Accutane

Accutane, also known as isotretinoin, is a much loved and much hated medication for treating acne. This is an interesting medication from a dermatologist's perspective because almost every patient with acne has thought about this medication and has some idea of where s/he stands on it.

Some patients with minimal acne come in asking for it right away and other patients dealing with painful nodules and cysts on the face, back, and chest refuse to even consider isotretinoin.

Dermatologists disagree about when isotretinoin should be given to patients, and because of the registry system known as iPLEDGE, some dermatologists do not use it at all. That being said, most agree that for scarring, cystic acne it is the drug of choice. I also like using it for patients who have tried multiple other medications without success.

Lately, isotretinoin has come under fire for its side effects, and for some reason the media and the public latch onto the side effects of certain medications more than others. Isotretinoin is in the former category of course.

The side effects of many medications, including over-the-counter medications like ibuprofen can be scary. Most people are shocked to learn that very rarely people take the prescribed doses of seemingly benign medications—like ibuprofen, for example—and die. (See a list of ibuprofen adverse reactions here for illustration.)

With that preface, what are the side effects of isotretinoin?I tell patients they definitely will get dry eyes, dry mouth, and dry noses. I ask about headaches, bowel problems, suicidal thoughts and depression, as there is some evidence that isotretinoin can make these worse. Finally, patients cannot get pregnant while on the medication or within a month after stopping the medication. I do not allow any women to take isotretinoin without also taking oral contraceptives, even if the patient practices abstinence, for many reasons including the fact that the contraception will likely help her acne. I also follow the outline of the iPLEDGE program and get a written consent from patients after they review the pamphlet (available here).

That is the formal procedure, but I also have some strong feelings about isotretinoin's side effects that I believe are supported by the dermatology literature. Personally, thought I find the evidence that isotretinoin causes depression and suicide shaky at best. There is more evidence that severe acne causes suicide. Likewise, the inflammatory bowel disease that has been linked (albeit loosely) to isotretinoin may be part of a syndrome in patients with severe acne since you can also find a loose association of oral acne antibiotic use and inflammatory bowel disease.

The truth will hopefully pan out in the upcoming years as more studies are released. The truth about isotretinoin is that there are real and potentially serious side effects, just like with any medication. However, my patients who had severe, scarring, and recalcitrant acne, who are now cured would not take back their choice to take isotretinoin for the world.