Isotretinoin (Roaccutane/Accutane)

What is Isotretinoin (Roaccutane / Accutane)?

How does Isotretinoin help acne?

• Inflamed (red) spots. Isotretinoin clears inflamed spots like red papules, pustules and nodules. Isotretinoin stops new inflamed spots from developing and causes existing inflamed spots to flatten and resolve.
• Cysts. Isotretinoin is good at reducing cysts that arise in acne.
• Comedones. Isotretinoin is also effective for comedones that may be open or closed. However, very large closed comedones might not clear with Isotretinoin and are best treated with hyfrecation before starting a course of Isotretinoin. Find out more about the hyfrecation of comedones.
• Greasiness. Isotretinoin reduces grease production in the skin and many people will notice their skin and hair become less shiny.

How does Isotretinoin work?

How effective is Isotretinoin for acne?

When is Isotretinoin used for acne?

Isotretinoin is used when

• Acne is very severe – such as nodular and cystic acne
• Acne is very extensive – such as extensive acne on the trunk
• Acne is causing scarring
• Acne is causing post-inflammatory hyperpigmentation
• Acne that does not clear with antibiotic treatment
• Hormonal acne that is difficult to treat with other means
• Acne that causes a lot of psychological distress

What is Isotretinoin not good for?

It is important to appreciate that there are limitations to Isotretinoin. Isotretinoin does not work for:

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• Scars. Isotretinoin does not work for scars. It also does not stop inflamed spots from causing scars either.
• Redness. Redness, where spots have healed, is extremely common with acne. This is called post-inflammatory erythema. Isotretinoin does not clear redness that is left by inflamed spots once they have flattened and the inflammation has gone. If post-inflammatory erythema is a concern then vascular laser treatment can be used while on Isotretinoin.
• Hyperpigmentation. Isotretinoin does not clear hyperpigmentation from acne.
• Pores. Isotretinoin will reduce pores while you are on treatment as it shrinks sebaceous glands, but the pores will return to their normal size within a few months of stopping Isotretinoin.

Does Isotretinoin cure acne for good?

• 1 in 3 can expect their acne not to come back
• 1 in 3 can expect their acne to come back at some point, but at a much milder level that can be controlled with topical treatments
• 1 in 3 can expect their acne to come back to a level that is similar to how it was before Isotretinoin

How does Isotretinoin cause long-term relief from acne?

How long will a course of Isotretinoin be?

• Your acne is slow to come under control
• We elect to stay on a low dose regime

Low dose Isotretinoin course

Personalised Isotretinoin dosing

Costs of Isotretinoin

• The cost of the medication will depend on the dose prescribed to you. This can range from £35 per month for those on a low dose to £135 per month for those on a higher dose. The cost of medicines will vary according to market forces at the time of your course.
• The cost of blood tests. A blood test is required before starting every time there is a dose change and every 2 or 3 months when there is no dose change. A blood test costs £95 per time though up-to-date prices will be provided at consultation.
• Follow-up consultations. These are charged at the prevailing rate and required monthly and can be remote or face to face. Prescriptions for women are 30 days in duration.
• Females of childbearing age will be required to carry out a urinary pregnancy test before and every 4 weeks during treatment and 4 weeks after the completion of treatment.
• For a typical 6 to 7-month conventional course, a cost estimate of between £1900 to £2700 is suggested. Please note this may vary and will fluctuate depending on individual circumstances.
• Please note there are additional costs of tests or specialist opinions in case these are required along the way. For example, you may be referred to a psychologist, psychiatrist, liver specialist, eye specialist or lipid specialist. You may require specialised eye assessments, ultrasound scans, blood tests etc. if you develop side effects or a complication of treatment.

How are blood tests for Isotretinoin done?

If you are unable to have tests and appointments on time

Side effects from Isotretinoin and how to keep them under control

Common side effects

• Dryness of the lips. This is the first side effect that is noticed. This can be managed by applying a lip balm every 2 or 3 hours (or more often if they become very dry) and avoiding licking the lips. Saliva makes the lips paradoxically more dry and prone to chaffing. Lip balms worth looking at are Vaseline, Blistex Intensive Moisturiser, Burt’s Beeswax Lip Balm and Dr Lipp’s Original Nipple Balm for lips. Other recommended products include O’Keeffe’s Lip Repair Balm, Carmex and Aquaphor Soothing Skin Balm.
• Dryness of the nose. This can cause itching and nose bleeds. Apply Vaseline or Aquaphor Soothing Skin Balm to the inside of the nose at least 3 times per day and more if they are very dry. If you suffer from dust allergy or hay fever that gives you an itchy nose anyway, then control this by minimising your exposure to dust and pollen, and taking an antihistamine daily.
• Dryness of the skin. You will need to stop all topical treatments for acne as your skin will become too sensitive to these while on Isotretinoin. Avoid using anything harsh on your skin such as soaps, gels, bubble baths, scrubs and loofas. Use a gentle soap substitute to was with such as Cerave Moisturising Lotion for Dry Skin, Cetaphil Lotion (note – not the cleanser, the lotion) or Dermol 500. While these products will not later or bubble, they will hydrate your skin as they cleanse. Use Dermol 500 to wash your hands unless your hands are visibly soiled or you need to wash them for virus prevention in which case you should use soap first then Dermol 500. You should also apply a non-comedogenic moisturiser three times per day. Use a light product in the daytime such as Cerave Moisturising Lotion for Dry Skin Cetaphil Lotion, Aveeno Lotion or Cerave Lotion, and a heavier product at night such as Epaderm Ointment or Cerave Moisturising Cream for Dry Skin. If your skin becomes very dry then you will need to use the heavier product in the day too. If you are seeking a Vegan product then consider Sukin Oil-Free Moisturiser.
• Dryness of the eyes and red eyes. Try to avoid wearing contact lenses and use artificial tears at least four times a day and more if required. Products to consider for regular use during the day are Thealoz Duo Eye drops or Visu XL drops and for nighttime use are Xailin Night lubricating eye ointment. If you are encountering persistent redness you should let your doctor know and you may need to be seen at a specialist eye clinic.
• Vaginal dryness. This can be improved by using vaginal hydrating products such as YES VM regularly – from once every three days to daily (or more) depending on the level of dryness.
• Aches and pains. Isotretinoin can cause stiffness, and aches and pains. Low back pain is particularly common. These are usually mild and can be managed with occasional Paracetamol use. If they are severe then let your doctor know. You will need to avoid strenuous exercise or starting fitness training for the first time while you are on Isotretinoin. Strenuous exercise includes weight lifting and intense cardio such as rowing for 30 mins. Intense exercise can cause muscle breakdown. If you are very athletic then plan to have Isotretinoin when out of season.
• Headaches. Mild headaches are very common at the start of a course of Isotretinoin. Severe headaches that are worse in the morning, associated with nausea and vomiting, and worse with coughing and sneezing is a rare side effect of Isotretinoin and means treatment must be stopped immediately, and a neurological review is required. Medications such as Doxycycline, Oxytetracycline and Lymecycline must be stopped before starting Isotretinoin to reduce the chance of this rare side effect.
• Severe damage to an unborn baby. Women can not get pregnant while on Isotretinoin or for one month after completing a course of Isotretinoin. This is because Isotretinoin causes severe birth defects and increases the risk of miscarriage. Women who are of childbearing age need to use one form of highly effective birth control such as the intra-uterine coil device or the hormonal implant, or 2 complementary forms of less effective birth control such as the pill and condoms. It is important to appreciate that even with these methods in place, there is a very small risk of pregnancy as any contraceptive method can fail. You should seek advice on contraception from your GP, a private gynaecologist or a private family planning clinic in order to ensure you are using appropriate methods before starting Isotretinoin.

Uncommon side effects

• Liver strain. Strain on the liver can be caused by Isotretinoin and if this occurs the medication needs to be reduced or stopped. This is why regular liver blood tests are required. Alcohol is also toxic to the liver and should be minimised to no more than 2 units per week for the course of Isotretinoin. If your liver blood tests are abnormal before starting Isotretinoin, you may be asked to see a liver specialist for an assessment.
• Elevated triglycerides. There are two main fats in the blood. Cholesterol and Triglycerides. Isotretinoin does not really affect the Cholesterol levels very much but it can raise triglyceride levels. If Triglyceride levels become very high then they may cause serious inflammation of the pancreas. This is why Triglyceride levels are tested before and during a course of Isotretinoin. Blood tests for Isotretinoin are done when fasting in order to be able to assess the Triglyceride levels properly. Fasting means nothing to eat or drink other than water or black tea or coffee for 8hrs before the blood test.
• Depression and self-harm. Overall, patients who take Isotretinoin feel happier at the end of a course because their acne is clear. However, very rarely, depression can be worsened, and suicidal ideas can occur with Isotretinoin such that suicide attempts and death by suicide have very rarely been reported. If you have a history of depression or bipolar disorder or have previously attempted suicide, you must see a Psychiatrist or Psychologist for assessment before being eligible for Isotretinoin and keep in touch with the mental health care professional during the treatment.You can find more more about psychological assessment for Isotretinoin here.It is best to let your close friends and family know you are starting Isotretinoin and to ask them to let you know if you appear different or low compared to your normal self. If you feel a lowering in mood or ideas of harming yourself on treatment, you should stop Isotretinoin straight away and let your GP know so you can be seen by a mental health professional.
• Decrease in nighttime vision. This is rare but if you notice this then stop Isotretinoin. You will need to see an Ophthalmologist for evaluation. If you are a pilot or plan to become a pilot then you should not take Isotretinoin as sometimes a decrease in nighttime vision can be permanent.
• Skeletal changes. If adults take Isotretinoin for more than two years continuously, there is a possibility they may be prone to calcification of tendons, causing stiffness. This has not been categorically proven though there are concerns.
• Sacroiliitis. While low back pain is very common on Isotretinoin, severe low back pain caused by inflammation in the sacroiliac joints can occur.
• Tendonitis. Isotretinoin can also cause inflammation of tendons leading to pain such in the Achilles tendon, the plantar fascia, and tendons around the knee and shoulder.
• Erectile dysfunction and reduced libido. There are rare reports of men having problems getting or maintaining an erection, and both men and women experiencing lower libido and decreased genital sensation. Some people have reported that the problems have continued after stopping treatment. If you have any sexual function problems, discuss this with your dermatology healthcare professional before taking isotretinoin.
• Gynaecomastia. In rare instances, men have reported to experience breast tissue enlargement.
• Inflammatory bowel disease. There are cases of Inflammatory Bowel Disease flaring and it is important you discuss this with your Dermatologist.

FAQs

When should I take Isotretinoin?

Should I take all my medication in one go?

What should I do if I miss a day by accident?

I have run out of Isotretinoin – what should I do?

I am not experiencing any side effects on Isotretinoin, is this normal?

Can I take vitamins and supplements with Isotretinoin?

How much alcohol am I allowed on Isotretinoin?

If I have depression, can I have a course of Isotretinoin?

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Many people who have depression have successfully taken a course of Isotretinoin.

You will be asked to have an Isotretinoin mental health assessment from an HCPC-registered practitioner psychologist or a GMC-registered Consultant Psychiatrist who is familiar with Isotretinoin to establish if it would be safe to proceed with this treatment.

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Your mental health practitioner should also be able to make arrangements for regular checkups and emergency plans for any change in mental health.

You can find more about psychological assessment for Isotretinoin here.

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