Patients are increasingly seeking alternatives to long-term antibiotics for acne.
Safety concerns have been raised in the wake of growing popularity of spironolactone for acne among young women and girls in the US, although an Australian expert says the drug has been well-tolerated in its long history of use here.
The cardiovascular drug is increasingly prescribed for androgen-related conditions such as acne, and this usually involved higher doses than its approved cardiovascular use, the authors of a research letter wrote in in JAMA Network Open.
But there was a lack of population-level data on these higher doses in younger women (100-200mg/d vs 25mg/d), and case studies had hinted at vulvar pain from androgen deprivation, they wrote.
The researchers analysed insurance claims data of US females aged 12-40 from the last two decades. They found that of the 52,000 women or girls who initiated the drug, one in 10 were aged 12 to 18 years.
Around half were diagnosed with acne, 8% with hirsutism, 8% with PCOS and 6% had multiple indications.
Very few participants had hypertension (4%) or congestive heart failure (0.8%) and 29% had none of these diagnoses.
New prescriptions of the diuretic increased from 17 to 88 per 100,000 between 2000 and 2020.
“The greatest rise was among those aged 19 to 25 years, though considerable increases were observed for all age groups,” they wrote.
“Consistent with prior studies, many prescriptions were associated with acne. However, this condition represented only a portion of total use. Most initiators had androgen-related conditions, indications frequently requiring higher doses than those examined in clinical trials for cardiovascular disease.”
Because the study was based on insurance data, the authors noted that some indications could have been mislabelled.
“A total of 29.4% lacked a diagnosis for the examined conditions; these patients may have been prescribed spironolactone to manage ascites and oedema-related symptoms during cancer treatment, an indication that could not be incorporated without cancer registry linkage.
“Despite these limitations, our findings indicate spironolactone among young women and girls is notable and growing, with the great majority having indications requiring higher doses than those examined in trials.”
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Professor Stephen Shumack, dermatologist at the Royal North Shore Hospital in Sydney, said the drug had been a mainstay of treatment in Australia, particularly in its off-label use for acne and female-pattern alopecia, and was increasingly being used in women seeking to avoid long-term antibiotics.
Australian doctors had been using this product for “many, many decades” and it was encouraging to see US clinicians were catching up with Australian prescribing patterns, he added.
“The other advantage [beyond avoiding antibiotics] is it’s medication that’s designed to be used long term,” he said. “Patients who use it for blood pressure or heart failure, for example, usually use it for months or even years, meaning you can be confident it’s quite safe.”
