MAUI, HAWAII — Treating severe acne with isotretinoin comes with several important considerations, two experts told Maui Derm attendees.
“I have fairly opiniated conclusions about dosing this incredibly effective drug,” said James Leyden, MD, emeritus professor of dermatology at Penn Medicine and a co-author on some of the first studies on isotretinoin.
A clinician unaffiliated with the presentation previously reported that systemic isotretinoin remains the most efficacious treatment for severe acne and cases of more moderate disease when other treatment options fail.
Leyden said clinicians should never start with a dose of isotretinoin higher than 0.5 mg/kg two times a day. He provided a simple algorithm for considering isotretinoin:
All patients should start severe acne treatment with benzoyl peroxide and a retinoid and be monitored for 3 to 4 months.
Treating severe acne with isotretinoin comes with several important considerations, two experts told Maui Derm attendees.
Females who do not respond to this treatment should receive 100 mg to 200 mg of spironolactone daily, oral contraceptives and the highest dose of isotretinoin that they can tolerate without adverse events.
Males who do not respond should receive the highest dose of isotretinoin that they can tolerate.
Guy Webster, MD, PhD, clinical professor of dermatology at Thomas Jefferson University in Philadelphia, said that in the rare instances when isotretinoin is not working, the prescribing clinician should consider increasing the dose and/or asking patients about treatment adherence.
“It is really uncommon for this drug not to respond,” he added. “But when it does happen, consider that the patient may be taking competing medications like diphenylhydantoin.”
Webster also warned of rare adverse events that have been tied to isotretinoin’s use, including flareups of inflammatory bowel disease, pediatric cases of sacroiliitis and muscle flaps during muscle surgery.
Leyden noted that some patients who use isotretinoin may experience behavioral health changes, adding that “we don’t know who these people are that experience mood changes until it happens.”
He said patients in their late teens may not need long-term doses of isotretinoin.
“We looked at data from 30,000 patients treated with isotretinoin that we could track down 1 year later,” Leyden said. “Only 3,000 patients went back on isotretinoin. These results fit into the natural history of the disease... that acne eventually fades into the sunset.” – by Janel Miller
Layton A. Dermatoendocrinol. 2009;doi:10.4161/derm.1.3.9364.
Leyden J. Isotretinoin dosing. Presented at: Maui Derm for Dermatologists; Jan. 25-29, 2020; Maui, Hawaii.
Webster G. Isotretinoin. Presented at Maui Derm for Dermatologists; Jan. 25-29, 2020; Maui Hawaii.
Disclosure: Webster reports professional relationships with 10 companies.. Healio Primary Care could not confirm Leyden’s relevant financial disclosures at the time of publication.