From the Journals

Evidence on spironolactone safety, COVID-19 reassuring for acne patients


Concerns about potential risks about the use of spironolactone for acne during the COVID-19 pandemic were raised on social media last month, but spironolactone and other androgen blockers might actually protect against the virus, according to a report in the Journal of the American Academy of Dermatology.

Dr. Carlos Wambier

The virus needs androgens to infect cells, and uses androgen-dependent transmembrane protease serine 2 to prime viral protein spikes to anchor onto ACE2 receptors. Without that step, the virus can’t enter cells. Androgens are the only known activator in humans, so androgen blockers like spironolactone probably short-circuit the process, said the report’s lead author Carlos Wambier, MD, PhD, of the department of dermatology at Brown University, Providence, R.I (J Am Acad Dermatol. 2020 Apr 10. doi: 10.1016/j.jaad.2020.04.032).

The lack of androgens could be a possible explanation as to why mortality is so rare among children with COVID-19, and why fatalities among men are higher than among women with COVID-19, he said in an interview.

There are a lot of androgen blocker candidates, but he said spironolactone – a mainstay of acne treatment – might well be the best for the pandemic because of its concomitant lung and heart benefits.

The message counters a post on Instagram in March from a New York City dermatologist in private practice, Ellen Marmur, MD, that raised a question about spironolactone. Concerned about the situation in New York, she reviewed the literature and found a 2005 study that reported that macrophages drawn from 10 heart failure patients had increased ACE2 activity and increased messenger RNA expression after the subjects had been on spironolactone 25 mg per day for a month.

Dr. Ellen Marmur

In an interview, she said she has been sharing her concerns with patients on spironolactone and offering them an alternative, such as minocycline, until this issue is better elucidated. To date, she has had one young patient who declined to switch to another treatment, and about six patients who were comfortable switching to another treatment for 1-2 months. She said that she is “clearly cautious yet uncertain about the influence of chronic spironolactone for acne on COVID infection in acne patients,” and that eventually she would be interested in seeing retrospective data on outcomes of patients on spironolactone for hypertension versus acne during the pandemic.

Dr. Marmur’s post was spread on social media and was picked up by a few online news outlets.

In an interview, Adam Friedman, MD, professor and interim chair of dermatology at George Washington University, Washington, said he’s been addressing concerns about spironolactone in educational webinars because of it.

He tells his audience that “you can’t make any claims” for COVID-19 based on the 2005 study. It was a small clinical study in heart failure patients and only assessed ACE2 expression on macrophages, not respiratory, cardiac, or mesangial cells, which are the relevant locations for viral invasion and damage. In fact, there are studies showing that spironolactone reduced ACE2 in renal mesangial cells. Also of note, spironolactone has been used with no indication of virus risk since the 1950s, he pointed out. The American Academy of Dermatology has not said to stop spironolactone.

Dr. Adam Friedman

At least one study is underway to see if spironolactone is beneficial: 100 mg twice a day for 5 days is being pitted against placebo in Turkey among people hospitalized with acute respiratory distress. The study will evaluate the effect of spironolactone on oxygenation.

“There’s no evidence to show spironolactone can increase mortality levels,” Dr. Wambier said. He is using it more now in patients with acne – a sign of androgen hyperactivity – convinced that it will protect against COVID-19. He even started his sister on it to help with androgenic hair loss, and maybe the virus.

Observations in Spain – increased prevalence of androgenic alopecia among hospitalized patients – support the androgen link; 29 of 41 men (71%) hospitalized with bilateral pneumonia had male pattern baldness, which was severe in 16 (39%), according to a recent report (J Cosmet Dermatol. 2020 Apr 16. doi: 10.1111/jocd.13443). The expected prevalence in a similar age-matched population is 31%-53%.

“Based on the scientific rationale combined with this preliminary observation, we believe investigating the potential association between androgens and COVID‐19 disease severity warrants further merit,” concluded the authors, who included Dr. Wambier, and other dermatologists from the United States, as well as Spain, Australia, Croatia, and Switzerland. “If such an association is confirmed, antiandrogens could be evaluated as a potential treatment for COVID‐19 infection,” they wrote.

The numbers are holding up in a larger series from three Spanish hospitals, and also showing a greater prevalence of androgenic hair loss among hospitalized women, Dr. Wambier said in the interview.

Authors of the two studies include an employee of Applied Biology. No conflicts were declared in the Journal of Cosmetic Dermatology study; no disclosures were listed in the JAAD study. Dr. Friedman had no disclosures.

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