• Alopecia
• Acniform eruptions
• Benign tumors
• Bullous diseases
• Dermoscopy
• Nevi, melanoma
• Nonmelanoma cancer
• Psoriasis and others
• Stds
• Vascular tumors
• Vulvar disease

• Acne
• Acne Psychology and Approach to Patient
• Acne Cause and Pathophysiology
• Acne Lesions and Classification
• Blackhead and Whitehead Comedone Acne
• Acne Pimples - Papules and Pustules
• Acne Pimples - Papules and Pustules
• Cystic Acne Information
• Cystic Acne Cases and Acne Scars
• Acne Treatment - How Acne Medicine Works
• Acne Treatment with Topical Antibiotics
• Acne Treatment with Topical Retinoids Retin-A
• Acne Treatment with Oral Antibiotics Doxycycline
• Acne Treatment Antiandrogens and Birth Control Pills
• Acne Treatment with Accutane Isotretinoin Part 1
• Acne Treatment with Accutane Isotretinoin Part 2
• Perioral Dermatitis
• Perioral Dermatitis Information
• Perioral Dermatitis cases
• Perioral Dermatitis Treatment
• Rosacea
• Acne Rosacea Information
• Acne Rosacea Erythema Telangiectatic
• Acne Rosacea Papulopustular
• Acne Rosacea Nose Phymatous
• Acne Rosacea Eye Ocular
• Acne Rosacea Treatment
• Hidradenitis
• Hidradenitis Suppurativa Information
• Hidradenitis Suppurativa Cases
• Hidradenitis Suppurativa Treatment

Acne Treatment with Accutane Isotretinoin Part 1

Treatment with isotretinoin Part 1

Mechanisms of action, indications, treatment schedules, response,

retreatment

Oral isotretinoin or 13 cis-retinoic acid was introduced in 1982 as

Accutane by Roche Pharmaceuticals It is the most effective and reliable treatment for acne. Isotretinoin treatment results in complete clearing and prolonged remissions in most patients. Many patients are cured of their acne after a single course of treatment. There are now two generic brands of isotretinoin.Isotretinoin is typically prescribed for 16 to 20 weeks. Most patients are clear at the end of this treatment period and many remain in remission. The reason for this remission is not entirely understood.

Isotretinoin mechanisms of action

Sebum suppression

Hyperkeratinization reduction

P. acnes reduction

Decreased inflammation

The drug effects all four factors in the pathogenesis of acne. Sebum

production is profoundly reduced with a reduction in the range of 90%.

P. acnes numbers typically increase in the environment of excessive

sebum and abnormally shed follicular cells that occurs in acne

patients. P. acne numbers fall to very low levels as sebum production

is reduced by isotretinoin. Acne inflammation is generated by

proinflammatory substances produced by P. acnes. This P. acnes

chemotaxis-induced inflammation stops as the numbers of P. acnes drop during treatment. Sebum and P. acnes levels increase after treatment is discontinued.

Indications

The indications for use of isotretinoin have expanded after years of

treatment experience. Isotretinoin is first line therapy for severe

cystic acne. Conventional topical and antibiotic therapy is a waist of

time for patients with severe cystic acne. Delaying effective treatment

increase the chance for scarring.

Indications for Isotretinoin

Nodulocystic acne

Unresponsive severe inflammatory acne

Papulopustular acne with scarring

Treatment resistant acne

Relapse after a course of antibiotics

Persistent acne for years

Acne with severe psychological distress

Marked seborrhea

Gram-negative folliculitis

Severe acne rosacea

Hidradenitis suppurative

Acne excoriated

Sebaceous hyperplasia

Isotretinoin was originally indicated for patients with severe nodular

cystic acne. The next indication was for patients with severe

inflammatory acne who did not respond to conventional therapy.

Scarring is preventable. Examine closely to determine the patients

propensity to scar. Conventional treatment with topical preparations

and oral antibiotics may be appropriate for patients who are scarring

but treatment with isotretinoin should be started without delay if that

short course of conventional treatment fails.

Isotretinoin is used for patients who have suffered with acne for

years, or those whose acne flares when conventional therapy is tapered or stopped.

Patients with significant psychologic distress are not continued on

long programs of ineffective conventional treatment. Promising that

acne will be clear in 5 months provides immediate comfort.

Patients with very oily skin referred to as seborrhea are greatly

relieved by isotretinoin. These patients are sometimes treated with

very low doses for long periods of time.

Gram-negative folliculitis may follow long term treatment with

antibiotics. It is treated with ampicillin, co-trimoxazole, trimethoprim and will also clear isotretinoin.

Isotretinoin is an option for treating severe rosacea and hidradenitis

suppurativa. Rosacea may respond to doses as low as 10 mg/day. Acne excori?e in women may respond to isotretinoin.

Extensive sebaceous hyperplasia is disfiguring and responds rapidly to doses as low as 10 mg/day or 10 mg every other day and sometimes even lower doses.

Isotretinoin treatment schedules

Dosing at 1 mg/kg/day for 4 to 5 months results in the lowest rate of

relapse. Isotretinoin should be taken with a fat containing food. The

intensity of side effects increases with increasing dose. Start with

0.25 mg/kg/day or 0.5 mg/kg/day for the first 2 to 6 weeks. Increase

the dose to 1.0 mg/kg/day if side effects are minimal. Initiate

treatment with low doses for patients with severe cystic acne to

decrease the chance ot stimulating an explosive flare.

The minimum total dose is 120 mg/kg. The rate of recurrence increases when lower doses are used. Most experts continue treatment until a total of 150 mg/kg has been reached. Lower daily dose courses require longer treatment times to reach a total dose of 150 mg/kg. An 80 kg man would take isotretinoin 40 mg twice each day for 20 weeks to reach a total dose of 150 mg per kg.

Some patients flare with inflammatory acne during the first month of

therapy. Stop isotretinoin and start prednisone at 0.5-1.0 mg/kg/day.

An average of 1 to 3 months of prednisone is required to control

flares.

Response

A cumulative dose of 150 mg/kg results in 60% of patients requiring no

further treatment. Of those who experience a relapse, 21% respond to

topical therapy, 16% require oral antibiotics, and 40% require no

constant therapy. 23% of those who relapse require another course of

isotretinoin.

Retreatment

Some patients relapse months or years after treatment. These patients

may be treated with another course of isotretinoin with the same total

dose of 150 mg/kg. Up to 5 courses have been prescribed for difficult

patients by some experts. Women who flare may respond to spironolactone 100 to 200 mg/day and or oral contraceptives.