SPIRONOLACTONE VERSUS DOXYCYCLINE FOR MODERATE ACNE IN ADULT WOMEN: EFFICACY, MENSTRUAL IRREGULARITY, AND HYPERKALEMIA RISK — A SYSTEMATIC REVIEW
Introduction: Oral antibiotics are effective for inflammatory acne but prolonged use contributes to antimicrobial resistance. Spironolactone offers a nonantibiotic systemic alternative for adult women, although comparative efficacy and concerns about menstrual irregularity and hyperkalemia influence prescribing. Objective: To compare spironolactone with doxycycline for moderate acne in adult women and evaluate menstrual and potassium-related safety. Methods: Seven bibliographic and trial registries were searched through August 10, 2026. Because fewer than ten directly comparative studies were found from 2021 onward, the search was extended to January 2016. Randomized comparisons and complementary spironolactone safety cohorts were appraised with RoB 2 or ROBINS-I, and evidence certainty was assessed using GRADE. Results and Discussion: Six primary studies were included. The FASCE randomized trial was the only head-to-head comparison and found that spironolactone plus benzoyl peroxide was slower initially but superior to doxycycline plus benzoyl peroxide by months 4 and 6. The SAFA trial independently confirmed increasing benefit through 24 weeks. Menstrual irregularity was clinically relevant but was often manageable and less frequent with combined oral contraception. Hyperkalemia was rare in healthy women aged 45 years or younger and more important with older age, renal or cardiovascular disease, and interacting medication. Conclusion: For appropriately selected adult women with moderate persistent acne, spironolactone is an effective antibiotic-sparing alternative and may outperform doxycycline over six months. Baseline risk assessment, pregnancy prevention counseling, and selective rather than universal potassium monitoring provide the most proportionate safety strategy.