Hormonal treatment of acne, limited to women, offers a different approach that is helpful when other treatments are ineffective. It is not known what triggers adult onset acne. Since it is most often seen in professional women, stress is given the blame. This leads to hormonal irregularities that increase "male" hormone levels, resulting in acne breakouts. Several hormones normally present in women have a male hormone-like action in all adult women.

Women who benefit most from hormonal treatment are typically in their 20s or 30s, have acne on the lower part of the face and neck, and have a history of failed treatment, or an intolerance to standard acne therapies (both topical and oral). In addition, many have a history of menstrual irregularities, premenstrual acne flare-up, and facial oiliness. Underlying problems include polycystic ovaries and congenital adrenal hyperplasia. Hormonal treatment is generally not used in the most severe forms of acne, nodular/cystic acne.

Most acne treatments require prolonged care, from months to years. Once improvement is achieved, a maintenance dose is usually necessary. Women who develop adult acne typically have the problem for years, frequently through menopause.

The modalities used most in hormonal acne treatment are oral contraceptives and anti-androgens (spironolactone or flutamide). It is common to start with oral contraceptives for one to two months, as sometimes just regulating the menstrual cycle is enough to stop the acne. Often this is only partly effective, and then we add anti-androgens. The combination is particularly effective.

Spironolactone is a medication used primarily for the treatment of high blood pressure. It was discovered by accident that it can be used to treat acne and excess hair growth in women. Spironolactone and flutamide (a more potent drug, but prone to affect the liver) act by blocking the effects of one male hormone (testosterone) on the oil glands and hair follicle. 

The optimal dose of spironolactone varies in different individuals, but usually from 50mg to 100mg daily is enough. While it is only effective in women who's acne is truly hormonally driven, sometimes fairly dramatic benefit can be seen after 2 or 3 months. Some women will be able to take the drug only 10 days each month, usually starting around the middle of their cycle. 

Spironolactone has been used for mild high blood pressure and fluid retention for many years, and has been shown to be very safe with few side effects. The most common side effects are irregularity of menstrual cycles and breast tenderness, but if birth control pills are also being taken, this should cause minimal problems. Potential side effects of elevated potassium and dehydration are not seen at the dose used for acne, and serious side effects are extremely rare.  It should not be mixed with blood pressure medications of the ACE type (Captopril, Vasotec, others) or taken with high doses of NSAIDs (Indicin, alleve, advil, others) as these may increase potassium concentrations.