Acne Treatment with Accutane Isotretinoin Part 2
Isotretinoin treatment Part 2: Relapse, side effects, monitoring,
Risk factors for relapse are:
Back and chest acne
Sinus tract lesions
Excess granulation tissue
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 contraceptivesand 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.
Increased cholesterol and triglyceride
Dry lips and nose bleeds
Dry skin and eczema
Contact lens users
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.
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.