Oral isotretinoin (13-cis-retinoic acid) is currently hailed as the best oral retinoid and drug to treat severe acne. Since its introduction more than 20 years ago it has remained the “gold standard” for acne treatment and is even earmarked by dermatologists as the drug that revolutionized acne treatments. It works by decreasing sebum secretion by the sebaceous glands, resulting in reduced comedone formation and Propionibacterium acnes (P. acnes) colonization on the skin ducts and surface.

Isotretinoin treatment often results in a 50% reduction of acne pustules after 2 to 4 weeks. 6-month treatment duration is enough for most patients, but a low dosage treatment should be continued beyond this duration for best results, as it has been observed that improvement continues during this post treatment period.

Approximately 40% of patients are totally cured of acne after one course, 40% have a recurrence of low severity that responds to more common medications, and 20% will need repeated isotretinoin treatment at a future time. Relapses are more likely to affect the following:

• Patients younger than 16 years
• Patients with severe acne on the trunk area
• Adult women

Relapses have been found to be less likely in patients receiving higher doses of isotretinoin, with the optimal dose being pegged between 120-150mg per kilogram of body weight. Multiple courses of isotretinoin over the acne-prone years may be required for younger patients and those with severe acne on the trunk area.

Serious Side Effects

As a potent teratogen, isotretinoin is not recommended for pregnant women or women wishing to become pregnant. Half of pregnancies affected by isotretinoin (sometimes from a single dose) result in spontaneous abortions, and 25% of surviving embryos suffer from neonatal cardiovascular or bone-related abnormalities. Women of childbearing age must test negative for pregnancy before starting isotretinoin treatment, and must be closely monitored for pregnancy prevention. Dermatologists must ensure that they are on effective contraception from one month before treatment up to six weeks after treatment.

While not supported by any studies, psychological disorders such as depression, irritability, and suicidal tendencies must be expected during and after isotretinoin treatment. These disorders have been found to cease upon the stoppage of treatment, but return upon continuation. Patients must have professional help at hand for immediate assistance in the event of the onset of these disorders.

Other Side Effects

Other side effects are mild and treatable. Dryness of the lips, skin, nasal passages, and eyes are the most common physical side effects of isotretinoin treatment. These may be alleviated through the use of moisturizers and lip balms. Isotretinoin may also cause hypertriglyceridemia and, to a lesser extent, affect cholesterol levels.

While possibly leaving the patient vulnerable to relapses, reducing dosages may also reduce the likelihood of side effects, as will certain changes in diet.