• 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 2

Isotretinoin treatment Part 2: Relapse, side effects, monitoring,

depression

Risk factors for relapse are:

Young teenagers

Back and chest acne

Sinus tract lesions

Excess granulation tissue

Androgen excess

There are several risk factors for recurrence. Patients with a high probability of relapse or failure with isotretinoin have been identified. Young teenagers with nodulocystic acne will clear with isotretinoin therapy but the chance of recurrence within 2 years is high. They may require 2 to 4 courses of therapy to maintain a durable remission. Patients with acne of the chest and back relapse more frequently.

Patients who form epithelial sinus tracts have a poor response to

therapy. These linear cystic structures extend with time as they

propagate through the dermis. Isotretinoin and intralesional steroids

may clear the lesions but surgical excision is often required.

Female patients with androgen excess states present with acne. They

relapse within 6 months of stopping isotretinoin. Oral contraceptives

and spironolactone are appropriate treatments.

Women with high abdominal fat content called android obesity have

waist circumferences greater than 80 cm and waist-to-hip ratios greater than 0.8. They look like Humpty-Dumpty with large upper bodies, flat buttocks and thin legs. They have a high incidence of diabetes, increased triglycerides and uterine cancer.

Side Effects

Teratogenicity

Increased cholesterol and triglyceride

Dry lips and nose bleeds

Dry skin and eczema

Contact lens users

Headaches

Bone pain

Granulation tissue formation

The potential to cause major fetal abnormalities is the major side

effect of isotretinoin therapy. Woman who are pregnant or breast

feeding do not take the drug. Isotretinoin is prescribed only by

physicians who have registered with the drug manufacturer. A detailed

manufacture created system for pregnancy prevention is an important

part of the treatment experience.

Increased cholesterol and triglycerides are a common problem. People

who develop hypertriglyceridemia during isotretinoin therapy are at

increased risk for future hyperlipidemia. Triglycerides and cholesterol

levels are measured each month.

All patients experience dry lips. Nose bleeds are more common in patients with a past history of nasal bleeding. Lotions and petrolatum

based lubricants applied to the lips inserted into the nose helps.

Dry skin and eczema commonly occurs in the winter especially in

atopics. Contact lens users may experience dry eyes and need to use

artificial tears or wear glasses. Headaches are uncommon but can be

severe. Pseudotumor cerebri has been reported.

Musculoskeletal symptoms are common in athletes. Bone pain, muscle and tendon injuries can occur.

Some lesions are unstable, break down. bleed and crust. Early treatment with high doses of isotretinoin can stimulate granulation tissue that leads to the development of pyogenic granuloma-like lesions.

Initial treatment consists of cool wet compresses, topical and or oral

steroids. Start with very low doses of isotretinoin 0.1 mg/kg/day and

increase slowly to 0.5 mg/kg. Explosive, highly inflammatory cystic

acne is treated with oral steroids. Isotretinoin is started only after

inflammation has been controlled.

Abnormal liver function test are rare. Skeletal hyperostosis of

apparently no consequence are sometimes seen on radiographs.

Monitoring

A pre-treatment CBC, fasting triglyceride, LFTs and pregnancy tests

are obtained and repeated 4 weeks later. Triglyceride tests are

repeated until the response to isotretinoin is established. Monthly

pregnancy testing should continue until 1 month after cessation.

The Depression Controversy

To date, no causal relationship between isotretinoin and psychiatric

adverse events has been established. A review of the existing

literature concluded that there was no evidence to support a causal

connection of the drug to depression or suicide. Adverse Drug Reaction reports suggest that depression and suicide or suicide attempt rates are well below those of the general population. As their skin improves, isotretinoin patients" moods also tend to improve, rather than the opposite.