Though there is no formal method for measuring hair loss whilst on isotretinoin, the following sensible steps may assist patients in monitoring their treatment. Early intervention provides the best outcomes.

1. Baseline photography. This gives an objective documentation of hair loss. Photography from the front. Include the frontal hairline, the temples on both sides. Photograph on the sides, then photograph the top. Part the hair in the middle. Take a photo of the part. This gives an objective measurement of hair density.
2. Ponytail measurements in females. Tie your hair in a ponytail (if possible), measure the circumference or the diameter. This gives an idea of density.
3. Counting the number of hairs lost in a day is not a good indicator of hair loss. Don’t bring a bag of hair to your dermatologist (unless they specifically ask you to – applies to cases of telogen or anagen effluvium). You will lose up to 150 -170 hairs a day, sometime more if your telogen cycle overlaps. If you count hairs, you will miss, or pull out more. This will give you anxiety, that may lead to telogen effluvium, which leads to more hair loss.

*Objective measurements are best. It does not matter how many hairs you shed, it is what the data of serial photos show that counts.  If you shed 200 a day, but regenerate 200, your next loss is zero. If you shed 60 but regenerate 10, your next loss is 50.

**If you have hair loss, flag this with your dermatologist early in the treatment. He or she will be keen to look at your photos (& pony tail circumference/diameter). Note: I am a procedural dermatologist. Though I may (seem) versed in medical management, I do not practice medical dermatology. The insights provided are common knowledge to all dermatologists, including your treating physician.

Patients on isotretinoin/Roaccutane may notice a deterioration in texture, thickness & hair quality. You may find your hair more difficult to style, more flyovers and frizz. Additionally, you may experience brittle hair that is more susceptible to breakage. These are early signs that may eventually lead to hair thinning. 

Reduced sebum (oil) from isotretinoin use may account for some of the changes to hair quality. Your scalp may be dry & flaky as this is a common side effect of isotretinoin.

There are no clear cut studies showing the benefits of Platelet Rich Plasma in the context of Accutane induced hair loss. Here are my thoughts-

1. Most cases of isotretinoin induced hair loss are self-limiting. This means the vast majority of cases will improve within 6 months. Hence PRP may give a false result.
2. A control study is difficult based upon the above. A large number of subjects need to be recruited for a statistically significant interpretation of the results.
3. A split scalp study is probably the best. This means half the scalp is treated with PRP injections & the other half not.
4. The above will not go through ethics approval (at least here in Australia). Possibly studies from China in the next few years will reveal the results.
5. Given the ease of application & the paucity of side effects, the use of PRP would be a sensible option for patients who are experiencing progressive hair fall and/or have plateaued at 4-6 months after ceasing Accutane. A sensible routine is monthly PRP for 3 consecutive months.

As with PRP the use of lasers including low level laser therapy & thulium 1927 laser would be sensible given the low side effects with either treatment.

Low level laser therapy uses light emitting diodes in the 600-1070nm range. They can work by stimulating the hair follicle. A sensible course of treatment is to have weekly sessions for 10 weeks then reassess.

Lasers including fractional thulium can treat many forms of alopecia, including androgenetic alopecia, alopecia areata & scarring alopecia. They work by stimulation of the hair follicle as well as indirect cytokine release from the epidermis. This laser can also be used to deliver growth factors into the scalp. The use of this wavelength would be sensible as an option for isotretinoin induced hair loss. The recommended number of treatments, as reflected in the studies, ranges from 8 to 12. Sessions are weekly.

Treatment depends on the diagnosis of hair loss. If the diagnosis is solely due to Accutane induced hair fall, no formal treatment is required, apart from hair care & supportive management. Supplementation with *B complex, folate, zinc, biotin, iron & minerals can be considered.

If there are other factors that contribute to hair loss, directed treatments are often initiated by your treating dermatologist. For example, if there is a contribution from androgenetic alopecia,  antihormone medications such as cyproterone acetate, spironolactone, finasteride, dutasteride etc. are prescribed.

What about minoxidil? This is a double-edged sword. Minoxidil can be useful in some cases (male or female pattern hair loss), however it may initially accelerate hair loss by ‘pushing out’ dormant follicles. This can result in rebound hair loss initially. You have to discuss this issue with your dermatologist. Additionally, topical formulations of minoxidil contain propylene glycol & ETOH, both can contribute to increased scalp dryness.

*Vitamin A supplementation is NOT recommended in cases of hair loss. RDi above 10,000 IU may contribute to more hair loss. Remember that Accutane – isotretinoin is a vitamin A derivative.

**Disclaimer: I do not see patients with hair loss. My work is procedural. For advice on hair loss, please consult a medical dermatologist, thank you for your understanding. Dr Davin Lim

Dermatologists think outside the box. In moderate to severe cases of hair loss, we need to exclude or confirm other associated factors that may either contribute to, or are co-incidental with the timeline of Roaccutane use. Your dermatologist will discuss and investigate in more detail. Simple blood tests & hair microscopy can be useful.

One of the most common associated causes is telogen effluvium. This is made worse by stressing about hair loss itself; and so continues the cycle. Telogen effluvium is commonly associated with emotional and/or physical stress. This includes trauma, (emotional & physical), crash dieting, extreme exercise & pregnancy (unlikely if you have been on isotretinoin). The cause of telogen effluvium is shedding of hair within the cycle of telogen (resting phase). This occurs 2-4 months after traumatic circumstances.

Androgenetic alopecia or male/female pattern hair loss is super common. The onset can be in the late teens (around the same time as acne & Accutane prescription). In some cases, mild androgenetic alopecia can compound isotretinoin induced hair loss. In others, Accutane is not the culprit but was coincidentally prescribed during the time of hair loss. ( Said another way, hair loss was inevitable but unfortunately Accutane was prescribed during the same time period of genetically programmed hair fall).

Scalp itch & dryness can lead to scratching with accelerated hair fall. If you experience significant dryness, simple olive oil can be helpful. Your dermatologist may prescribe you an anti-inflammatory lotion to use 2-3 nights per week.

Nutritional disorders are another cause of incidental hair loss. The most common is iron deficiency anemia. B12, biotin, & zinc deficiency are extremely rare.

Rare causes such as lichen planopilaris, discoid lupus, folliculitis de calvans, & trichotillomania can be excluded by your treating dermatologist.

You can take measures to reduce the chances of hair loss on this medication. One of the best ways to monitor hair loss is to take baseline photographs of your scalp prior to starting Accutane. Photograph the hairline (including the temples), sides, & the vertex or crown. You can part the hair in the midline as this gives a good indication of your baseline hair density. Remember, it is normal to lose between 100-150 strands of hair daily, so don’t stress.

1. Early communication with your dermatologist is the key. This is the most important step as early hair fall can be mitigated. Your treating dermatologist may reduce the dose of Accutane, or stop it altogether.
2. Use a good moisturizer/hair conditioner as hair care is super important. This will keep your hair moisturised & reduce breakages.
3. Limit drying your hair with a hair dryer as this can lead to hair shaft fragility.
4. Don’t bleach or color or dye your hair whilst on Accutane & for 2 months after stopping this medication. This increases fragility & can accentuate hair loss.
5. Brushing techniques include using a wide toothed comb or better still running your fingers through your hair.
6. Supplementation with B12, B complexes, Biotin, Iron. This is controversial. There are some reports that suggest isotretinoin can lower vitamin B levels. You can supplement this with foods such as avocado, bananas & broccoli, or simply pop a vitamin tablet.

Disclaimer: I am a procedural dermatologist. I do not manage hair loss medically. Discuss this issue with your treating physician or dermatologist. My work is procedural, namely I cut, inject, laser & peel.

Side effects are universally seen on Accutane, hence patients are carefully monitored. The most common side effects include-

• Dry lips & mucous membranes
• Sun sensitivity
• Dry skin & skin fragility including hair fragility
• Ingrown toenails
• Mood changes including depression
• Elevation of liver enzymes & cholesterol
• Headaches
• Joint aches & pains, muscle soreness

The majority of side effects can be mitigated with adjustment of Roaccutane/ Accutane dosage & proper care. Your dermatologist will be able to guide you accordingly.

The decision is yours, dermatologists merely guide you. The decision to continue or to cease is in your court.

Here is an insight as to how a dermatologist views who is a suitable candidate for isotretinoin / Accutane / Oratane. This is based upon my thought processes when I used to prescribe Accutane ( I do not prescribe now as my work is entirely procedural). Patient suitability is based upon a risk benefit ratio for that patient. We (I) consider suitability based upon-

• The likelihood of significant acne scarring. Factors such as truncal acne, cystic acne, family history of acne/scars, & picking are considered. The threshold to prescribe is lowered if scarring is an issue.
• Patterns of acne (as reflected by propensity to scar). Some forms of chronic acne, including acne excoriee & adult female jawline hormonal acne are more likely to scar.
• Previous non-pharmacological treatments by the patient. Dermatologists prescribe drugs. Has the patient tried & failed sensible non-pharmacological methods to address their acne. This includes, a super strict acne diet, good makeup practices, acne washes that include BHAs, OTC retinol, niacinamide, & others (see guide in the acne section of this website).
• Has the patient failed treatment with standard pharmacological treatments including adapalene, anti-inflammatory antibiotics, hormonal regulation etc ?
• What is the emotional impact of acne on the patient, balancing the risks vs benefits of prescription? This can get very complex as the patient may be motivated, but not motivated enough to practice non-pharm methods.
• The IQ & intelligence of the patient. This is not discussed much, but face it, everyone lies on a bell curve. Quick cats to the right, not so sharp tools on the left. If one has side effects to isotretinoin, the common sense approach is to stop. For example, if you are noticing changes such as mood swings, hair loss, sore joints etc. the majority of people would cease the medication. Obviously, the job of your treating dermatologist is to point out common side effects.

Disclaimer: I am a procedural dermatologist. I do not manage acne, I am not a pro Accutane lobbyist, nor am I against it. Discuss the treatment with your medical dermatologist.

Dermatologists utilize many anti-acne treatments, depending on the severity of acne, the impact it has on your life as well as individual factors. 

The most important concept to grasp is that you should try everything sanely possible to place your acne under control (or better still, remission). This includes a strict anti-acne diet, good skin practices (make up etc) as well as simple over the counter products like retinol, salicylic acid washes, niacinamide, benzoyl peroxide & even zinc supplementations. Give yourself 6 to 8 weeks to control your acne (take baseline photos as a guide).

Next step: See your GP. Treatments include topical retinoids like adapalene, trifarotene,  & tretinoin. Option for antibiotics & in females the OCP.

Next step: medical dermatologists. My colleagues prescribe medications, not fairy dust, so be prepared. It is highly recommended to try all the other fluff before seeing a dermo because chances are, they will not prescribe you tea tree oil, witch hazel or give you a gluten free diet to follow.  Sensible options include high strength salicylic acid peels, low level lasers with phototherapy, higher strength topical retinoids, anti-hormones & other medications. Our aim is to treat your acne in the fastest, safest possible way. Be guided by your dermatologist.

Disclaimer: I am a procedural dermatologist. I do not prescribe acne medications, nor do I get involved in your management. My job involves surgery, lasers, scary peels & complex injectables. For acne management, please see one of my nurses or my medical colleagues.

Discuss this with your treating dermatologist as they have your records. Dermatologists are all knowledgeable in the management of disorders of the skin, hair & nails.

If you would like a second opinion, book a consultation with my colleagues at Clinic Cutis.

Disclaimer: I am a procedural dermatologist. I do not treat hair loss medically. My job involves surgery, lasers, scary peels & complex injectables. For medical management of hair loss, please see one of my medical colleagues. Thank you, Davin Lim.