Isotretinoin Treatment for Acne
Oral isotretinoin or Accutane treatment is a retinoid (closely related to Vitamin A) for the treatment of severe or resistant acne. It is marketed by different companies such as Roaccutane, Accutane, Oratane and Acnotin. The introduction of this drug into the market in the early 1980s has helped countless individuals improve their acne significantly, and greatly improving their quality of life. Oral isotretinoin is currently the single most effective medical therapy for severe acne, cystic acne, and moderate acne not responding to standard therapies.
How does Isotretinoin Work?
The four main factors contributing to acne vulgaris include:
- Excessive sebum (oil) production
- Clogged pores due to abonormal skin turnover
- Bacterial P.acnes involvement
Standard acne treatments that include antibiotics, topical retinoids and benzoyl peroxide can only target these processes partially. Interestingly, there is currently no topical treatment or oral antibiotic that can reduce sebum production. Moreover, we are now seeing many individuals with moderate stage acne vulgaris who are becoming resistant to oral antibiotics worldwide.
Oral isotretinoin effectively targets all the above 4 factors contributing to acne. It targets the sebum gland, and the production of keratin that is involved in clogging the pores. By 6 weeks, there will be about 80-90% reduction in sebum. At 12 weeks, 80-90% of whiteheads and blackheads will be reduced. The significant reduction in inflammation and change in the skin's micro-environment reduces the total P. acnes bacterial count.
How much Isotretinoin do I need to take?
Majority of individuals who have severe facial acne need a course of treatment that lasts 4-6 months on average. Treatment for back acne is at least 6-8 months, as it slower to respond to treatment.
The dosage of oral isotretinoin is weight based. Traditionally, doctors would start off with 0.5mg/kg/day and increase the dosage to 1mg/kg/day gradually after the first month. For example, if you weigh 60kg, your initial starting dose would be 30mg of oral isotretinoin daily, and may be increased up to 60mg of oral isotretinoin per day. Now such high dosages would inevitably increase the side effect profile, tolerability and costs.
Another factor regarding treatment is the goal cumulative dosage, often between 120-150mg/kg. Lower rates of relapses are noticed in dosages >120mg/kg, compared to those <120mg/kg. There does not appear to be much difference in extending the cumulative dose beyond 150mg/kg in some studies.
Fortunately, there have been studies to demonstrate that low dose isotretinoin (0.25-0.4mg/kg/day) is as effective as conventional dosing. The lower dose option has the advantages of lesser side effects, improve tolerability and more affordable costs.
What are the common side effects?
Invariably, the most common side effect encountered is dryness. Dryness to the skin, nose, eyes, lips and genitalia is common. Dry skin can be improved by using a non-comedogenic moisturizer. We advise lips balms to manage chapped lips, and artificial tears eye drops to combat dry eyes. There can be sensitivity to sunlight while on treatment, and the use of a regular sunblock (of at least SPF 30) is strongly advised.
You may experience mild joint and muscle pains, but not significant enough to interfere with sports and exercise in the great majority of individuals. Some report temporary hair loss or even hair growth during the course of treatment.
A worsening of acne when starting treatment is also commonly encountered in the first month of treatment. This gradually subsides after the first month of therapy. We may prescribe some anti-inflammatory medication to help with this process.
A blood test is necessary before you begin the course of treatment. We will check for blood chloesterol levels and liver tests, which has to be done periodically while on treatment. This is for safety purposes, and ensures that the medicine does not adversely increase your blood cholesterol or liver enzymes.
There have been reports of individuals reporting changes in mood including depression and suicidal thoughts while on oral isotretinoin. However, to date there is no direct evidence from several studies to suggest a direct link between oral isotretinoin and mood disturbances. On the other hand, studies have shown quite the contrary. Oral isotretinoin improves mood, memory and attention span. Given how prevalent depression, anxiety and suicidal thoughts are in the general population, we monitor for changes in your mood during your review.
Who is not suitable for Oral Isotretinoin?
It is important that a doctor takes a medical history, and carries out some basic laboratory tests before you consider oral isotretinoin.
Individuals who cannot take oral isotretinoin include those with:
- Liver or Kidney disease
- Excessive high blood cholesterol levels
- Hypervitaminosis A
Oral isotretinoin can cause night vision disturbances. If your job requires you to drive at night (pilot, drivers) or operate heavy machinery, you will not be suitable for this treatment for the safety of yourself and those around you.
Will Isotretinoin Cure My Acne?
While some patients need only one course of treatment, a smaller segment of patients may need a second course. In a follow up study of patients over a 3 year period; 38% did not have acne, 42% had their acne controlled by standard therapies, while only 20% needed a second course of oral isotretinoin treatment.
The recurrence rate between conventional and low dose isotretinoin treatments appear similar.
Can I take other medicines while on oral isotretinoin?
It is important to inform your doctor that you are on oral isotretinoin in case there are drug-drug interactions.
Generally (but not exclusively) avoid:
- Oral Tetracycline Anbitiotics (e.g. Doxycycline is commonly prescribed for acne)
- Vitamin A containing supplements
- Alcohol (may cause liver inflammation)
Isotretinoin and Pregnancy
After the introduction of oral isotretinoin in the United States in 1982, there were hundreds of reported cases of congenital malformations associated with the treatment. To this day, there continues to be about 150 cases of isotretinoin exposed pregnancy in the United States. Oral isotretinoin is given an 'X' label under the FDA Pregnancy Category. This drug carries a high risk of severe birth defects that could malform the foetus brain, heart and facial structures.
Women of child bearing age are counselled regarding the use of contraception before starting treatment. More than one contraceptive menthod (e.g. condom and contraceptive pills) are recommended while on treatment. 3 months after the cessation of treatment, family planning is then considered safe.
What do I need to avoid while on treatment?
There is a concern of delayed wound healing and scarring, and some treatments should be delayed 6-12 months after you stop medication. Such treatments and procedures include waxing, dermabrasion and laser resufacing.
However, there are recent studies that show the safety of chemical peels, dermabrasion, CO2 laser, laser hair removal, and pulsed dye laser on patients who are currently or recently treated with oral isotretinoin. These treatments should be carried out on a case by case basis, and done by a professional with sufficient experience.
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- Lee JW, Yoo KH, Park KY, Han TY, Li K, Seo SJ, et al. Effectiveness of Conventional, Low-dose and Intermittent Oral Isotretinoin in the Treatment of Acne: A Randomized, Controlled Comparative study. Br J Dermatol. 2010 Nov 29.
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