Acne Treatment with Systemic Retinoids

Isotretinoin - Accutane Acne Treatment

Isotretinoin is a synthetic oral retinoid that is the single most effective agent for treating acne with many qualifications on the point of its use.

Accutance is administered in doses of 0.5 to 2.0 mg/kg per day for severe acne that has been resistant to several different oral antibiotics and in patients with severe acne who are unable to tolerate standard acne treatments.

A daily accutane course of 1.0 mg/kg for 16 to 20 weeks often produces a remission that lasts months to years in the majority of patients but isotretinoin is not a cure for acne.

Overall, one-fourth of acne patients will need to repeat a course of accutane in the future, one-half will need other forms of therapy (topical agents or oral antibiotics), and one-fourth will need no further therapy.

All acne patients who take isotretinoin experience side effects. Preparing acne patients for side effect management before administration produces more satisfied patients.

Patients unwilling to experience common side effects such as cheilitis and xerosis should not initiate treatment. The side effects are similar to the hypervitaminosis A syndrome and limit use to more severe or scarring cases of acne. Most patients experience cheilitis, xerosis, conjunctivitis, and pruritus, and many may have bone and joint pain, headaches, epistaxis, and nausea. Uncommon complaints include alopecia, headaches, depression, and night blindness. Extremely rarely, this agent may produce pseudotumor cerebri.

Laboratory monitoring is required, and the clinician should pay particular attention to pregnancy tests, the presence of hypertriglyceride mia, and elevated liver transaminase tests.

Some clinicians choose to monitor a great number of laboratory tests in addition to the ones mentioned above, including urinalysis, complete blood count, and electrolytes.

There are no firm guidelines suggesting the minimum or maximum number of laboratory tests required. Some acne patients desire treatment with isotretinoin but refused to undergo laboratory monitoring. Without appropriate monitoring, this agent is not safe to administer, and the clinician should refuse to prescribe it.

The most important concerns in giving isotretinoin are the possible teratogenic effects on the fetus. This agent is highly teratogenic, and one capsule may be sufficient to induce severe fetal abnormalities. Sexually active women who use unreliable forms of birth control are poor candidates for this therapy. A thorough informed consent is essential before initiating therapy. Dual-method contraception control in women at risk of becoming pregnant should be stalted at least 1 month before beginning therapy and should continue 1 month after the cessation of therapy. The only women with 100 percent reliable contraception are those who have undergone a hysterectomy and those who engage in no sexual activity (not necessarily those who report no activity). We go through the informed consent process for women who have undergone a tubal ligation and women whose sexual partners have had vasectomies. These sterilization techniques are highly but not totally effective. In sexually active women, a negative pregnancy test should be obtained before beginning isotretinoin therapy and at monthly intervals during the treatment course.