Acne can be challenging for anyone. While some preliminary treatments can make small differences, some more extreme cases call for more extreme measure.
Let’s take a deeper dive into one treatment in particular, isotretinoin, most commonly referred to as “Accutane.” (Absorica, Amnesteem, Claravis, Myorisan, Zenatane).
What is Accutane (or Isotretinoin)?
In short, isotretinoin is a medication used to treat severe cases of acne, in most cases cystic or stubborn acne that has not responded to other well-known acne treatments.
This medication works by targeting the sebaceous gland itself, where it works to slow the production of sebum (the oil secreted by these glands) and to make it less sticky, reducing the chances of clogged pores and acne.
Why does one acne medication deserve an entire blog?
Isotretinoin is an extremely effective, but equally controversial medication. There are many unfounded misconceptions about the drug that have not been supported with real-world data.
Sadly, these misconceptions may be enough to scare patients away from using a potentially life-alternating drug that, when used appropriately and diligently, can prevent acne scarring and permanent disfigurement.
As dermatologists, it is never our job to force treatments on patients, even when we think that our patients can potentially benefit.
However, it is our job to take the extra time to provide all of the facts and data during the informed consent process so that medical decisions are based on substantiated facts and not unsubstantiated fears.
“I can live with patients and their parents refusing treatment when they are properly informed, but it is extremely heartbreaking to see a patient have acne scars because the previous clinician did not want to take the extra time to listen to their concerns.”
Who is a candidate for isotretinoin therapy?
Patients with severe nodulocystic acne or even mild or moderate acne that hasn’t responded to conventional treatments are excellent candidates for isotretinoin. The bottom line is that any patient with acne scarring potential should at least be considered.
In the past, isotretinoin used to be thought of as the last resort medication, but now dermatologists are using the medication earlier in the disease course.
Due to the safety concern for the overuse of antibiotics in acne patients, an argument can be made that isotretinoin should be considered first-line treatment for acne.
How does isotretinoin work to stop acne?
The major factors that cause acne involve the skin not being properly shed, increased sebum (oil) production, and bacteria feeding on the oil to cause inflammation.
Isotretinoin targets all three causes by shutting down the sebaceous glands and the bacteria which depend on the oil to cause inflammation.
The medication also helps normalize proper skin shedding, which cuts down on comedones (blackheads and whiteheads) formation.
This all sounds great…
So why does isotretinoin get such a bad reputation?
The majority of the controversy stems from the high likelihood to cause birth defects if a female taking the medication were to become pregnant as well as the inconsistent associations with depression, suicide, and inflammatory bowel disease.
How do you try to prevent pregnancies for patients on isotretinoin?
Isotretinoin is a highly government-regulated medication. All dermatologists, pharmacists, and patients that are involved with isotretinoin must be enrolled in the iPLEDGE program.
Specifically, the iPLEDGE program requires all patients with pregnancy potential to commit to use two forms of contraception one month before starting, during, and one month after treatment.
Additionally, all female patients with pregnancy potential must have two negative pregnancy tests before starting the medication along with additional negative pregnancy tests each month during and one month after treatment.
Unfortunately, unintended pregnancies still happen and it is tragic so we do everything in our power to help prevent them. Finally, it should be reassuring and comforting that patients know that they can safely get pregnant one month after stopping the medication without fear of any birth defects.
So does isotretinoin actually cause depression and suicide?
The short answer is that we do not know for sure so it is really important to discuss the data.
Yes, there are isolated case reports and small case series that report depression and suicide while taking the drug. But, we also know that depression and suicide increase in the adolescent and young adult population regardless.
Furthermore, we know that acne can cause depression and anxiety. The bottom line when looking at isolated case reports is that correlation does not imply causality.
Interestingly, when we look at larger, better designed, controlled studies, we actually see a positive effect of isotretinoin on depression and anxiety common in the population requiring isotretinoin. Unfortunately, it is the isolated case reports and not the well-designed studies that garner the majority of the attention.
Still, it is absolutely imperative for dermatologists to take the time to have this discussion with patients and their families so that appropriate action is taken if the patient were to develop these side effects.
If I already have depression or anxiety, does that mean that I can’t take isotretinoin?
No, but we need to be careful. Again, if we go back to the data and look at another population-based cohort study, the risk for major depressive disorder was higher among patients with acne than in the general population without acne and the risk was unchanged after excluding patients who received isotretinoin.
Acne patients with pre-existing depression require a careful multidisciplinary approach.
Before starting isotretinoin, it is important to have the patient’s parents, psychiatrist and primary care physician on board and part of the team.
Does isotretinoin cause inflammatory bowel disease?
Most likely not, as the best available evidence does not support a causal association between isotretinoin and inflammatory bowel disease.
Just as depression and suicide increases in adolescents and young adults so does inflammatory bowel disease.
This is most likely another case where correlation should not imply causality. Interestingly, one study suggested that if there is increased inflammatory bowel disease, it is associated with the acne and not with the therapy.
What side effects should I expect when starting isotretinoin?
Dry lips and dry mucous membranes (eyes, lips, nose).
Luckily, these pesky side effects are temporary and we have ways to control them through the treatment course.
Additionally, we can see elevations in blood lipids, such as triglycerides, which are routinely monitored during treatment. The elevations are temporary and resolve at the end of the treatment course. Far less common side effects include muscle aches after strenuous exercise and headaches.
How long do I have to be on the medication?
Every patient is different, but the average patient will take 20-24 weeks to reach the treatment goal. Sometimes, we can get there quicker if the patient is able to tolerate the dryness from higher daily doses.
Can I drink alcohol while taking isotretinoin?
Although alcohol is not contraindicated, it is advisable to limit consumption during treatment as both alcohol and isotretinoin can raise blood triglyceride levels.
Can I donate blood while on isotretinoin?
No. You cannot donate blood until one month after completing the treatment course.
Oral antibiotics seemed to help my acne, so would it be a good idea to combine them with isotretinoin to get an even better result?
No! When on isotretinoin, we do not recommend any additional oral acne treatments due to the dangerous risk of causing horrible headaches and increased intracranial hypertension (pseudotumor cerebri).
Can I have other skin procedures done while on isotretinoin?
Most likely. In the past, dermatologists would make patients wait 6-12 months due to the theoretical risk of scarring and abnormal wound healing.
However, there has been no data to support this notion so superficial peels, cutaneous surgery, laser hair removal, and fractional ablative and nonablative laser procedures are generally regarded as safe to use during isotretinoin therapy.
However, dermatologists would still recommend waiting before doing mechanical dermabrasion and fully ablative laser procedures due to limited data regarding possible scarring.
Would you prescribe isotretinoin to your own family members?
Yes. In fact, I have personally taken the medication.
As a teenager, I struggled with acne and found success with isotretinoin after trying and failing every other treatment option out there.
Seeing first-hand how skin disease can have such a profound psychosocial impact on the quality of life, especially on a teenager, and how much my confidence improved with clear skin, it motivated me to become a dermatologist and do the same for others.
If you think this acne treatment is right for you, make sure to book an appointment to discuss your options with a board-certified dermatologist.