When I start oral isotretinoin, will my acne get worse before it gets better?

In some cases, there can be a flare of the acne in the first month after starting oral isotretinoin (sold under the trade name of Accutane, and its generics is known as Sotret or Amnesty). However, to avoid this from happening, we may start a short course of prednisone (i.e. a corticosteroid commonly used to treat inflammation) to minimize the inflammation and to avoid the flare that would accompany it.

In most cases, we should start at a lower dose and incrementally increase the dose over the first one to two months for us to get used to the drug.

What should I avoid while taking oral isotretinoin to treat my acne?

The following may come in handy:

1. Women should not get pregnant while taking oral isotretinoin or for at least one month after stopping oral isotretinoin to treat their acne.
   
   
2. Remember not to give blood while taking isotretinoin or for 1 month after stopping it. Studies show that those who are pregnant when exposed to your blood, her baby risks exposure to birth defects.
   
   
3. It is advisable to use 2 forms of contraceptive, i.e. oral contraceptive and a condom while on oral isotretinoin, this is to make sure pregnancy does not occur. Do note that birth control pills that do not contain estrogen (i.e. female sex hormone) may not work while we are on Accutane. Always check with the doctor where appropriate.
   
   
4. Do not take isotretinoin with other antibiotics unless after talking to our doctor.
   
   
5. Do not have cosmetic procedures to smooth our skin (which shall include waxing or laser procedures), while on isotretinoin or for 6 months after we stop.
   
   
6. Never breastfeed while taking isotretinoin or for 1 month after stopping the drug for treating our acne.
   
   
7. Try to avoid excessive sunlight and ultraviolet lights and tanning booths, because oral isotretinoin can make our skin more sensitive to ultraviolet light.
   
   
8. Let our doctor know what other drugs or herbal products that we are currently taking. This is important as some of these products may decrease the efficacy of our oral contraceptive and would have to be discontinued for the duration of our acne treatment and 1 month after.
   
   
9. Avoid vitamin A supplements as they will increase our chances of having side effects.

For other acne clear and acne care questions and soultions, we may want to refer this page here.

How many courses of oral isotretinoin can I take?

To minimize the risk of adverse long-term reactions that oral isotretinoin can have on our bones and other organ systems, we should follow the maximal lifetime dose of oral isotretinoin that is considered safe and appropriate.

In general, most people on a typical course of oral isotretinoin of 0.8 mg/kg for a 16 to 20 weeks’ course could do three treatment courses over their lifetime if necessary. However, the 0.8 mg/kg is considered as an average acne treatment dose, hence dose may be increased in order to get the desired acne treatment results.

Studies show that low-dose oral isotretinoin can still be very effective in some people. This not only minimizes the side effects but also allows us to use it intermittently, over time, as needed and with proper monitoring without concern of reaching the maximal dosage.

Good news is that many of the side effects caused by taking oral isotretinoin are dose related, what that means is that we may work along and within the dose limit given to achieve the desired acne treatment results, and to avoid and minimize those harmful side effects.

Can I have laser or cosmetic treatments, waxing, or other treatments done while I am on oral isotretinoin?

It is learnt that oral isotretinoin (sold under the trade name of Accutane, and its generics is known as Sotret or Amnesty) affects our skin cell turnover, which means that any surgery or laser resurfacing treatment, or even deeper chemical peels when done within 6 months of taking oral isotretinoin can lead to excessive scarring and disfigurement.

In fact, our skin is drier and more sensitive while on oral isotretinoin therapy, as such any treatment that potentially irritates the skin can be a problem. Hence, our skin may react more strongly to waxing or other hair removal methods too.

Nevertheless, with the advent of the newer lasers today, i.e. nonablative lasers, this is probably less of a risk today because they do not remove the upper layers of our skin. Still, many doctors prefer to wait for at least 6 months before doing any elective procedure, especially if it is for cosmetic purposes.

Laser or intense pulsed light hair removal is sometimes done while on oral isotretinoin, but we should be careful to have the procedure done by a qualified doctor and let the doctor know we are on oral isotretinoin.

What dose of isotretinoin is right for me?

As a matter of fact, the dose can vary and depend on our weight and the severity of our acne condition. The doctor will first determine how much we weigh in kilograms and prescribe the dose accordingly. The dose can range from 0.1 to 2 mg/kg, with the most common dose being 0.8 mg/kg/day and divided into two, i.e. morning and night. It is noted that oral isotretinoin is best absorbed and most effective when taken with food and when taken twice a day.

Usually, our doctor will start us on a lower dose for the first month or two so that we can acclimate to the side effects (at least to some extent), and then increase the dose for the rest of the 16 to 20 weeks severe acne treatment course. However, depending on the acne treatment results achieved and in some cases, higher doses for longer than 20 weeks may be required. Also, in some very severe cases of acne, oral prednisone (i.e. a corticosteroid commonly used to treat inflammation), will be given for a duration of 2 to 6 weeks, usually before oral isotretinoin acne treatment is begun.

We may want to know that before we start oral isotretinoin, we should have a detailed discussion with our doctor regarding any concerns that we may have about oral isotretinoin acne treatment, more so if we have any personal or family history of depression. The doctor will give us a booklet that the makers of oral isotretinoin provide; this is for us to review at home and to discuss with our family. Once we have made up our mind, we and our doctor must sign and date on several pages on our next visit. At this pre-oral isotretinoin visit, we are required to have our baseline blood tests, which will be repeated monthly while we are taking the drug.

If we are a woman, the doctor will also review pregnancy and contraceptive issues with us and make sure that we are not pregnant at the start of oral isotretinoin treatment. We have to aware that the risk of birth defects exists while the retinoid is in our body. Once the retinoid is cleared, usually 6 weeks after discontinuing oral isotretinoin acne therapy, there is no longer a risk. Also, patient information form and video are obtainable from the manufacturer to help us better understand on any contraceptive and pregnancy issues.

Why didn't oral isotretinoin work for me?

It is good to know that recurrence of acne is not uncommon after an oral isotretinoin course. However, some people are able to successfully retreated with oral and topical acne antibiotics, benzoyl peroxide, and topical retinoids, though a significant number may require retreatment with isotretinoin. A study conducted showed that, only 38% of patients had no acne at the 3-year follow-up after a single course of oral isotretinoin, while the remaining patients were able to control their acne with topical acne treatment, topical treatment plus oral acne antibiotics, or a retreatment with oral isotretinoin.

The study also showed that relapse was more likely to occur in patients who were 16 years old or younger and in women than in men, and that relapse is most common in the first year after treatment too. From the acne clear and acne care point of views, maintenance acne treatment such as with a topical retinoid may reduce the relapse rate.

What are the side effects of oral isotretinoin?

We may not know that oral isotretinoin is considered by many as a very controversial drug because of some of the side effects associated with it (in fact there are congressional hearings and attempts to take it off the market). On the other hand there are also many considered oral isotretinoin treatment to be life saving as no other drug available at this time that can actually treat and often clear those severe, scarring, and disfiguring acne.

Nevertheless, through proper counseling and monitoring, oral isotretinoin can really be a miracle cure for those with severe, scarring acne condition as well as help avoiding the worst side effects that might happen.

Potential Side Effects of Oral Isotretinoin

Common side effects:

1. Dry skin, dry eyes, chapped lips and dry mouth – it is noted that some new formulations of oral isotretinoin are less affected by food and also have fewer side effects in terms of dryness of skin, eyes, and mouth and less of a potential effect on our lipids;
2. Nosebleeds;
3. Muscle aches, backaches, and mild headaches usually at the start of oral isotretinoin therapy;
4. Skin fragility especially on the hands.

Uncommon or serious side effects:

1. Hypertriglyceridemia (liver function abnormalities) – studies show that this can be improved with continued administration of the drug or after oral isotretinoin was stopped; however, regular blood tests are still required to ensure our liver function as normal. What is important is that we should try to avoid drinking alcohol while on this acne therapy as oral isotretinoin is easily metabolized or digested by our liver;
2. Severe headaches;
3. Mood swings/depression/suicidal ideation – though this may be due to different reasons, should this happen, oral isotretinoin should be discontinued in these cases;
4. Pseudotumor cerebri (i.e. increased pressure build-up on the brain);
5. Bone changes (including osteoporosis) - typically found in patients on higher doses of the drug or in whom high doses are used over longer periods of time than usual. Example of this included loss of bone density, bone fractures or delayed healing;
6. Visual changes, e.g. decreased night vision, may last even after oral isotretinoin was stopped.

Most serious but avoidable:

Birth defects – it is very important for any woman who is of child-bearing potential who plans on taking isotretinoin to have two negative pregnancy tests before starting oral isotretinoin treatment and for at least 1 month after the therapy. Adequate contraception is essential, and the importance of this cannot be overstated before and during treatment, and for 4 weeks after discontinuing oral isotretinoin treatment. It is good to know that oral isotretinoin is a potent teratogen that is known to cause birth defects in children whose mothers get pregnant while taking oral isotretinoin or within 1 month after stopping isotretinoin. To know more about “should women continue topical or oral acne treatment while they are pregnant,” we may want to read here.

What is hormonal therapy? Do I need to have my hormones evaluated?

Hormonal therapy is an excellent option for women with acne (i.e. moderate to severe acne or in women with late-onset acne. To know more about different types of acne, please refer to this page), more so if oral contraception is also desired. In fact, hormonal therapy implies oral contraceptives, either alone or in conjunction with other hormone treatments for undesirable increased of hair growth on our face or other parts of our body, excessive hair loss from the scalp, irregular menstrual periods, and other conditions as well.

Generally, hormonal therapy is useful for women with endocrine abnormalities and for women who are nonresponsive to or unable to tolerate those conventional acne therapies, i.e. oral antibiotics, topical antibiotics, and retinoids along with benzoyl peroxide. Nevertheless, hormonal therapy is proven effective when used in conjunction with other antiacne therapies/conventional acne therapies (i.e. oral or topical acne antibiotics, topical retinoids, azelaic acid, salicylic acid, and benzoyl peroxide). For those with concerns about the reduced effectiveness of contraception when oral contraceptive pills are used in conjunction with oral acne antibiotics, recent evidence suggests that their effectiveness in contraception should not be reduced.

Studies show that hormonal therapies work best in adult women and sexually active teens with persistent, painful, deep, inflammatory papules and nodules, and often comedones on the forehead and chin, though the skin may or may not be oily in this case.

How hormonal therapy works to treat acne is to block the effects of androgens (i.e. a class of hormones that cause the sebaceous gland to enlarge and produce more serum, which is an important factor in the causation of acne) on our sebaceous gland (i.e. oil-producing glands located in the deeper layers of our skin, and are attached to the hair follicle and the oil can travel up to the surface of our skin. We may want to read here for the details of human skin structure) and the skin cells that are lining our pores. It accomplishes this with the use of estrogens (i.e. female sex hormone) or a class of drugs known as antiandrogens (i.e. androgen receptor blockers such as cyproterone acetate, chlomadinone acetate, desogestrel, drospirenone, flutamide and spironolactone) or by agents designed to reduce our body's production of androgens by the ovary or adrenal gland, example of this included oral contraceptives, low-dose glucocorticoids, cyproterone acetate, estrogens, or gonadotropin-releasing hormone agonists.

An evaluation of hormones done by an endocrinologist is usually required for women with acne who have proven resistant to conventional acne treatments or if there is a sudden, severe onset of acne. Other cases in which an endocrine evaluation is required:

• Women with acne who have irregular menstrual periods or increased hair growth in the face and abdomen (called hirsutism, which is generally caused by increased androgens, a common sign of polycystic ovary syndrome);
  
  
• Women who relapse shortly after oral isotretinoin therapy

Hormonal screening tests (such as DHEAS, total testosterone, free testosterone, luteinizing hormone/follicle-stimulating hormone ratio, prolactin, 17-hydroxyprogesterone) shall involve a physical exam by the doctor and a series of blood tests to measure specific levels of hormones in the blood that are timed to correlate with a certain phase of women menstrual cycle. These tests are designed to help us pinpoint the source of our increased androgen production so that appropriate therapy can be instituted. It is no surprise to know that though women with acne are more likely to have abnormalities in hormonal evaluations than women without acne, however, most women with acne who are evaluated for hormonal abnormalities have androgen levels that are within normal limits.

What is dermabrasion? Is it ideal for acne scars?

It is a process whereby the upper and middle layers of our skin are removed in order to improve our acne scarring condition. However, dermabrasion is ideal for people with the following skin types who have superficial acne scars:

Unexposed Skin Color	Tanning History
Ivory white, pale white White White Beige or lightly tanned	- Burns easily, never tans - Burns easily, tans minimally - Burns moderately, tans evenly - Burns minimally, tans easily

We have to take into account the healing time involved, and that local anesthetic is a must because dermabrasion is indeed a very painful experience.

If we have very deep, pitted acne scars then dermabrasion is not an ideal solution as the scars would end up deep and wide and would most likely be more obvious than before. In this case, the best acne skin care treatment for this type of acne scars is either we try to fill them with some temporary fillers, such as collagen (i.e. the main protein in connective tissue that is responsible for the elasticity of our skin and plays an important role in the development of scars) or Restylane, or with one of the more permanent fillers available on the market like Artecoll. Alternatively is to use a method called punch grafting, a technique that use a cookie-cutter type of blade to punch out the scar, and then followed by adding skin taken from another site to fill in the hole, and thereafter with dermabrasion to smooth the edges.

Are chemical peels safe?

From the acne clear and acne care perspective, it is safe if done properly and can be done along with a topical or oral acne regimen to achieve better acne treatment results.

In fact, chemical peels have become an increasingly popular option for us to treat acne and to minimize scarring from acne. There are several different solutions available for chemical peels, and each has its advantages and disadvantages.

Common peeling agents shall include α-hydroxy acids (or glycolic acid), salicylic acid, and trichloroacetic acid. Among them, salicylic acid which is fat soluble does have anti-inflammatory effects and may penetrate into those sebum-heavy follicles more easily than the water-soluble α-hydroxy acids. On top of that, there is usually more active peeling after a salicylic acid treatment than with glycolic acid. Hence, many consider salicylic acid as a very useful peeling agent in the treatment of acne.

As for trichloroacetic acid which can be used in strengths from 5% to approximately 20%, is generally a more active peeling agent for achieving a superficial peel. Because the strength of the peel does varies depending on how it is applied, and with the possibility of some risk of scarring associated with deeper penetration of trichloroacetic acid, as such this treatment should be done by a qualified dermatologist.

Light chemical peels is generally useful to help correct our surface scarring and hyperpigmentation (i.e. darkening of skin resulting from higher amounts of melanin in a particular spot). Although the light chemical peels do not penetrate beyond the upper layers of our skin, its light or superficial chemical peel may cause our skin to stay red for a few hours before returning to normal. It is considered unusual to have blisters or areas of bleeding after a superficial chemical peel and we should have no obvious peeling of the skin after the treatment.