Isotretinoin

1. Introduction

Isotretinoin is a retinoid (vitamin A derivative) primarily used to treat severe acne that does not respond to other treatments, such as antibiotics or topical therapies. It works by reducing sebaceous gland activity, decreasing oil production, and preventing clogged pores and inflammation.

2. Indications

  • Approved Indications:
    • Severe nodular acne.
    • Acne unresponsive to conventional therapies (oral antibiotics, topical treatments).
  • Off-Label Uses:
    • Rosacea (severe refractory cases).
    • Seborrhoea.
    • Hidradenitis suppurativa.

3. Dosage

  • Adults and Adolescents (≥12 years):
    • Starting dose: 0.5 mg/kg/day in two divided doses.
    • Maintenance dose: 0.5–1 mg/kg/day.
    • Maximum dose: 2 mg/kg/day in severe cases (e.g., truncal acne).
    • Cumulative dose: 120–150 mg/kg over the treatment course (typically 16–24 weeks).
  • Elderly:
    • Start at the lower end of the dosing range, monitor for adverse effects.

4. Administration

  • Take orally with food to improve absorption.
  • Swallow capsules whole with water; do not chew or crush.

5. Forms Available

  • Capsules: 10 mg, 20 mg, 30 mg, 40 mg.

6. Side Effects

6.1. Common Side Effects

  • Dry skin, lips, and eyes.
  • Cheilitis (cracked lips).
  • Dry nose, leading to nosebleeds.
  • Mild headache.

6.2. Less Common Side Effects

  • Joint and muscle pain.
  • Temporary worsening of acne during the first few weeks.

6.3. Rare but Serious Side Effects

  • Depression, mood changes, or suicidal thoughts.
  • Severe skin reactions (e.g., Stevens-Johnson syndrome).
  • Elevated liver enzymes and lipid levels.
  • Pseudotumor cerebri (increased intracranial pressure).

7. Warnings

  • Teratogenicity: Isotretinoin can cause severe birth defects. It is absolutely contraindicated in pregnancy.
  • Psychiatric Effects: May cause depression, anxiety, or suicidal thoughts. Monitor closely for mood changes.
  • Liver and Lipid Monitoring: Can elevate liver enzymes and triglyceride levels.

8. Precautions

  • Avoid vitamin A supplements, as they can increase toxicity.
  • Avoid waxing, dermabrasion, or laser treatments during and for at least 6 months after treatment due to skin fragility.
  • Minimise sun exposure and use sunscreen, as isotretinoin increases sensitivity to UV light.

9. Interactions

  • Drug-Drug Interactions:
    • Tetracyclines: Increased risk of pseudotumor cerebri.
    • Vitamin A: Increased risk of toxicity.
    • Corticosteroids: May increase risk of osteoporosis.
  • Drug-Food Interactions:
    • High-fat meals enhance isotretinoin absorption.

10. Monitoring Parameters

  • Before Initiation:
    • Pregnancy test (for women of childbearing potential).
    • Liver function tests (LFTs).
    • Lipid profile.
  • During Treatment:
    • Monthly pregnancy tests (for women).
    • Periodic liver function tests and lipid profiles.
    • Monitor mood and mental health.

11. Use in Children

  • Approved for adolescents ≥12 years. Use is similar to adult dosing, adjusted for weight.

12. Use in Pregnancy

  • Category X: Contraindicated in pregnancy. Enrolment in a pregnancy prevention programme (e.g., iPLEDGE in the US) is mandatory for women of childbearing potential.

13. Use in Elderly

  • Safe for use but monitor for increased risk of joint pain and changes in lipid profile.

14. Use in Kidney Disease

  • No specific dose adjustments required in mild to moderate renal impairment, but monitor for adverse effects.

15. Use in Liver Disease

  • Avoid use in active liver disease or elevated baseline liver enzymes.

16. Patient Counselling Points

  • Take isotretinoin with food to enhance absorption.
  • Avoid pregnancy during treatment and for at least 1 month after stopping isotretinoin.
  • Use lip balm, moisturisers, and artificial tears to manage dryness.
  • Avoid alcohol consumption, as it may worsen liver effects.
  • Notify your doctor immediately if you experience severe mood changes, headache, or vision problems.
  • Attend all scheduled follow-ups, including blood tests.

17. Table of Brand Names, Manufacturers, and Prices

Brand NameManufacturerPrice (USD)
AccutaneRoche$250–350 (30 capsules, 40 mg)
RoaccutaneRoche$200–300 (30 capsules, 40 mg)
Generic IsotretinoinVarious manufacturers$50–150 (30 capsules, 40 mg)

18. FAQs (15 Questions)

  1. What is isotretinoin used for?
    It is used to treat severe acne that does not respond to other treatments.
  2. How does isotretinoin work?
    It reduces oil production from sebaceous glands, unclogs pores, and prevents inflammation.
  3. Can isotretinoin be used during pregnancy?
    No, isotretinoin is strictly contraindicated in pregnancy due to severe birth defects.
  4. How long does it take for isotretinoin to work?
    Most patients see improvement within 4–8 weeks, with full effects by the end of the treatment course (16–24 weeks).
  5. Can isotretinoin cause depression?
    Yes, it may cause mood changes, including depression. Report any symptoms to your doctor.
  6. Is isotretinoin a lifelong treatment?
    No, it is usually prescribed as a single course lasting 16–24 weeks.
  7. What should I avoid while taking isotretinoin?
    Avoid alcohol, excessive sun exposure, waxing, and vitamin A supplements.
  8. Can isotretinoin cause dry skin?
    Yes, dryness of the skin, lips, and eyes is a common side effect.
  9. How should I take isotretinoin?
    Take it with food, preferably a high-fat meal, to enhance absorption.
  10. Do I need blood tests during isotretinoin treatment?
    Yes, regular monitoring of liver function, lipid profile, and (for women) pregnancy tests is required.
  11. Can I wear makeup while taking isotretinoin?
    Yes, but use non-comedogenic products to avoid clogging pores.
  12. How soon can I get pregnant after stopping isotretinoin?
    Wait at least 1 month after stopping isotretinoin before trying to conceive.
  13. Can isotretinoin cause hair thinning?
    Rarely, isotretinoin may cause temporary hair thinning.
  14. What should I do if I miss a dose?
    Take it as soon as you remember, but skip it if it’s close to the next dose. Do not double up.
  15. Can isotretinoin be taken with antibiotics?
    Avoid tetracyclines during isotretinoin treatment due to the risk of increased intracranial pressure.