Some women may prefer not to use oral contraceptives, or should not take them because they are smokers or otherwise at high risk. These women, as well as those who only get partial acne relief from contraceptives, are often prescribed a drug called spironolactone.
This medication is a diuretic -- that is, a "water pill" that causes frequent urination. It also blocks receptors for male hormones, which modulates the hormonal surges that can stimulate oil production, causing acne. Spironolactone isn’t approved by the FDA to treat acne and probably won’t be, Schlosser says, because as a generic drug there’s little motivation for a manufacturer to pay for the trials needed to go through the approval process. But most dermatologists agree that it works well as an acne treatment.
Treating Severe Inflammatory or Cystic Acne
When acne does not respond to the standard one-two punch of topical retinoids and oral antibiotics, patients have two other choices: the drug isotretinoin, or one of several procedure-based treatments for acne that involve using laser or light treatment to reduce inflammation and kill acne-causing bacteria.
Isotretinoin is an extremely powerful treatment for acne, often clearing up severe, scarring breakouts that had not responded to any other treatments within a matter of a few months.
But it also carries with it a host of risks and side effects, including inflammatory bowel disease, ulcerative colitis, liver damage, bony malformations, depression, and a virtual certainty of severe birth defects for the babies of women who take isotretinoin while pregnant.
In 2005, the FDA established an online tracking database, called iPledge, and now requires all patients to sign onto the database to continue receiving their prescriptions. The iPledge system requires women to submit two negative pregnancy tests before they can receive an initial prescription for isotretinoin. Women must also undergo a monthly pregnancy test before each refill. Men are also tracked because of isotretinoin’s depression risk.
"Anyone taking [isotretinoin] really needs to be counseled properly about all of these risks,” Alexiades-Armenakas says. The drug also impairs wound healing, so if a patient with severe cystic acne begins taking the drug, those cysts typically resolve with scars. "It gets rid of the underlying problem, but you’re almost guaranteed to heal with scars if you’re at that level of inflammation when you start taking [isotretinoin]."