Oral isotretinoin for acne

Oral isotretinoin is the treatment of choice for acne that is severe and cystic or scarring. It can also be used when acne is resistant to other treatments, persistently relapses, or has a marked negative emotional and social effect on the patient. A typical oral isotretinoin course is 6 to 9 months, which achieves prolonged remission in most patients. Some patients may need more than one course or a more prolonged course at a lower dose.

Oral isotretinoin is a potent teratogen, and must be managed by experts—at the time of writing, Australian State and Territory law restricts prescribing to specialists and dermatologists¹. Before isotretinoin therapy, all patients must test negative for pregnancy. Patients must avoid pregnancy during therapy and for one reproductive cycle after therapy has finished. It is recommended that patients use two effective methods of contraception (eg combined oral contraceptive pill and a barrier method) for at least one cycle before starting oral isotretinoin, throughout isotretinoin therapy, and for one cycle after stopping therapy. Oral progestogen-only contraceptives are considered unsuitable as contraception for patients on isotretinoin therapy.

Oral isotretinoin must not be taken with tetracyclines, because of the rare occurrence of benign intracranial hypertension when combined.

Adverse effects of oral isotretinoin are dose-related. Most patients develop dry lips. Dryness of other parts of the body is common, particularly of the eyes and the mucosal lining of the nose. Many of these adverse effects diminish during treatment and cease within weeks of stopping the drug. If adverse effects are distressing, liaise with the treating dermatologist.

The link between oral isotretinoin and depression or suicide has not been proven. A recent review suggests an association of the use of isotretinoin in patients with acne with significantly improved depression symptoms; however, more randomised controlled studies are required²Li, 2019. Studies have found that when a patient is taking oral isotretinoin, their mood and wellbeing usually improve as the acne improves. A history of depression is not a contraindication to the use of oral isotretinoin, and patients can be treated for depression and acne at the same time.