Spironolactone

Indications                                                                                                                                                                                                     

• no FDA approved derm indications

• off-label: hirsutism, acne, androgenic alopecia, HS

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Pharmacology                                                                                                                                                                                                

• relatively weak antagonist of the androgen receptor and also provides some inhibition of androgen biosynthesis

• steroid molecule that resembles mineralocorticoids

• metabolized to canrenone which is the primary active antiandrogen (and diuretic)

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Side Effects                                                                                                                                                                                                    

Menstrual Dysfunction

• Heavy menstrual bleeding can occur, typically at doses of >100mg

  • reduce dose to 50-75mg​

  • add OCP

  • cycle 3 weeks on 1 week off

  • often improves on own in 2-3 months

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Hypotension 

• It seems there is a dose response relationship between spironolactone and hypotension for doses <50mg daily but not above 50mg daily.  A paper looking at 2084 female patients treated for acne, alopecia, or hirsutism found an ~3% hypotension rate.  Dose did not correlate with development of hypotension. It does not appear that spironolactone causes hypotension in patients being treated for these conditions. 38483433

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Hyperkalemia

• Very uncommon in young and healthy patients (cit needed).  

• typically affects those with severe renal insufficiency or on other potassium sparing diuretics, or Addison disease

• if opting to monitor, should be done within 1-4 weeks to minimize the effects of prolonged hyperkalemia. (39033981)

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Malignancy

• Concerns regarding malignancy come from chronic toxicity studies in rats where they were given 25-250 times the dose by weight.  This caused benign adenomas of thyroid and testes, malignant mammary tumors, and proliferative changes in the liver. 

• A study of 3692 women showed no increased risk of benign or malignant tumors of the breast or uterus with spironolactone use for dermatologic conditions. 38423468