madman
Super Moderator
Optimizing Isotretinoin Treatment of Acne: Update on Current Recommendations for Monitoring, Dosing, Safety, Adverse Effects, Compliance, and Outcomes
Megan N. Landis
Abstract
Acne vulgaris is the most common skin disease treated by dermatologists. It can be severe and result in permanent scars. Isotretinoin is the most effective treatment for acne and has the potential for long-term clearance. Prescribing and monitoring protocols can vary widely among prescribers. Recent studies, reports, and consensus statements help shed light on optimizing the use of isotretinoin for acne. A recent literature review is summarized in this article to help the practitioner optimize isotretinoin use for acne. The article outlines the advantages and disadvantages of standard, high-dose, and low-dose isotretinoin regimens; discusses the current status of controversies surrounding isotretinoin (including depression/suicide, pregnancy, and inflammatory bowel disease); reviews monitoring recommendations and treatment for hypertriglyceridemia and elevated transaminase levels; and discusses common adverse effects seen with isotretinoin, along with their treatment and prevention.
Key Points
Isotretinoin monitoring recommendations for otherwise healthy patients include the baseline lipid profile, and liver profile (including alanine aminotransferase and aspartate aminotransferase) at baseline and around month 2, or when peak daily dose is achieved. However, γ-glutamyltransferase may be more indicative of liver injury. Creatine kinase may be monitored in physically active patients.
High, low, and low intermittent dosing regimens have been reported to be well tolerated and with varying degrees of efficacy. The standard dosing regimen (achieving a cumulative dose of 120–150 mg/kg) is associated with some recurrences but there are limitations of previous studies. The current recommendation based on consensus is to treat until the acne is clear and continue for 1 more month. Patients with more severe disease may require higher cumulative doses.
Patient counseling, use of patient-independent contraception, and limiting the ‘use’ of abstinence to previously sexually inactive women only may decrease fetal exposure to isotretinoin.
2 Methods
3 Indications
4 Potential Adverse Effects and Their Management
4.1 Mucocutaneous Adverse Effects
4.2 Systemic Adverse Effects
4.3 Depression
4.4 Pregnancy
5 Laboratory Monitoring and Interpretation
6 Dosing
7 Surgical and Other Procedures
8 Post‑Treatment Prophylaxis
9 Conclusions
Isotretinoin is the most effective treatment currently available for acne. Patients who are good candidates for the treatment typically do very well and are extremely satisfied. While there are potential adverse effects, with close monitoring and good patient counseling these can be monitored for and can typically be easily managed.
Megan N. Landis
Abstract
Acne vulgaris is the most common skin disease treated by dermatologists. It can be severe and result in permanent scars. Isotretinoin is the most effective treatment for acne and has the potential for long-term clearance. Prescribing and monitoring protocols can vary widely among prescribers. Recent studies, reports, and consensus statements help shed light on optimizing the use of isotretinoin for acne. A recent literature review is summarized in this article to help the practitioner optimize isotretinoin use for acne. The article outlines the advantages and disadvantages of standard, high-dose, and low-dose isotretinoin regimens; discusses the current status of controversies surrounding isotretinoin (including depression/suicide, pregnancy, and inflammatory bowel disease); reviews monitoring recommendations and treatment for hypertriglyceridemia and elevated transaminase levels; and discusses common adverse effects seen with isotretinoin, along with their treatment and prevention.
Key Points
Isotretinoin monitoring recommendations for otherwise healthy patients include the baseline lipid profile, and liver profile (including alanine aminotransferase and aspartate aminotransferase) at baseline and around month 2, or when peak daily dose is achieved. However, γ-glutamyltransferase may be more indicative of liver injury. Creatine kinase may be monitored in physically active patients.
High, low, and low intermittent dosing regimens have been reported to be well tolerated and with varying degrees of efficacy. The standard dosing regimen (achieving a cumulative dose of 120–150 mg/kg) is associated with some recurrences but there are limitations of previous studies. The current recommendation based on consensus is to treat until the acne is clear and continue for 1 more month. Patients with more severe disease may require higher cumulative doses.
Patient counseling, use of patient-independent contraception, and limiting the ‘use’ of abstinence to previously sexually inactive women only may decrease fetal exposure to isotretinoin.
2 Methods
3 Indications
4 Potential Adverse Effects and Their Management
4.1 Mucocutaneous Adverse Effects
4.2 Systemic Adverse Effects
4.3 Depression
4.4 Pregnancy
5 Laboratory Monitoring and Interpretation
6 Dosing
7 Surgical and Other Procedures
8 Post‑Treatment Prophylaxis
9 Conclusions
Isotretinoin is the most effective treatment currently available for acne. Patients who are good candidates for the treatment typically do very well and are extremely satisfied. While there are potential adverse effects, with close monitoring and good patient counseling these can be monitored for and can typically be easily managed.
