Acne Management with Isotretinoin

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Oral isotretinoin is a retinoid used for severe or scarring acne and for acne that has not responded to other treatment. In Australia it is generally initiated and supervised by a dermatologist, and GPs most often meet it as the doctor who co-manages the patient. This post covers the questions GPs are asked most often.

What are the side effects of isotretinoin and how can GPs help manage them?

Common

  • Dry lips, in nearly all patients: moisturiser or lip balm.
  • Dry skin, including eczema on the backs of the hands and arms: moisturiser.
  • Photosensitivity: take care in summer and use extra sunscreen.
  • Some patients have an initial flare of their acne early in treatment.

Less common

  • Muscle aches and pains.
  • Headaches.
  • Mood change and depression. The link is controversial, but ask about it at every review.

Pregnancy is an absolute contraindication, because isotretinoin is teratogenic. Women need reliable contraception from one month before treatment until one month after it ends, a recent negative pregnancy test before starting, and regular pregnancy tests during treatment.

Are there any problems with stopping isotretinoin suddenly?

There is no known withdrawal problem. The drug and its metabolites are not stored in the body and are largely eliminated within about a week of stopping. Contraception and the ban on blood donation still continue for one month after the last dose.

How long is a patient usually on isotretinoin?

  • Australian courses usually run for 5 to 8 months, to a total dose of about 120 mg/kg.
  • Relapse is more likely if treatment stops early.
  • Severe acne, especially on the body, may need uninterrupted treatment for up to 12 months.

What should a patient expect after isotretinoin is stopped?

  • Benefit often lasts for years, but the skin becomes oily again and a little acne may come back, especially in patients who started young. It is usually not as bad as before treatment.

Is any blood test monitoring required?

  • Check liver function tests and fasting lipids (cholesterol and triglycerides) before starting and again during the course. Australian Prescriber advises investigating liver enzymes that rise above 2.5 times normal.
  • Some dermatologists test monthly. At the lower doses used today, problems are unlikely except in patients with pre-existing disease, so test earlier and more often if there is a family history of high cholesterol or a risk factor for hepatitis B.
  • Pregnancy tests in women of childbearing potential are part of the safety plan (see above).

Take-home messages for the GP

  • Ask about mood and how the patient is coping.
  • Ask about side effects.
  • Avoid tetracyclines (doxycycline, minocycline). Both drug classes can raise intracranial pressure, so the combination is not used.
  • The patient should not donate blood during treatment or for one month afterwards.
  • Isotretinoin is related to vitamin A. Ask about vitamin A supplements.

References