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When it comes to their effects on acne, not all hormonal contraceptives are created equal, researchers said.

On average, depot injections, subdermal implants, and hormonal intrauterine devices worsened acne while the vaginal ring and combined oral contraceptives (COCs) tended to improve it (P≤0.001 for all pairwise comparisons), according to a large retrospective study performed by , of the Curology Medical Group in San Diego, and colleagues.

There were no other statistically significant differences among contraceptive classes, the researchers said in a report appearing online in the .

Within COC categories, the analysis revealed that drospirenone (Gianvi, Loryna, Nikki, Ocella, Syeda, Vestura, Yasmin, Yaz, Zarah) was most helpful in clearing acne followed by norgestimate (Ortho-Cyclen, Tri-Sprintec) and desogestrel (Desogen, Mircette) and then levonorgestrel (Plan B) and norethindrone (Aygestin, Norlutate, Norlutin; P≤0.035 for all pairwise comparisons).

The presence of triphasic progestin dosage in COCs had a positive effect on reducing acne, but variation in estrogen dose did not.

"Our results are consistent with the [2102] that COCs containing drospirenone are superior to those containing norgestimate," the study authors wrote. "Additionally, our results demonstrate a more detailed hierarchy where drospirenone pills are superior to norgestimate pills and desogestrel pills, both of which in turn are superior to norethindrone pills and levonorgestrel pills. These findings are also consistent with those of a that found no significant difference in effect on acne between COCs containing desogestrel versus norgestimate."

The study analyzed de-identified information from the medical records of 2,147 consecutive female patients. All were using hormonal contraception at the time of telephone consultations for acne that took place from March 2014 to May 2015.

Mean age was 24.9 years. Levonorgestrel-releasing IUDs were the most commonly used progestin-only contraceptives. Next most commonly used were etonogestrel subdermal implants (Implanon, Nexplanon), followed by medroxyprogesterone acetate intramuscular depot injections (Depo-Provera) and norethindrone pills.

COCs made up of multiple combinations of different hormones were the most common combined contraceptive. Vaginal rings consisting of etonogestrel and ethinyl estradiol or transdermal patches consisting of norelgestromin and ethinyl estradiol were the least commonly used forms of hormonal contraception.

"Because this is a self-selected population of patients who sought medical treatment for acne, the distribution of hormonal contraceptive use is not likely representative of overall utilization rates in the United States," the authors acknowledged.

Each patient was asked to rate her contraceptive's anti-acne effectiveness, as to whether the product makes acne worse, has little effect, helps a bit, or helps significantly.

Only those contraceptives used by 50 or more patients were included in the analysis.

A triphasic progestin dose (such as OrthoTri-Cyclen), that was stepped up in three phases in the cycle appeared to control acne better than a monophonic progestin dose (such as Ortho-Cylen). In the latter there was no variation in progestin dose during the active phase of the pills.

This difference was strongly significant, the researchers said (P=0.005). They also noted that the effect of progestin dose couldn't be analyzed because of the wide variation in potency of different progestin types.

Possible explanations include the triphasic pills more closely mimicking normal hormone fluctuations or the fact that the triphasic pills in the study had a lower cumulative progestin dose than corresponding monophasic pills, Lortscher and colleagues suggested. "Because no similar comparisons in the scientific literature were found, further investigation would be needed to confirm this finding," they said.

The copper-releasing IUD was not included in the study. Since this long-acting reversible contraceptive doesn't contain hormones, it's unlikely to have a significant effect on acne, the researchers noted.

They pointed out that a comparing a levonorgestrel-releasing IUD to a copper-releasing IUD showed that the former led to an increase in acne scores while the latter did not.

"Accordingly, the copper IUD may be a good choice for patients who desire long-acting reversible contraception but who are concerned about acne."

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