The use of isotretinoin in acne

Figures & data

Table 1 Recommendations in the European Directive

	Pre-Directive	Post-directive
Dosage	0.5–1.0 mg/kg/day	Start 0.5 mg/kg.day
Indications for use	Isotretinoin recommended as first line therapy for severe acne (nodular and conglobata) as well as acne not responding to 3 months systemic antibiotics in combination with topical	The new recommendations suggest isotretinoin should only be used in severe acne (nodular, conglobata) that has or is not responding to appropriate antibiotics and topical therapy. The inference of this being that it should now not be used at all as first-line therapy.
Age	Previously no age limit	Not indicated in children <12 years
Monitoring	Liver enzymes and lipids should be checked before treatment and 1 month after the maximum dosage has been used	Baseline investigations as before but at 1 month and 3 monthly through out the course of treatment
Physical treatments	It was recommended that chemical and physical peeling should be avoided during treatment and for 6 months afterwards and that wax depilation should be avoided during and 6 weeks post-therapy.	All forms of peeling and wax depilation should be avoided during therapy and 6 months afterwards.
Pregnancy prevention programme	See text on PPP

Table 2 Prognostic factors which should influence the early use of isotretinoin

• Family History

• Early onset

• Hyperseborrhoea

• Truncal acne

• Scarring

• Psychosocial difficulties

• Persistent or late onset acne

Table 3 Isotretinoin dose schedules that may be most appropriate for patients with significant systemic disease

(1) Protocol A standard regimen	(2) Protocol B initially half the standard regimen	(3) Protocol C once-a-week regimen with gradual dose increase
Crohn’s disease	Chronic renal failure	Behçet’s syndrome
Diabetes mellitus	Renal dialysis	Cerebellar spongiform encephalopathy
Epilepsy	Hypertriglyceridaemia purpura	Idiopathic thrombocytopenic
Spina bifida	Immunosuppression	Leukaemia
Ulcerative colitis	Manic depressive psychosis	Mitochondrial degeneration
	Myalgic encephalopathy	Paroxysmal nocturnal haemoglobinuria
	Motor neurone disease	Polymyalgia rheumatica
	Multiple sclerosis

Table 4 Most common mucocutaneous problems that may arise from isotretinoin use

Adverse effect	Incidence up to
Cheilitis	98%
Conjunctivitis/blepharitis	35%
Dermatitis	65%
Desquamation	20%
Facial erythema	65%
Epistaxis	35%
Epidermal atrophy	25%
Fragility of skin	20%
Hair loss	5%
Itching	25%
Mucositis	40%
Vestibulitis	50%
Xerosis	50%

Table 5 Less common but recognized side effects of isotretinoin

• Achilles tendonitis

• Acne fulminans

• Depression

• Diarrhoea/colitis

• Headaches/benign intracranial hypertension

• High-tone deafness

• Mood changes

• Night blindness

• Paronychia

• Pyogenic granulomas

• Sticky palms

• Urticaria

• Vasculitis