Trigger warning: This article discusses suicide.
A pimple can easily feel like the end of the world, especially if it’s big, painful, red, and you get the picture. For those of us with the occasional breakouts or smatterings of blemishes across our faces and bodies, topical acne products, antibiotics, or birth control usually do the trick to clear them. But for people with excessive amounts of pimples, visible redness, and deep-rooted cysts, dermatologists may suggest isotretinoin, popularly known by the now-discontinued brand name Accutane.
The name alone may raise eyebrows: Isotretinoin can cause serious congenital disabilities and has been associated with an increased risk of suicide and depression. So we asked three top dermatologists our burning questions: How does Accutane work? Who should take it? And how much should you worry about the side effects?
Ahead, experts break down exactly how isotretinoin works and all the need-to-know details.
Meet the Expert
- Onyeka Obioha, MD, FAAD, is a Los Angeles–based medical and cosmetic dermatologist. She practices at Cedars-Sinai Medical Center.
- Hadley King, MD, FAAD, is a cosmetic and medical dermatologist based in New York City. She is also the clinical instructor of dermatology at the Weill Medical College of Cornell University.
- Elizabeth Tanzi, MD, FAAD, is a dermatologist in Washington, D.C. She is the founder and director of Capital Laser & Skin Care.
What Is Isotretinoin?
What Is Isotretinoin?
Isotretinoin is an oral prescription medication derived from vitamin A that's used to treat moderate-to-severe acne. Formerly known as Accutane, you may also know isotretinoin by the brand names Amnesteem, Sotret, Claravis, Absorica, Myorisa, and Zenatane.
Isotretinoin is the closest thing to a “cure” for acne. Although it's not unheard of for acne patients to need multiple courses of isotretinoin, about half of patients who take just one course of the med never need acne treatment again. The American Osteopathic College of Dermatology says of isotretinoin, “There is nothing else in the world that comes close to being this effective for severe acne.”
“Accutane can be a life-changing medication for people who suffer from severe acne," King affirms.
"It’s the gold standard for treating severe nodulocystic acne," Obioha adds. "I use it a lot [on my patients] because it’s the best medication for cystic acne."
There are plenty of other prescription medications for treating pimples—like topical medications and oral antibiotics—but they don't work as well as isotretinoin does against severe cystic acne, Obioha insists.
"For deep cystic lesions, topicals aren’t able to penetrate as deep down into the oil glands to be effective," she advises. "Oral antibiotics can be effective for this type of acne but are not a good long-term treatment option due to the concern for antibiotic resistance."
Spironolactone is a great option for treating hormonal acne in women, she says—but not all cystic acne is hormonal, and it's a no-go for guys. (Spironolactone causes breast growth in men).
When other acne medications fail to deliver for acne patients, derms often look to isotretinoin, Obioha explains. "I also commonly use isotretinoin for patients who don’t have severe cystic acne but have moderate acne that has not responded to topical or other oral medications."
How Does It Work?
“One of the main effects acne has on the body is in the sebaceous glands of the skin," Tanzi explains. People with deep, inflamed acne may have excess sebum in their skin, a symptom that isotretinoin targets. "[Isotretinoin] reduces sebum production and makes the pores less ‘sticky’ so they don’t get clogged," she says.
When pores aren't clogged with sebum, they're "less likely to be colonized by the acne-causing bacteria Propionibacterium acnes," Obioha adds. By depriving this bacteria of a moist, comfy place to grow, isotretinoin prevents new blemishes from forming and calms active zits, too.
Isotretinoin is usually taken daily for about four to six months, but it's a gift that keeps on giving long after you stop taking it. Isotretinoin not only reduces sebum production while you're on the medication, it curbs your sebum output forever. "[It] changes your oil glands for the long term, making you less likely to break out in the future when you’re off of the medication," Obioha explains.
If that's music to your ears, Obioha agrees. She calls isotretinoin "magical," especially for patients at risk of scarring. "If cystic acne goes untreated, it can leave lifelong scarring even after the acne breakouts stop, which is very difficult and expensive to treat," she says. "Thus, for my new patients who present with severe cystic acne, I initiate the discussion about starting isotretinoin at the first consult."
What Are the Side Effects?
There are quite a few potential side effects of isotretinoin—but the operative word here is potential.
Dry skin and chapped lips are practically a given since isotretinoin stops your skin's oil production. "The most common side effect is dryness—dry skin and chapped lips," Obioha explains. "The dryness is actually how we as dermatologists know the medication is being absorbed."
One study showed that a whopping 100 percent of isotretinoin patients experienced cheilitis (inflamed, cracked lips), and roughly 66 percent complained of dry skin. Isotretinoin also makes skin more sensitive to sun exposure, so sunscreen is an absolute must.
"Other common side effects include elevations in blood lipid levels," she adds. Crappy news for needle-phobes: People taking isotretinoin need regular blood testing to monitor their blood lipid levels and liver function. That's because people taking isotretinoin often show liver test abnormalities, although lasting damage to the liver is very, very rare.
Common complaints from isotretinoin users are dermatitis, facial redness, nose bleeds, dry eyes, and mucositis, which involves swelling, pain, and sores in the mouth and digestive tract. Joint pain and muscle aches affect about 15% of isotretinoin patients. Some rarer side effects include night blindness, rashes, headaches, hair loss, and worsening asthma symptoms in people who are already asthmatic.
Whether isotretinoin causes inflammatory bowel disease has been debated. Still, research suggests IBD is either a very unusual side effect of isotretinoin use or somehow linked to having severe acne.
The potential isotretinoin side effects that have grabbed the most headlines are psychiatric. Isotretinoin's link to suicide and depression has sounded major alarm bells in the medical community, yet no one can say for sure that the med causes people to become depressed or suicidal.
"The relationship between isotretinoin and depression/suicide is not completely clear," Obioha explains. Just having severe acne makes you more likely to become depressed and suicidal, she points out. "The potential relation is something to be aware of and counsel patients about."
Having a history of depression doesn't mean you're uninvited to the isotretinoin party, Obioha says. But if you want to take the medication, be sure to seek support for your mental health.
"In a patient with a history of depression, it’s important that the patient has a multidisciplinary team monitoring the patient’s mood," she says. "This team should consist of the patient’s dermatologist, family members, psychiatrist and/or therapist, and primary care physician."
What Is the iPledge Program?
If you want a prescription for isotretinoin and are physically capable of getting pregnant, your derm is bound to bring up the iPledge program.
"iPledge is a risk management program for isotretinoin," Obioha explains. "It is designed to prevent pregnancy and other potential adverse effects while taking the medication," since isotretinoin can cause devastating congenital disabilities.
Patients, providers, and pharmacists all enroll in the iPledge registry in order to take, prescribe, and dispense isotretinoin, respectively. iPledge requires isotretinoin patients of childbearing potential to use two—yes, two—forms of contraception while taking their meds. If you're sexually inactive, that's considered a form of birth control under the iPledge program; nevertheless, you're still required to use a second contraceptive method even if you swear up and down you're celibate.
Also, patients in the iPledge program have to repeatedly prove they're not pregnant to get their prescriptions. They have to submit two negative pregnancy tests to their doctors one month apart before even starting isotretinoin, then continue submitting negative pregnancy tests each month after that.
In other words, physicians don't play around when it comes to preventing pregnancy in isotretinoin patients, and neither should users.
Should You Take Isotretinoin?
If you have moderate-to-severe acne that isn't chilling out with OTC treatments and other prescription meds, isotretinoin may have the potential to transform your skin for good. Schedule a thorough chat with a dermatologist to learn more about the side effects and find out if this med is a good fit for you.
American Osteopathic College of Dermatology. Accutane.
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