Isotretinoin update

Abstract

Background Acne is a common, chronic inflammatory condition seen in nearly all teenagers and many adult females, with a global lifetime prevalence between 70‐85%. While a majority of individuals with acne can be appropriately managed with a combination of topical therapies, oral antibiotics, and/or oral anti‐androgens, 10‐20% of individuals will have acne severe enough to warrant isotretinoin. When necessary, isotretinoin is highly effective and the only drug to offer the likelihood of a durable response. Aims To review the literature regarding known adverse effects of isotretinoin therapy and nuances during and post‐isotretinoin therapy important to patient care. Materials and Methods A literature search was conducted for original, English‐language case reports, case series, original studies and/or meta‐analyses published between 1982‐2021 on isotretinoin, related adverse effects, and laboratory assessment and treatment nuances during and after a course of isotretinoin. Results Adverse events categories include mucocutaneous (e.g., xerosis, cheilitis, epistaxis), ocular (xerophthalmia, nyctalopia, blepharitis, conjunctivitis), non‐specific gastrointestinal, musculoskeletal (myalgia, pre‐mature epiphyseal plate closure, DISH), neurologic (idiopathic intracranial hypertension, hearing loss, tinnitus). Most adverse events are mild, self‐limiting, and/or resolve with drug discontinuation. Teratogenicity is of utmost concern especially given the risk of patient nonadherence to iPLEDGE precautions. Laboratory testing at baseline and after month 2 of therapy or upon reaching maximum daily dose may be sufficient. Utilizing creatine kinase and gamma‐glutamyl transferase in lieu of aspartate aminotransferase and alanine aminotransferase may better assess hepatic function during treatment. Improved formulations of isotretinoin may improve absorption and decrease reliance on patient adherence to a high‐fat diet. Dermabrasion and fully ablative laser procedures should be avoided in the immediate post‐isotretinoin period. Discussion Although adverse events associated with isotretinoin therapy are common, a majority of side effects are limited, self‐resolving (with completion of treatment course) without long‐term implications, and/or easily managed. Unfortunately, the advent of the internet and social media has given a platform to misleading law‐firm claims and medical pseudoscience inaccuracies that may frighten patients in need of treatment, ultimately delaying or even preventing therapy. Conclusion It is important that physicians are knowledgeable about the nuances of isotretinoin therapy, including efficacy, real potential adverse events, and appropriate laboratory monitoring. By honing this expertise, physicians may confidently counsel and guide patients through a course of isotretinoin to achieve a more permanent solution for their acne and improve their quality of life.

Efficacy and Safety of Micronized Isotretinoin Administered Once Daily Without Food in Patients With Recalcitrant Nodular Acne

“…18 The improved bioavailability, lower required daily dose, and lack of dietary requirements with micronized isotretinoin provide more dosing flexibility, and this formulation therefore exhibits greater potential to improve treatment adherence. 19 The findings of this pilot study support future investigation of the efficacy and safety of once-daily micronized isotretinoin as an effective and practical treatment regimen in patients with severe recalcitrant nodular AV. In addition, the lack of dependence on the administration of each dose with a high-fat meal removes the need for the clinician and their staff to educate the patient on specific dietary requirements when taking isotretinoin, which saves time during office visits.…”

Use of isotretinoin among girls and women of childbearing age and occurrence of isotretinoin-exposed pregnancies in Germany: A population-based study

“…Another potential reason could be an increased awareness of antibiotic resistance related to the antibiotic stewardship programs launched during the past decade [ 27 ]. Considering recommendations from experts, regulatory authorities, and the WHO to shorten and reduce the number of treatment episodes with antibiotics, the threshold to proceed to second-line treatment with systemic isotretinoin might have become lower when treating acne patients [ 3 , 28 ].…”

“…Systemic (oral) treatment with the vitamin A derivative isotretinoin (13-cis-retinoic acid) is indicated in moderate to severe acne (e.g., nodular or conglobate acne or acne at risk of permanent scarring) resistant to therapy with systemic antibiotics and topical anti-acne treatment [ 1 ]. Systemic isotretinoin is considered to be the clinically most effective anti-acne therapy, achieving long-term remission or significant improvement in many patients [ 2 , 3 ]. At the same time, isotretinoin is one of the strongest human teratogens known today [ 4 ].…”

“…Girls and women initiating systemic isotretinoin treatment are required to have monthly pregnancy tests and to use 2 complementary contraceptive methods from 1 month before treatment initiation to 1 month after treatment cessation [ 5 ]. The continuation of contraception for 1 month after treatment cessation is recommended due to delayed plasma elimination [ 3 ]. Because of this delayed elimination, pregnancies beginning shortly after treatment with isotretinoin may also be exposed to potentially harmful plasma concentrations.…”

Truncal Acne: An Overview

“…A recent systematic review also estimated the prevalence of acne to range from 20% to 95% [2]. Of note, the global lifetime prevalence of acne is estimated to be 70-85% [3]. Despite its high prevalence, truncal acne has been neglected by many clinicians and patients.…”