|Best Taken:AM or PM with food||Caution: Mood changes, pregnancy warning & others||Best for: Cystic or recalcitrant acne|
|Mode of action: Multiple, see below||Science Score: *****|
What is the science behind Accutane / Oratane?
Retinoids are one of the most powerful molecules in dermatology. This family of drugs can be applied as a cream (Tretinoin, Differin/ Adapalene, Zorac) or taken orally. The most well known oral medication is Accutane (in the US, disc.), Oratane (in Australia). The generic name is isotretinoin. In the context of acne, retinoids work by-
- Decreasing inflammation that leads to red pimples, pustules, papules & cysts.
- Decreasing bacteria counts responsible for pus, namely decreasing the numbers of bacteria named C.acnes.
- Reducing excessive oil production, also known as sebum.
- Reducing abnormal shedding of skin cells that can lead to blackheads & skin congestion.
Will my acne purge if I am on Accutane / Oratane?
Skin purging is frequently seen with oral isotretinoin as well as topical retinoids. Think of it as the medication pushing acne from within, much like a slow internal squeeze! Purging typically lasts 2-4 weeks, however in some cases can last up to or even longer than 6 months ! There are several ways your dermatologist can reduce this purge. This includes-
- Starting you on a very low dose of isotretinoin, say 5 to 10 mg for the first few weeks or months.
- Starting you with an anti inflammatory during or even before the course of Oratane / Accutane
- Using a pre-treatment peel prior to escalation. Frequently used peels pre or during treatment include salicylic acid or retinoic acid 1-3%
- Manual extraction of acne cysts, whitehead & blackheads
- Laser assisted cyst extraction for submarine comedones (probably the best solution)
- Reducing your dose of isotretinoin if you have a significant flare
- Direct injection of cysts with very dilute anti-inflammatories
Will one course of Oratane/Roaccutane cure my acne?
One course of oral isotretinoin also known as Roaccutane/Accutane/Oratane will place 60-70% of patients in remission. This means 30-40+% may require a second course. A course can be defined by a total cumulative dose based upon body weight; 120 to 150 mg/kg total dose. Additionally another benchmark is to be acne free for 8 to 12 weeks before cessation. Your goal post will depend on what journal papers your dermatologists read, or believe. There are predictive values that may place you in the 30-40% of patients that may require a further course of isotretinoin. This includes-
- A family history of severe acne
- Clinical findings including truncal acne/bacne, or severe cystic acne
- Hormonal changes including PCOS
- An incomplete previous course of medication
- Acne at an early age (<12-13 year old)
- Timing of intake (with food, better outcomes)
- BMI, smoking & other comorbidities may be related (conflicting literature)
- Ethnicities (relapse dependent on studied ethnicities)
- Rare derm conditions including FGF-1 gene mutations, RAR resistance
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What should I try prior to seeing a dermatologist for Accutane / Oratane?
You should consider all the lifestyle changes you can make prior to seeing a dermatologist. These include diet, skin care, cessation of smoking, de stressing & simple things such as taking makeup off before sleeping. Some or all of these factors can actually place your acne in remission. As a guide-
- Acne Diet; can work. Eat healthy, if it’s in a packet, it’s probably not acne friendly. Eat less processed food, eat more leafy greens, stay away from sugar & dairy products. If you are sensitive to gluten, don’t eat it.
- Supplement your diet with elemental zinc or zinc sulfate.
- Take your makeup off before sleeping. This will allow your skin to breathe.
Consider good acne targeted skin care products including retinol, adapalene, niacinamide, salicylic acid washes, benzoyl peroxide washes, & azelaic acid.
Where to from the above? Your general practitioner can discuss the role of topical retinoids as adapalene is not available in Australia. Hormone control with the OCP such as Diane, Estelle, Yaz, Yasmin, Juliette, or hormonal control with spironolactone or even cyproterone acetate. Anti-inflammatory antibiotics can be considered. So, when should you consult a medical dermatologist for acne? My guidelines are if you fail to respond to the above, including medical intervention from your GP &/or if you have scarring associated with acne.
Three important markers for acne scarring are-
- The time taken to effectively control your acne. This is very, very different from the time taken to see someone or to start medication. In some cases it can take years to control acne. This is most commonly seen when patients keep persisting to find a solution for chronic acne. Scarring can be seen within 4-10 weeks of some cases of acne.
- A family history of acne scars
- A history of habitual picking, also known as acne excoriee. Frequent squeezing or picking will lead to long term scarring.
Place careful consideration to the above, as acne scars can often take up to 12 months to treat. Treat & control acne early will prevent life long scarring.
*Disclaimer: I do not treat acne. My job is a procedural dermatologist. I cut, lase, peel, inject. If you have acne, please consult your dermatologist or ask to be referred to one of my colleagues @cutis_dermatology. This practice also offers acne treatments by qualified dermal therapists & nurses.
Will my dermatologist give me Accutane?
Good candidates for isotretinoin are people who have not had success with other acne medications & or you exhibit acne scars. Your dermatologist may prescribe medications such as topical creams, antibiotics or hormonal control if you have not already had a trial. Decision to go onto Accutane is made on a case to case basis. Other factors they take into consideration include-
- Pregnancy plans
- Contraception reliability
- Treatment success or failures with other anti-acne medications
- Family history of acne
- Extent of acne
- Type of acne
- Presence of scarring
- Lifestyle factors
- Emotional aspects
- Your ability to understand the risk benefit ratio of medications
How important is skin care during my course of Accutane / Oratane?
Probably the most important factor in determining how smooth your course of isotretinoin will be. 3 words- KEEP THINGS SIMPLE. This means-
Lips– moisturise 3-6 times a day, especially just before bed time.
Sunscreen– SPF 50+, applied 2-3 times a day, more if you are in the water,
Cleansers– Simple soap substitutes by Ego, La Roche, Cetaphil, Cerave
Moisturisers- Emollients: Ointment at night if your skin is super dry, creams & lotions during the daytime. Cetaphil, Cerave, Ego, Obagi Luxe, Hydrate & many more
Retinol, AHAs, BHAs, Ascorbic acid– put them aside during your course of Roaccutane as these products can increase skin irritation. You can recommence these actives one at a time two weeks after stopping your course of isotretinoin.
How long will I need to be on this drug?
In the context of acne treatment, the majority of patients are on this for 4 to 12 months, depending on the extent of acne, family history, flare ups, side effects, previous treatment cycles etc… Some patients are on a very low dose for a longer period of time. Your treating dermatologist will discuss your treatment plan including an expected end date.
Is Oratane / Accutane the only thing a dermatologist can do for my acne?
No. The flipside is that most dermatologists see the ‘pointy end’ of acne, namely patients who fail to respond to acne diets, salicylic acid washes, salicylic acid peels, topical retinol, niacinamide, tea tree oil, witch hazel, oral zinc, acne support vitamins, Omnilux Blue, Red, Kleresca, PDT, vascular laser, carbon Spectra Peels, oral & topical antibiotics, hormonal control, topical dapsone, azelaic acid, etc..etc..etc..
Dermatologists are well versed with all the above & may elect to treat acne conservatively. If you would like to treat your acne naturally, with oils, diet, meditation & not medication, consider seeing a naturopath. Most dermatologists approach acne based upon scientific papers. This does not mean we only prescribe drugs. Most of my colleagues offer non-drug methods to address acne including-
- Chemical peels: Incl AHA, BHA & retinoid peels
- LLED: Incl Blue, Red, Omnilux, Heallite
- Photodynamic Therapy / Kleresca: PDT with Blue or Red lights
- Lasers: Including VBeam Lasers, BBL with Blue Light, Carbon Peels
- Skin Care: Incl; OTC Retinol, Niacinamide, Azelaic acid
Be guided by your skin care specialist. If you would like to trial non-prescription methods to control your acne, please book in to see one of our dermal therapists or nurses @cutis_dermatology.
Will my acne come back if I stop the drug too soon?
We can only assess based upon probability. If you undertake one full course of isotretinoin, you have a sixty to seventy percent chance of long term remission. If you cut short your course of medication, your relapse rate will be in the range of thirty to seventy percent. This figure will depend on many factors including lifestyle changes, implementation of a sensible skin care regimen, family history of acne, exogenous factors such as diet, stress, hormonal changes & much, much more. Discuss your treatment plan with your skin specialist.
Does Accutane address acne scars?
Isotretinoin does not make acne scars or PIH (post inflammatory hyperpigmentation), or post inflammatory erythema (PIE) disappear. The role of this medication is to reduce & prevent formation of new acne lesions including blackheads, whiteheads, pustules, zits, cysts & excessive oil production.
If your scars improve, it is NOT directly because of Accutane, it is due to your body’s immune system repairing itself for the inflammatory response caused by acne. Note however there have been formal scientific studies showing that mild acne scars can respond to topical retinoids including Adapelene. I suspect that this is universally seen when any therapy reduces inflammation & modulates expression of TIMP/ tissue metalloproteinases. More research will be needed in the future.
Does Accutane cure hormonal acne?
A course of treatment can also be effective for hormonal acne, but dermatologists tend to save this option for those with severe, cystic acne, scarring acne or acne that does not respond to conventional treatments. Other treatments for hormonal acne include topical retinol/retinoids, as well as anti-hormone medication including spironolactone & cyproterone acetate.
Does Roaccutane affect your hair?
Yes. One of the most common effects of Roaccutane is suppressed oil or sebum production. This can be a plus if you are excessively greasy, however on the other hand Accutane can also cause changes to make the hair shaft more brittle. Most of the time, any hair loss is temporary, and the thin hair should start to thicken again with time. However, some people may notice a permanent change in their hair after taking isotretinoin.
Can you drink while on Accutane?
On record, alcohol consumption is not recommended whilst on Accutane. This is due to the added potential toxicity of both Accutane & ETOH to your liver. Off record, having a drink or two every week will not increase your risk. This needs to be discussed with your treating dermatologist.
What other skin conditions can Isotretinoin treat?
This drug is commonly used to treat a myriad of dermatological conditions including-
- Oily skin or seborrhoea
- Pre-cancerous cells including extensive sun damage
- Seborrheic dermatitis, extensive sebaceous hyperplasia
- Hidradenitis suppurativa
- Disorders of hair follicles
- Disorders of keratinisation
- Extensive viral warts
- Scarring hair disorders
- Super rare dermatological conditions
The indication of treatment will be determined by your treating dermatologist. Retinoids are powerful drugs, & careful consideration will be given to your condition, lifestyle, as well as previous treatment successes or failures. Other analogues of isotretinoin, including Acitretin, may be prescribed for common conditions such as psoriasis or extensive skin cancer.
Can I use my skin care products whilst I am on Oratane?
Depends. As this medication will make your skin more sensitive you should avoid most acids including ascorbic, retinoic, glycolic, lactic, mandelic & salicylic acids. You are however allowed to use hyaluronic acid. The most important aspect of skin care whilst on Oratane / Accutane is to form a close bond with sunscreen, a good moisturizer & lip balm. These three products will ensure your Accutane journey is smooth. You can restart your normal skincare routine within 2-4 weeks of stopping isotretinoin.
Can I use Retinol or Ascorbic Acid during my Accutane treatment?
The use of skin care acids during your course of treatment is not recommended. This is due to the fact that Accutane/Oratane can make your skin very dry & more sensitive to some ingredients such as retinol, glycolic, lactic, ascorbic & salicylic acids. In some cases there are added photosensitive reactions, especially when combining oral retinoids with topical retinol & glycolic acid. You can use hyaluronic acid & niacinamide as the irritation potential of these ingredients are low.
What is the average daily dose on Oratane?
Most acne patients are on 10 to 60 mg of isotretinoin daily (+/- 30%). The current prescription patterns are low dose for a longer period of time. This way side effects are less. Some dermatologists start you off at a very low dose (5 to 10 mg), then escalate to around 20-60 mg, before weaning you off this medication. Be guided by your dermatologist.
Patients who are treated for rosacea & oily skin, also known as seborrhoea are usually on a very low dose varying from 5 to 10 mg every few days.
How do I take my Accutane / Isotretinoin tablets?
As Accutane is a fat soluble vitamin, your dose should be taken with your heaviest meal. The highest absorption rate is when a wee bit of fat is consumed at the same time. For most patients it will be at dinner, however if your greatest caloric intake is breakfast, take Accutane at that time.
Can I get laser treatment on Oratane / Isotretinoin?
Yes. Based upon the recent JAMA guideline 2017, the majority of dermatological treatments can be performed on this medication with the exception of deep fully ablative laser resurfacing, & chemical peels. Note the findings show there is no INCREASED risk, not NO risk from laser treatments including-
- Hair removal lasers
- Acne scar lasers & EBDs including Fraxel, Fractional lasers, RF microneedling
- Vascular lasers to treat PIE
- Pigment lasers to address PIH
- Focal Deep Peels incl. TCA & phenol croton oil
The decision to undertake procedures is based upon your treating specialists comfort levels, experience & ability to understand evidence based medicine. Be guided by your specialist.
Should I get my acne scars treated when I am undergoing acne treatments?
Yes. There is good evidence that treating scars early will mitigate future long term scarring. Once inflammation from acne is controlled, your skin has the potential & ability of regenerating collagen & remodelling early mild to moderate scarring. Treatments such as RFM/ Fractional laser/ Nanofractional treatments/Pico/ Tixel & many more can reduce overall scarring during your course of Accutane/Roaccutane.
Even though there are numerous publications in the scientific literature, your dermatologist may elect NOT to perform procedures when you are on this medication. This reasoning will only be known by your prescribing physician.
@cutis_dermatology we treat early scars whilst patients are on Accutane with VBEAM Prima, Fractional CO2 & NA lasers, picolasers & Tixel.
What are the expected accutane side effects?
Expected & common accutane side effects are almost universally seen. They include the following-
Dry skin or xerosis: Most common in winter, usually on the face & arms
Solution: Moisturise 2-4 times a day. Soap substitutes, oil bath
Dry lips or cheilitis: Most common in higher doses & winter time
Solution: Moisturise lips 4-8 times daily, heavy coat before bedtime
Sun sensitivity: Commonly seen, especially in high UV index days
Solution: Hats, sunscreens
Skin purging: Common if you have cystic acne or submarine comedones
Solution: Go slow, extract, cover with anti-inflammatory meds. Easy solution.
Skin Sensitivity: To products that contain retinol, AHAs, BHAs, Ascorbic acid
Solution: Keep those products aside until your finish your course of Accutane
Now, have I addressed ALL the side effects of this medication? No, however the above is based upon probability & not what you MAY possibly experience. Read further for other rarer side effects.
What are the rarer serious accutane side effects?
Rare but important accutane side effects include-
- Birth defects– serious defects can be seen if the washout period is not one month.
- Sore joints & muscles. More common in elite athletes, often dose dependent.
- Elevated cholesterol levels, can be picked up on blood tests
- Elevated liver function levels, as above
- Bleeding nose, usually sorted with emollients
- Ingrown toenails, usually sorted with proper fitting shoes & dose decrease
- Hair loss, usually reversible if picked up early
- Inflammatory bowel disease
- Mood changes including depression or elevation, can’t be picked up with blood tests, very important that patient voices any changes to doctors & family members
- Neurological side effects (headaches, blurred vision)
It is important to understand the difference between rare side effects & all possible side effects. This webpage is not a PhD dissertation on all the historical including anecdotal side effects of isotretinoin, it is designed to provide a clinical unbiased overview on the prescription patterns, indications & clinically significant outcomes as well as the side effects on this medication. For a more in depth view on all the side effects, including rare ones like loss of night vision, osteoporosis, neutropenia, RB/LB heart block, & others, perform a PubMed search & base your decisions accordingly. I am not here to promote nor to discredit this medication. The decision to go on this medication is based upon a discussion with your medical dermatologist.
Are mood changes frequently seen on this medication?
Emotional changes are not uncommon on isotretinoin & include depression, anxiety, elevated & depressed mood. This is the MIMs warning, & hence regardless of our view point, it is important to discuss this issue with patients prior to prescription.
The risks of depression on isotretinoin have been explored with various studies, including a 2017 analysis published in the Journal of the American Academy of Dermatology. Researchers concluded that isotretinoin is not associated with an increased risk for depression. In fact treatment of acne seems to improve depressive symptoms.The flipside was that a 2012 meta-analysis published in the Journal of Clinical Psychiatry found that, while infrequent, there is a reported link between isotretinoin use and depression—and higher doses of the drug are linked with more psychiatric side effects.
The meta-analysis authors noted that isotretinoin studies are limited in their size and conducting a large trial brings up ethical questions when there is “adequate aggregate information supporting a causal role of isotretinoin in the development of depression in some individuals.” Study authors concluded that isotretinoin does not cause depression, but can increase a person’s risk of depression (especially if they’re predisposed to it). So who to believe? As a dermatologist I am going for the side of the psychiatrists (it much like doing a study on Botox for wrinkles & asking the psych to be involved).
In summary, for adults, one should consider the risk benefit ratio of isotretinoin including risks for depression, other mental health conditions along with other serious side effects of the drug both prior & during the course of treatment. As parents, if you are uncertain about what effect isotretinoin may have on your child, consult a psychologist or psychiatrist during their course of treatment. There is no blood test for mood changes, if you can not express how you feel, maybe oral isotretinoin is not for you.
I am not a pro-isotretinoin nor am I against this medication. I do not practice medical dermatology, however I do refer patients to my medical colleagues for an option on the managing recalcitrant acne. My view on treating acne, do everything you possibly can to stop physicians prescribing powerful medications with potentially bad side effects. If witch hazel or meditation works for your acne, then there is possibly one less isotretinoin debate-discussion needed by my colleagues.
Is there a cream form of this medication?
Yes. There are many ‘creams & gel’ formulations available. Retinoids come in many different molecules, from over the counter retinol, retinyl palmitate & retinaldehyde to first, second & third generation prescription retinoids. The decision to ‘try’ a cream or gel version of a retinoid first before considering oral retinoids are based upon many factors including the clinical examination & your acne history.
As a guide-
|Moderate skin |
Sun damage, wrinkles
|Second Generation |
|Indication: Acne, |
Acne scars (early)
|Third Generation |
|Tazarotene||Highest skin irritation||Acne, disorders of keratinisation|
Who do I see if I have side effects on Accutane - Oratane?
Discuss any issues with your treating dermatologist or general practitioner. Most dermatologists will schedule you for regular follow-up whilst you are on this medication. If you are experiencing any significant side effects, it may be sensible to stop this medication & seek advice from a medical practitioner.
*Disclaimer: I can not provide any advice both legally, ethically & personally. Any side effects your experience will need to be discussed with your treating physician. As mentioned, I am a procedural dermatologist, I do not treat medical conditions such as acne. This webpage is designed as a general guideline for patients after solid scientific based information.
How expensive is Accutane / Oratane?
In Australia this medication is subsidized by the PBS. Depending on if it is issued on a private or authority prescription, price ranges from $0.75 to $2.10 a day.
Davin’s ProTip on the use of Accutane
This drug is the most controversial medication for the treatment of acne. Side effects are almost universally seen, however in the vast majority of cases they can be sorted out with adequate action early in the course of treatment. Skin side effects such as dry lips, dry skin, sunburn can be mitigated with adequate care. Liver, blood count & cholesterol levels can be checked with regular screening. The most important side effect, namely mood changes can not be detected on a blood test. This is especailly important when treating teenages. Most dermatologists are mindful of this side effect. The decision to go on this powerful medication requires careful consideration. Most dermos view this as the last resort treatment for acne.
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