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
- 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