Accutane (isotretinoin)
Patient Information
Isotretinoin (formerly branded as Accutane) is a medication that is taken by mouth to treat moderate to severe acne. It is in the retinoid class of medications (a vitamin A derivative). It is not a ‘cure’ but certainly the most effective treatment for acne. A general rule of thumb is that about ~⅓ of patients never again experience acne after treatment, ⅓ will get mild but manageable return of acne, and ~⅓ will relapse to the point that they request to do an additional course of treatment in the future.
Dosage and monitoring
Treatment duration is usually 6-8 months but may be longer if dosage modifications are required. The goal is to achieve a certain cumulative dosage based on weight. Classically this number was 150mg/kg but many are now recommending closer to 220 mg/kg for better chance of long term clearance. The first month we start at half dose (usually 30-40mg once daily). If well tolerated, the remaining months will be at full dose (60-80mg daily) depending on your weight. Monthly monitoring is required with office visits and fasting blood work (liver function, triglycerides, pregnancy status).
Common Side Effects (and how to manage them)
Accutane is generally well tolerated, but like every medicine there are potential side effects. We separate side effects to the common/benign and the rare but potentially serious side effects.
-Generalized Dryness: Dryness is an unavoidable feature of this medication during use but the effects can be greatly mitigated with the following recommendations.
Chapped Lips: generous ointment use from the beginning of treatment (aquaphor, vasoline)
Dry skin: Frequent use of unscented moisturizer particularly immediately following shower.
(vanicream, neutrogena, aveeno, cetaphil)
Nosebleeds: Vaseline ointment at night and frequent use of saline nasal spray
Afrin nasal spray can assist in stopping an active bleed (vasoconstriction)
Dry Eyes: Lubricating eye drops may help
- Sun Sensitivity: Everyone will experience sensitivity to the sun during treatment.
Use great caution while on accutane to avoid sunburn.
Frequent SPF use, clothing, and avoidance are the most effective strategies.
-Joint/muscle aches: Some patients may experience increased muscle/joint aches or pains.
Consider Advil (ibuprofen) or Aleve (naproxen). Avoid taking Tylenol (acetaminophen).
Inform us if pain is severe, or if you have severe Headaches or visual changes.
- Acne Flare: A minority of patients can experience an initial exacerbation of their acne before seeing improvement. This tends to be more common in patients whose acne is severe and cystic at the time of treatment. We can treat these exacerbations with oral or intralesional steroids.
Important Points During Treatment
-Stop all other acne products (especially oral antibiotics) except gentle cleanser and moisturizer
-Avoid vitamins with high doses of Vitamin A (>5000IU)
-Avoid Alcohol and Tylenol (also metabolized by liver like isotretinoin)
-Avoid waxing and tweezing of hair (threading and shaving are considered safe), Avoid Sun
-Avoid chemical peels, lasers, piercings, tattoos or elective surgeries until 1 month after treatment
-DO NOT get pregnant, DO NOT donate blood
-Take with food to get proper absorption of medicine
Special Considerations for Females or any Patient with Childbearing Ability
Birth Defects Risk: Birth defects are certain to occur if a patient becomes pregnant while on Accutane (isotretinoin) and is the reason that the medication is so closely monitored. There is no long term risk of birth defects after you finish your course and it has no effect on your ability to become pregnant in the future. Isotretinoin is regulated by the iPledge program to help prevent accidental pregnancy while on this medicine, and for one month after you stop the medication. This program requires you to use two forms of birth control to prevent pregnancy. In some circumstances, it is possible to use abstinence and abstinence as your form of birth control.
iPledge: After being entered into the iPledge system by our office, please look out for mail from ipledge with your user name and password after 7-10 business days. User Name is ipledge ID. This password will be used to log in when the medicine is prescribed. After each monthly appointment, you will need to log on to iPledge and complete the required questions prior to getting your prescription. If you do not receive the mail you may always call Ipledge (see welcome packet) to get your password over the phone.
Pregnancy tests: 7 Day Window
Monthly pregnancy tests are required by iPledge. The day you get your pregnancy test (included in your blood work), is Day 1 of your 7 day window, which is the window of time you are allowed to pick up your prescription. If your window closes before you can get the medication, you will need to have another pregnancy test drawn. If you have not been contacted by our office with your labs results by day 4 of your window, please call us during working hours to avoid missing your window.
Rare but Potentially Serious Side Effects
Liver damage- Accutane is metabolized by liver just like alcohol and Tylenol so you should avoid these products during use. In addition, we monitor your liver early on to make sure there are no issues.
Triglyceride elevations- Accutane causes modest elevations of triglycerides, we monitor to make sure these do not continue trending upwards
Increased brain pressure- (AKA pseudotumor cerebri) can be a side effect of many medications including Accutane. Risk is increased if you take with Tetracycline class antibiotics which is why you should avoid this antibiotic during use. Inform us if you have severe Headaches or blurred vision.
Depression/Mood Changes- There have been reports of worsening depression/ mood changes during treatment. The link between accutane and depression is not proven and the vast majority of patients will not experience any changes in mood. However, inform us if you are experiencing any changes in mood.
IBD exacerbation- Accutane used to be blamed for causing inflammatory bowel disease. Extensive studies have shown that there is no evidence of causation. Nevertheless, it could theoretically exacerbate or expose underlying IBD so we defer to GI doctor before considering or avoid in these patient.
Bone and Joint: Bone ossification and osteophyte formation have been reported. Severe back pain representing sacroiliitis has been reported. Inform us if back pain is severe.
*See medication package insert for complete information