Acne and Rosacea Charity Training Manual

Oral Isotretinoin
Oral isotretinoin is the most powerful drug we have for the treatment of acne. It reduces sebum production by up to 90%, normalizes keratinocyte growth so clears
follicular hyper-cornification, kills P acnes and has powerful anti-inflammatory effects. It thus is the only drug that targets the 4 principal pathological changes in
acne.
It is generally started at a dose of 0.5mg/kg/day for the first month and then increased to 1mg/kg/day until the skin is clear. Early studies showed that a cumulative
dose of 120mg/kg i.e. 1mg/kg/day for 4 months, reduced the risk of recurrence after stopping the drug. This had led to the misconception that the drug should only
be used for 4 months which is wrong. It should be used for at least 4 months even if the skin is clear, but should be used until the skin is totally clear of spots, which
in some patients may be 9 months or more.
In some patients, there can be a flare of acne in the first month of treatment, and if patients have particularly inflammatory acne, it is often started with a course of
systemic prednisolone or systemic antibiotics for the first month.
Isotretinoin is potentially hepatotoxic and can elevated serum triglycerides. It is also diabetogenic. Baseline blood tests must be performed on all patients and
repeated every month – these include:
• Full blood count
• Electrolytes and urea
• Liver function tests
• Fasting lipids and glucose
If liver functions are abnormal, the drug should be avoided. If lipids are high, patients should be put onto a low-fat diet and the fasting lipids carefully monitored.
Oral isotretinoin is a potent teratogen and women of childbearing age should be warned that they cannot get pregnant while on the drug or for 1 month after
stopping. An EU directive means that women of childbearing age can only be prescribed 4 weeks treatment at a time and must have a negative pregnancy test
before a further prescription can be given.
Symptomatic side effects are universal and all patients should be warned about them:
1. Cheilitis which may be severe- lip balms and Vaseline
2. Dry skin which may become eczematised – lots of moisturisers
3. Dry eyes may occur – avoid the use of contact lenses and use artificial tears
4. Myalgia and arthropathy –if these occur reduce exercise
5. Nose bleeds – apply Vaseline to nares
6. Photosenisitivity – occurs in about 25% of patients and can be severe and SPF 50+
sunblocks should be used
Severe cheilitis in a patient on Roaccutane
Rare or unusual side effects