Treatment of Acne With Isotretinoin - Accutane

How Accutane Works & Starting Therapy

Isotretinoin (formerly sold under the brand name Accutane) is a medicine that revolutionized the treatment of acne. Isotretinoin belongs to the family of medicines called retinoids, which are similar to vitamin A. Isotretinoin, like other retinoids, works by altering DNA transcription. This affect decreases the size and output of sebaceous glands. It also makes the cells that are sloughed off into the sebaceous glands less sticky, and therefore less able to form blackheads and whiteheads (comedones).

It also reduces the number of bacteria in the sebaceous gland and on the skin surface.

Who Takes Isotretinoin?
Isotretinoin is generally used for nodular, pustular acne that has not responded to full courses of several oral antibiotics. The trend in isotretinoin prescribing for acne has been towards using it earlier in the course of the disease, especially if there is significant scarring. While isotretinoin is used primarily for severe acne, it has also been used for other disorders such as psoriasis, lupus, and lichen planus, with varying degrees of success.

Starting Therapy With Isotretinoin 
Several dosing regimens are used, but the most common regimen involves starting with a low dose, then increasing the dose after several weeks. The length of the treatment course varies but generally lasts from 16 to 20 weeks. Some people notice that their acne gets worse after starting isotretinoin therapy.

The number of acne lesions usually does not increase; rather the lesions may become redder or more painful. This is normal, lasts only a short while, and is not a reason to stop using isotretinoin.

Edited by Susan J. Huang MD

Birth Defects With Accutane
The side effects of Accutane have been a controversial topic. The most noticeable, serious, side effect is its teratogenicity. This means that Accutane causes birth defects if women take it while they are pregnant. The birth defects Accutane causes include central nervous system, facial, cardiac, and thymus gland abnormalities. After Accutane treatment has been completed for one month, a woman can get pregnant without worry about birth defects.

Accutane does not affect fertility, or make it difficult to get pregnant. Women who are taking Accutane should use two forms of birth control starting a month before treatment and continuing one month after treatment.

Serious Side Effects With Accutane

Accutane therapy also has the following serious side effects.

  • Headaches, if persistent and associated with nausea, vomiting, and blurred vision, may be a sign of a condition called pseudotumor cerebri.
  • The incidence of depression, psychosis, and suicide attempts is increased, and returns to normal after discontinuing the drug.
  • The production of tears in the eyes is decreased, which can cause, red eyes, itchy eyes, and possibly ulcerations of the cornea, especially with contact lens wearers.
  • The ability to distinguish between shades of black and white can be decreased causing night blindness.
  • Liver enzymes can be elevated causing jaundice, hepatitis, and abdominal pain.

    Other Side Effects With Accutane

    Accutane therapy can also cause the following less serious, but potentially annoying side effects.

    • Dry skin requiring the frequent use of moisturizers
    • Dry and cracking lips
    • Nosebleeds
    • Itchy skin (pruritis)
    • Thinning hair
    • Excessive peeling, especially of the palms and soles
    • Muscle aches and pains, even worse with physical activity
    • Increased sensitivity to the sun causing sunburns more easily
    • Elevated triglyceride levels

    Lab Monitoring of Accutane
    Prior to starting Accutane therapy, patients should have blood work to check triglyceride levels, liver functions, and a complete blood count. Women should also have a pregnancy test. Periodically during the course of therapy, but especially one month after starting therapy, these labs are checked again.

    Finishing Therapy With Accutane
    A standard course of therapy is 16 to 20 weeks.

    At the end of 16 weeks, about 85% of patients are clear. The beneficial effects of Accutane do not stop when the drug is discontinued. A further reduction of acne lesions and improvement of scarring is seen for months after treatment has stopped. Another beneficial affect of Accutane is that after a course of the drug, the skin usually responds better to conventional acne therapy.

    Final Thoughts About Accutane
    The side effects of Accutane therapy have prevented some people from considering it as a viable therapy. However, the majority of side effects go away after the drug is discontinued with the notable exception of the birth defects. Despite its side effects, Accutane remains the most powerful and promising therapy for moderate to severe acne. Used in a prudent manner, with careful monitoring, it can change the life of an adolescent or young adult.

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