video consultation with one of our doctors. This is where you tell them about your skin or hair, your medical history and any medicines you take.
• Assessment: Your doctor will they will prescribe a bespoke compounded formula to suit your needs and detailed protocol for you to follow.
• Delivery & monitoring: A specialist compounding pharmacy formulates your treatment and delivers it to your door. The same doctor will continue to monitor your progress and adjust future formulas as needed.

At City Skin Clinic, we are passionate about personalised skin and hair care. We offer safe and effective custom treatments using ingredients like spironolactone, tretinoin, azelaic acid, minoxidil, finasteride and dutasteride where appropriate through our online clinic. Our doctors treat acne, hyperpigmentation, melasma, rosacea, skin ageing and hair loss through bespoke compounded treatments designed around you. To start your personalised plan, book a virtual video consultation or use our online consultation form. The journey towards great skin and hair starts here.

This article is for informational purposes only and is not a substitute for medical advice, diagnosis or treatment. Always consult a qualified medical provider for any concerns or questions you might have.