What is Accutane?
Accutane is a molecule that is very similar to Vitamin A in that it is a ring-like structure. Its primary mechanism of action is to reduce the size of the oil-producing sebaceous glands in the skin to almost imperceptible levels so that it oil secretion, clogging and inflammation due to not result in acne. No sebaceous glands = no acne. However, we can remove sebaceous glands from skin, so Accutane or isotretinoin is the next best thing. Considered the gold standard in the treatment of acne, there are two indications for its use.
The first indication is cystic scarring acne.
The second indication is acne that is refractory to all other traditional therapy.
When a patient is prescribed Accutane properly, it is dosed by weight and considered a cumulative or additive effect. Typically treatment courses last 5-6 months, and it is dosed twice daily with food. The “with food” is important because this medication is better absorbed by the body with consumption of food. Specifically, it is best absorbed with consumption of fatty foods. I recommend patients take their pill twice daily with some type of fat–nuts, cheese, avocado, meats or fatty fish such as tuna or salmon.
Once a patient begins treatment, the first month is typically the worst month because it is a new experience to the patient. I caution patients in this first month, they may worsen before they improve, but they should press on with their treatment as it WILL WORK. The thing that we know about this drug, is that it works every time. The question we do not know is “what patients required more than one course of Accutane?” Normal expectations include dry, chapped lips. This is an indication that the drug is properly dosed. Additional side effects can be dry eyes or dry nasal mucosa. If this is the case, symptomatic treat using artificial tears or placing some Vaseline Petroleum Jelly in the nostrils before bedtime is a good way to ensure these side effects are controlled easily.
Also, in younger patients who are very athletic, joint or muscle aches can occur. I recommend taking anything OTHER THAN TYLENOL as Accutane is cleared through the liver, the same as Tylenol. We are giving the liver a break by using over-the-counter non-steroidal anti-inflammatory agents such as Motrin, Aleve or ibuprofen to treat those aches and pains if it is even necessary.
Most patients with this side effect state it is not life-altering in any way and therefore to not treat it with anything, including over-the-counter pain relievers. As per the I-Pledge protocol, it is necessary to remind female patients at each and every visit NOT to get pregnant and to use two methods of birth control. Also, it is important to remind all patients not to donate blood or share their medication while on Accutane.
When monitoring a patient on Accutane, I am checking their liver function tests and their fasting lipids (fats) monthly as per I-Pledge protocols. In females, we are also required to test for pregnancy status monthly in compliance with I-Pledge. Regarding females on Accutane, those of child-bearing age are required to be on two separate methods of birth control. If a woman is unable to bear children through menopause or surgically due to a tubal ligation of hysterectomy, she is considered “male status” and these items are not as stringent. However, if a male spouse of a female has received a vasectomy, this is only considered to be one single method of contraception for the female Accutane user. Due the value of this drug, I-Pledge was developed as a governmental program to ensure that physicians prescribing the drug were following proper standards of care while administering the drug, that patients who took were in compliance with the regulations, and that the pharmacy where the drug was dispensed was in compliance as well. It is too valuable a drug to have been taken off the market due to the issue of birth defects in females who consumed the medication WHILE PREGNANT.
By the second month of Accutane, a patient has typically started to see improvement and, rarely clearance. Clearance will occur towards the end of the fifth month since the dosing is additive and weight-based. I encourage my patients to stop at the end of their fifth month, as they will continue to see improvement in their skin in the six months after taking the drug. In the thirty days after discontinuing the medication, patients will see all of the expected side effects of dryness and any muscle aches or pains resolve. They are still advised not to donate blood or get pregnant (in the case of female patients). They also will need to completely take all medication that they have left over at the end of the five month period, as there are missed days that can add up which are critical to achieve the expected success of this drug.
There has been literature on Dr. Google, as I like to call it, regarding inflammatory bowel disease and Accutane. Fortunately, it is total and complete bunk. It was studied extensively in four separate clinical trials in four different countries once those allegations were made years ago. All four studies revealed that not only did Accutane or isotretinoin not increase risk of inflammatory bowel disease in those patients who took the medication, but it decreased their risk slightly of developing the condition! Thus, I reassure patients that other than a pregnancy during an Accutane course (which would be disastrous due to the fetal defects associated with that), there are no long-term risks or sequelae that result from taking this valuable medication.