Fear vs Science
If you have been battling with acne, then chances are you’ve heard about Accutane. You no doubt have a lot of questions about the potential outcomes, risks and side effects, and with good reason: Accutane (also known as isotretinoin) is one of the most effective yet controversial treatments for clearing up chronic or severe acne. But just what is it? How does it work? Why is there so much fear surrounding it? And perhaps most importantly, should you use it? To answer all these questions and more, we asked two experts in their respective fields on skin health: dermatologist Dr. Carly Roman, MD, FAAD and master esthetician and President of Sapien Aesthetics, Stephanie Powers.
What is it and how does it work?
Stephanie Powers, LME: As a common treatment for severe acne, isotretinoin has long been hailed as a miracle drug for those with persistent skin issues. At its core, isotretinoin is a type of retinoid, a group of compounds derived from Vitamin A. Think tretinoin, but stronger and in a pill.
Its mechanism of action isn’t totally understood, but scientists think it work by targeting several different factors involved in the development of acne.
One of the key factors is that isotretinoin reduces the production of sebum, the oily substance that is produced by the skin’s sebaceous glands. Sebum is known to contribute to the development of acne by clogging pores and providing a favorable environment for the growth of acne-causing bacteria.
Isotretinoin also has anti-inflammatory properties, which can help to reduce the redness, swelling, and pain associated with acne. It is thought to do this by inhibiting the production of certain inflammatory molecules, such as leukotrienes and prostaglandins.
Another way that isotretinoin may work is by affecting the differentiation and proliferation of the cells that make up the lining of hair follicles. This can help to prevent the formation of new comedones, the plugged hair follicles that are characteristic of acne. Although scientists are still learning how it works, we all know that it works.
When do you prescribe isotretinoin to your patients?
Dr. Carly Roman: Isotretinoin has been traditionally reserved for severe nodulocystic acne but can also work well in any patient failing more conservative therapy. These therapies can include prescription topical medications, oral antibiotics, birth control pills, or spironolactone.
How effective is isotretinoin?
Stephanie Powers, LME: The remission rate after isotretinoin treatment varies depending on several factors, including the severity of the acne, the dose and duration of treatment, and individual patient factors. In general, studies have shown that isotretinoin is highly effective at achieving long-term remission of acne. One study published in the Journal of the American Academy of Dermatology found that 85% of patients achieved complete or near-complete clearance of acne after a single course of isotretinoin treatment, with a mean duration of remission of 10.9 months.
Another study published in the British Journal of Dermatology found that 95% of patients had sustained clearance of acne six months after completing a course of isotretinoin treatment, with a median duration of remission of 18 months.
It is important to note that acne can recur after isotretinoin treatment, and some patients may require additional courses of treatment to achieve and maintain remission.
When combined with lifestyle changes, proper skincare, and regular facials, patients experience the best outcomes.
Is isotretinoin dangerous?
Dr. Carly Roman: Isotretinoin is an oral medication that can be safely used to treat acne. There are a few situations in which this medication should be used cautiously.
A woman of childbearing age should not get pregnant during the isotretinoin course (average of a 6-month course) and one month after to not harm the developing fetus. The risks to a fetus exposed to isotretinoin are significant. Fifty percent of those exposed will have some defect including cardiac and bony abnormalities.
The other consideration is in those with a diagnosis of depression. It is not an absolute contraindication, and it can still be used if the depression is well managed and there is trust and open dialogue among the patient, dermatologist and treating psychiatrist.
Stephanie Powers, LME: Although isotretinoin, like all drugs, have risks and side effects, there are a lot of myths about its use and safety. One common myth is that isotretinoin causes inflammatory bowel disease (IBD). In reality, there is very weak scientific evidence linking the drug to IBD, but acne itself is linked with the condition. Similarly, many people believe that isotretinoin causes permanent liver damage, but studies have shown that any damage done to the liver is generally mild and reversible. Finally, while there have been reports of depression and suicide linked to isotretinoin, studies have not found any direct causation between the drug and these outcomes, and there is only a weak correlation. We have to consider the fact that acne itself is strongly linked to increased rates of depression, and isotretinoin helps improve acne dramatically for most patients. The benefits outweigh the risks for many people. Talk to your doctor about any concerns you may have, but don’t believe the hype on the internet. The evidence is clear: isotretinoin is safe and effective for everyone but fetuses.
What is the history of isotretinoin?
Stephanie Powers, LME: Isotretinoin, a powerful acne medication, has an interesting backstory that spans several decades. NIH’s Senior Investigator Gary Peck discovered, in the 1970s, that a powerful drug called isotretinoin (or 13-cis retinoic acid) was effective against treatment-resistant severe acne. Isotretinoin eventually gained FDA approval in 1982 and became commercially available under the brand name Accutane. While the drug has faced controversy and legal battles over the years, it remains an important tool in the fight against acne and its painful symptoms.
Approved by the FDA in 1982 under the brand name Accutane, and quickly became very popular due to its effectiveness. However, it also came with fear about potential side effects such as depression, IBS, liver damage and birth defects. In 2009, the brand name Accutane was discontinued in the US market due to generic alternatives becoming available. Today, isotretinoin is still prescribed for severe acne under various brand names and is highly regulated due to its history.
What are your thoughts about the perceived risk vs the evidence and data?
Dr. Carly Roman: The two major concerns regarding isotretinoin are the risk to a developing fetus and mental health concerns.
In patients with childbearing potential, it is important to either adhere to strict abstinence or use two separate forms of birth control to prevent unintended pregnancy. One may safely get pregnant one month after completing their isotretinoin course with no consequences to the fetus.
There is a proposed but highly debated potential association with isotretinoin and depression and suicide. Systemic reviews and meta-analyses have concluded that the data is inadequate to establish a causal relationship. Some literature suggests that mood symptoms improve while on the medication as their acne improves as does self-image.
Would you take isotretinoin yourself?
Dr. Carly Roman: Yes! I have a thorough understanding of the risks and benefits and believe in the right person it can be a game changer. It is the closest option we have to a ‘cure’ for acne. Even if there is acne recurrence in the future, the severity is dramatically reduced. I’ve had patients refer periods of their life as ‘pre-accutane’ and ‘post-accutane’ because it was such a defining and life improving treatment.
Stephanie Powers, LME: Not only would I, but I have under the care of Dr. Carly Roman! Acne is a chronic inflammatory skin condition that is hard to manage, and isotretinoin is as close to a cure as I can get.
What is iPledge?
Stephanie Powers, LME: The iPLEDGE program, which was implemented in 2006 to prevent pregnancy and birth defects caused by the drug Accutane, has been met with controversy due to its gender based discrimination. Under the program, women of childbearing age must undergo monthly pregnancy testing as well as a questionnaire, and adhere to strict contraceptive measures while taking the medication regardless of whether they are sexually active or not. With the government monitoring the sex lives of women without any proof of the efficacy of this program, iPledge has been widely criticized. It is evident that the iPLEDGE program, while well-intentioned, is in dire need of reform in order to address these issues of sexism and inefficacy.
What can I do to manage the side effects?
Stephanie Powers, LME: Some of the most common side effects of isotretinoin include dry skin, chapped lips, dry eyes, and nosebleeds. Patients can use a variety of moisturizers and lip balms to combat dry skin and chapped lips, and your Dermatologist or esthetician can help you find the right one for you. Eye drops can relieve dry eyes, and nasal saline sprays can relieve nosebleeds, as well as sleeping with a humidifier (game changer!). Awareness of potential side effects can help patients make an informed decision about whether or not Accutane is the right treatment for their acne.
What would you like to say to people considering isotretinoin for their acne?
Dr. Carly Roman: Talk to your dermatologist about it. Be upfront with any of your concerns regarding side effects. Most of my patients do great with the medication and experience only the cutaneous side effects (skin and lip dryness) and mild achiness after exercise. Be open with family members or roommates about being on the medication so that if they note any concerns, they can bring it to your attention, and you can notify your care team.
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MD, FAAD
Dr. Roman is a board certified dermatologist originally from the Midwest. She grew up in Michigan and Ohio, which is where she completed her undergraduate and medical school education. She started her westward journey by moving to Chicago and completed her internship and dermatology residency at the University of Chicago. During her training, her interests in acne and women’s health led to authoring several papers and a book chapter on the topic. Within dermatology, her interests include acne, rosacea, hair loss, psoriasis, women’s skin health, Botox and cosmetics. She recently relocated to the Pacific Northwest to join the Modern Dermatology family. In her free time, she can with her young family and pup!
LME & OWNER OF SAPIEN AESTHETICS
Stephanie is a certified Mast Esthetician in the state of Washington, and the President of Sapien Aesthetics and Sapien Skin and Beauty, a med spa in Seattle. She moved to Seattle for esthetics school, and after 13 years she has built a following with her results-driven treatments, straightforward approach, meticulous practices and a deep commitment to serving her clients. She specializes in medical aesthetics providing treatments and customized plan to her clients. She loves art, science, psychology and is a curious creature to her core. She stepped into the role as a business owner when she opened Sapien Aesthetics in 2017, and has been determined to solve the problems ever since, both for her clients and employees. Stephanie is a lifelong nerd and continually seeks the best science, information, mentors, skills and tools in order to serve to the clients she adores.
When she’s not at work you can find her wandering around the city, hitting up local parks and museums along the way
Huang YC, Cheng YC. Isotretinoin treatment for acne and risk of depression: A systematic review and meta-analysis. J Am Acad Dermatol. 2017 Jun;76(6):1068-1076.e9. doi: 10.1016/j.jaad.2016.12.028. Epub 2017 Mar 11. Erratum in: J Am Acad Dermatol. 2017 Nov 14;: PMID: 28291553.
Lee, Stephanie Y.a; Jamal, Mohammad M.c; Nguyen, Emily T.b; Bechtold, Matthew L.d; Nguyen, Douglas L.a,c. Does exposure to isotretinoin increase the risk for the development of inflammatory bowel disease? A meta-analysis. European Journal of Gastroenterology & Hepatology 28(2):p 210-216, February 2016. | DOI: 10.1097/MEG.0000000000000496
Ben-Shoshan D, Gomolin A, Litvinov IV, Netchiporouk E. Time to Change Guidelines for Laboratory Monitoring During Isotretinoin Treatment. Journal of Cutaneous Medicine and Surgery. 2020;24(1):92-93. doi:10.1177/1203475419879882
Kovitwanichkanont T, Driscoll T. A comparative review of the isotretinoin pregnancy risk management programs across four continents. Int J Dermatol. 2018 Sep;57(9):1035-1046. doi: 10.1111/ijd.13950. Epub 2018 Mar 6. PMID: 29508918.
