Isotretinoin treatment

Isotretinoin is a chemical derivative of Vitamin A. It is very effective in clearing acne and providing the drug is continued for the full course, there is an 80%+ chance of a long-term cure of acne. For patients under the age of 20 years following the treatment course, there is around 85% success rate. For patients over the age of 20 years, the success rate is around 90%. These success rates are expected providing the full course of Isotretinoin is taken under the dermatologist’s instructions.

How effective is Isotretinoin?
Isotretinoin has been available for use for nearly thirty years. Over that time dermatologists have become experts in management of acne and acne related conditions with the use of this drug. No other drug has proven as effective in the management of acne and it is unlikely in the foreseeable future that any other drug will become available which is as effective over time. How we use the medication has changed. It has been a trend over recent years to reduce the daily dose of the drug, thus limiting the side effects. As a consequence of this treatment courses are slightly longer than previously. There is a direct dose dependent relationship between the daily dose, the clinical response rate and side effect profile, i.e. the higher the daily dose, the greater the side effects. It is through patient preference that lower daily doses are now being used. If the drug treatment is taken as prescribed the effectiveness is not compromised and the side effects of treatment are minimised.

Over the years the threshold for treating acne with Isotretinoin has also reduced. This is a direct reflection of the drug being the most effective treatment of acne. It is predicted that over the forthcoming years the threshold for treatment will reduce further. It is likely that many current medications, both oral and topical (skin applied) drugs currently being used will be used less frequently or not at all. As experience has grown it is clearly apparent this is really the only effective disease modifying drug in the management of acne and acne related problems.

How long before I notice improvements?
Unfortunately, while most of these side effects are worse in the first month, Isotretinoin is much slower to produce improvement in the acne. In fact, one in five people on Isotretinoin experience a worsening of their acne about three to four weeks into the treatment. It usually only lasts for several days and is not a sign of treatment failure. Real improvement in acne is generally not evident until six weeks into the treatment, when it usually begins on the upper face and then gradually proceeds downwards, such that people with severe acne over the trunk may expect to be on treatment for 6-9 months whereas those with just severe facial acne will usually only need 6 months treatment. The treatment duration is obviously dependent on the dose of the drug which the patient can take. While side effects are almost always temporary and disappear when the drug is stopped, it does require obsessive care of your skin while on the drug. Provided you are careful to control any dryness with moisturisers and to keep your lips repeatedly moistened with lip moisturisers, few problems will be experienced. Scarring is not improved with Isotretinoin. Methods to improve scarring will be discussed once the course if finished. No treatment for scarring, such as dermabrasion, chemical peel or carbon dioxide laser ablation, should be contemplated until at least 6-12 months after completing the course, as these treatments can possibly accentuate the scarring.

Can I take other medications?
Although Isotretinoin is a very effective medication, there are a few important drug interactions. Vitamin A should not be taken while on Isotretinoin. Isotretinoin is a modified form of Vitamin A and taking extra Vitamin A, not in the form of ordinary food but vitamin tablets that contain Vitamin A, may increase the side effects. Taking tetracyclines such as Doxycycline or Minocycline in combination with Isotretinoin is to be avoided as the combination raises the pressure inside the brain and can lead to severe headaches. There is no interaction between the oral contraceptive and Isotretinoin. Isotretinoin does not in itself interact with alcohol. If you are one of the few people who have upset liver function tests on Isotretinoin you will be advised to stop other liver toxins such as alcohol. Isotretinoin is a one drug treatment for acne and there is no advantage in adding other agents to it, in particular there is no need to continue the antibiotics that you have been on for your acne, while on Isotretinoin. Certainly, the over-the-counter acne preparations which tend to be drying and irritating to the skin, will be even more irritating and drying for those on Isotretinoin and should be avoided.

What are the side effects?
Against the great effectiveness of this medication are its numerous side effects. They are all temporary and resolve completely when the drug is stopped. Its most disastrous side effect is on a developing baby. Should a woman become pregnant within a few days of starting the drug, to up to one month after stopping it, there is a high likelihood of an abnormal baby. The drug has an effect only on the developing baby, not on eggs. There is no risk to pregnancies one month after stopping the medication. Isotretinoin has no effect on male sperm or male fertility. While women on the drug should not be pregnant, children fathered by those on Isotretinoin are not at any risk. There are other side effects that accompany the use of Isotretinoin. Two of these occur with everybody and appear within the first week of taking the medication. The first is general dryness of skin. This is due to a 50-80% reduction in oil production in the skin which leads to a drier scalp, face and skin everywhere else. The maximum anti-oil effect is achieved in four weeks. Many acne sufferers have a very oily complexion and in fact find this an advantage rather than a side effect. It may become so severe as to lead to dry, itchy, scaling skin. This can be easily controlled by moisturisers, which are usually applied once a day immediately after bathing. Provided these are non-Lanolin containing, e.g. QV Lotion, Cetaphil, it should not lead to a worsening of acne. Waxing is not recommended while on Isotretinoin. The second effect of the drug that appears on the first week is dry, peeling lips. This is due to the drug’s ability to accelerate turnover rate of skin, so that the skin renews itself too fast to form properly, leaving it more fragile and thinner. This causes dry, peeling lips. Unless lip moisturisers are used all the time, the lips become cracked and infected. The most commonly used moisturisers are Vaseline Lip Therapy, which can be found in supermarkets, or Lipsed Gel, Blistex and Elizabeth Arden 8 Hour Cream, which can be bought from a chemist. One of these agents should be applied first thing in the morning as soon as you awake, after any food, snack or drink, last thing at night and any other time in between that your lips become dry. In practise, this means that you need to carry the lip moisturiser with you. Other side effects occur with Isotretinoin, but do not effect everybody on the drug. Half the people on the drug experience some drying of the lining of the nose, giving you a feeling of just recovering from a cold. While this is an advantage to hayfever sufferers, in a very small number of people it may lead to cracking of the nasal lining and repeated minor nose bleeds. This can generally be controlled by squeezing the soft front part of the nose together for three minutes. This needs to be timed, as shorter squeezing of the nose will not be long enough for blood to clot. Regular application of Vaseline to the nasal mucosa on a twice-daily basis will usually be sufficient to avoid nose bleeds. A few people on the drug experience problems with their eyes. This is due to the tear film being made thinner by Isotretinoin, which leads to occasional drying out of eyes with red, sore and uncomfortable eyes. All patients on this drug should wear sunglasses outside whenever possible, as this protects the tear film from wind, dust etc. Swimming is best done with eye goggles. Should eye problems occur despite this, artificial tears such as Liquifilm Tears or Refresh Eye drops, two drops twice daily, will usually control the problem. Dryness of the eyes may be particularly difficult with contact lens users. As some contact lens may interact with some forms of artificial tears, altering their optics, contact lens supplies should be consulted as to what form of artificial tears to use. One in five people on the drug get aches and pains. These are very similar to everyday aches and pains or minor sports injuries. Some experience them after prolonged periods of rest and others after going beyond a certain level of exercise. While these are annoying, they are not a sign of destruction of joints or muscles and should be ignored. Exercise and sports can be continued. A few people on the drug can experience fluctuating fatigue and tiredness and even a flu-like feeling. This will subside once the course of medication is completed. Of more recent concern and highlighted in the media, both from published and open unreferenced internet postings, is the possibility of depression, mood disturbance and even psychotic episodes. It should be noted that no cause and effect relationship has ever been established between the use of this medication and these side effects. It is however very difficult scientifically to categorically refute such associations, but it should be noted that if one were to exist it would be extremely rare. This issue is pertinent as the group most frequently treated with this medication are a high risk group for such symptoms and disorders. Many of the problems that have arisen have occurred in patients also taking unsolicited drugs, thus it is important to inform us if you are using any recreational drugs, as this may have a bearing on your suitability as to whether to continue on Isotretinoin therapy. About one in twenty people are more sensitive to sunburn while on the drug and it is a good practise to use sunscreens if you are going skiing or are getting more than minimal midday summer sunlight exposure. Almost all sunscreens available now are non-acne promoting and anything with a sun protective factor of 30 or greater would be appropriate. You may notice your skin is more fragile and easily damaged while on Isotretinoin. Small cuts may need to be treated with a topical antiseptic cream such as Crystacide if they become infected or slow to heal. Washing once a week in an antiseptic wash can be helpful to prevent localised sores developing. If you develop redness, swelling or tenderness around the finger or toenails, please contact your dermatologist as you may require a course of antibiotics. Lastly, and most rarely, a few people on the drug experience minor upset of liver function or elevation of blood lipids. If this is allowed to become severe, they become quite unwell. For this reason, it is recommended that a blood test be done one to two months into the treatment to check that this abnormality is not occurring. If abnormalities in blood tests were to appear, they do so within the first month and therefore if the first test is normal, tests are not repeated unless the dose is increased. Please note: You are not allowed to donate blood while you are on this medication. Capsules are best taken with or after food. If taken on an empty stomach, the drug is not so well absorbed. We usually recommend that all capsules be taken together. If headaches occur as a consequence of taking the capsules together, the dose should be split. Even if your acne has cleared, it is still important that you complete the full course or Isotretinoin capsules recommended. If you discontinue the course earlier than instructed then it is much more likely that your acne will recur at a later date. If the full course instructed by your dermatologist is not taken, then you cannot expect the cures mentioned above. When having blood tests, please make sure that breakfast is avoided on that morning. Isotretinoin can be collected from any pharmacist.

If you are having problems or side effects you do not understand, or cannot control, phone us – it is much easier to sort these out early on. Isotane is a subsidised medicine only when a Special Authority number is provided by the Ministry of Health. Your dermatologist will apply for this number at your initial visit and it is required on all prescriptions for the duration of your treatment.