When It Comes To Accutane, More Is Not Necessarily Better
Accutane (also known as isotretinoin or 13-cis-retinoic acid) is sometimes a miracle drug for cystic acne, but the benefits of the medication1 come at the cost of side effects. Just a few of the potential side effects of Accutane include:
- Dry skin and peeling skin. Accutane breaks down the “glue” that holds skin cells together over cysts and blemishes. The peeling of skin opens a cyst without lancing, but it also can cause itchy2 and raw skin all over the body. It can cause nosebleeds in both sexes and vaginitis in women. About 40% of Accutane users experience dry or peeling skin.
- Irritation at the corners of the mouth. About 90% of Accutane users experience irritation at the corners of the mouth.
- Closing of bone ends. When the ends of bones close3, growing stops. Bones in the upper body stop growing at about age 18, but bones in the lower body may continue growing until age 22.
- Rosacea. Changes in the “basement material” surrounding capillaries in the skin can cause rosacea outbreaks in people who have never had rosacea before.
- Miscellaneous side effects. Accutane has also been known to cause hair loss4, elevated liver enzymes, back pain, high blood sugar levels, permanent thinning of the skin, easy bruising, formation of calcified cysts in the muscles, high blood pressure, cataracts, and erectile dysfunction.
Some of these side effects may become permanent. There is a well-known increased risk of suicide among users of Accutane, and about 10% of women who use Accutane during the first trimester of pregnancy bear children with facial birth defects5. Using lower doses of Accutane, many researchers have reasoned, ought to reduce the risk of side effects. But would lower doses of Accutane control acne as well?
Lowering The Dose Of Accutane For Acne
Accutane comes in 10 mg (pink), 20 mg (red), and 40 mg (yellow) pills. American doctors, in particular, tend to prescribe the 40 mg dosage. American acne sufferers have to pay out of pocket for their medications, and the various sizes of the drug cost about the same. Many expect to get their money’s worth by taking the highest available dose of the medication.
Many of the dosing recommendations that appear in English-language medical journals include studies of patients who were not being treated for acne. Accutane is also used as a treatment for certain kinds of cancer6. Cancer treatment requires much higher doses of the drug, but these dosages were included in the recommendations recorded in the medical literature for dosing Accutane for treating acne. It is entirely possible that decades-old dosage recommendations are simply too high, but have become standard medical procedure in the USA.
In Italy, there is no incentive to prescribe a higher dosage of the drug. Researchers in Italy conducted a clinical study to see if dosage really makes a difference.
In the Italian study, 114 people with “mild” acne and 36 people with “moderate” acne were given about 75% of the dosage usually prescribed, 30 mg a day (one pink pill and one red pill). Essentially all of the patients in the group studied by the researchers went into remission from acne during the study. Only about 10% relapsed after they were taken off medication after taking the lower dose of the drug.
These results are consistent with the results of a study of the 30 mg daily dosage conducted in Germany in the 1990’s. German researchers found that about 1/3 of patients given 30 mg of Accutane a day instead of 40 mg of Accutane a day needed a second course of treatment, on average a little under 8 months after they first came off the drug. The German doctors only had one person who failed to respond at all to taking just 30 mg of Accutane a day.
In another study, Korean researchers studied7 60 people who had “moderate” acne. They were given either a regular dosage of Accutane, a low dose, or intermittent Accutane treatment, taking Accutane only one week per month. In the regular dosage group, 12% relapsed when they were taken off the drug. In the low-dose group, 18% relapsed after being taken off the drug. In the one-week-a-month group, however, 50% had their acne come back when they stopped taking Accutane. Taking Accutane once a week was apparently enough to control acne but not enough to cure it.
It seems that lower (30 mg) doses of Accutane are about as likely to cure acne as higher (40 mg) doses of Accutane if they are taken regularly. Taking a vacation from Accutane treatment for 3 weeks out of the month results in relapses soon after the drug is discontinued.
The reality is, however, that many people take Accutane on an intermittent or occasional schedule even though their doctors tell them to take it every day. Some people don’t take all the Accutane they are prescribed because they cannot afford it. Some people don’t take all the Accutane they are prescribed because they find side effects to be intolerable. And some people don’t take all the Accutane they are prescribed because the simply forget to take their pills.
Should You Ask Your Doctor About Low-Dose Accutane?
Many doctors are sold on Accutane. It’s the only oral medication for acne that both opens the skin and shrinks the oil glands that become inflamed at the base of pores. It shrinks cysts as it opens the skin above them, and it treats blackheads and whiteheads by peeling skin that covers them, too. Some studies suggest8 that Accutane is also anti-inflammatory and anti-bacterial if it is taken in the right dose.
Probably the best time to ask your doctor about taking the smallest dose of Accutane is when it is first prescribed. Ask your doctor if he or she thinks that a 10 mg dose might be as effective for you as 20 mg or 40 mg—and why. Be especially sure to ask about lower doses if you have any history of inflammatory bowel disease, as this sometimes life-threatening condition can be aggravated by taking the drug.
- Isotretinoin: Treatment for severe acne. American Academy of Dermatology (Website). Accessed 2019.
- Pile H.D., Nicolas D. Isotretinoin. StatPearls. 2019.
- DiGiovanna J.J. Isotretinoin effects on bone. Journal of the American Academy of Dermatology. 2001;45(5):S176-82.
- Kmieć M.L., Pajor A., Broniarczyk-Dyła G. Evaluation of biophysical skin parameters and assessment of hair growth in patients with acne treated with isotretinoin. Postȩpy dermatologii i alergologii. 2013;30(6):343-9.
- Bérard A., Azoulay L., Koren G., Blais L., Perreault S., Oraichi D. Isotretinoin, pregnancies, abortions and birth defects: a population-based perspective. British Journal of Clinical Pharmacology. 2007;63(2):196-205.
- Dahl A.R., Grossi I.M., Houchens D.P., Scovell L.J., Placke M.E., Imondi A.R., Stoner G.D., De Luca L.M., Wang D., Mulshine J.L. Inhaled isotretinoin (13-cis retinoic acid) is an effective lung cancer chemopreventive agent in A/J mice at low doses: a pilot study. Clinical Cancer Research. 2000;6(8):3015-24.
- Lee J.W., Yoo K.H., Park K.Y., Han T.Y., Li K., Seo S.J., Hong C.K. Effectiveness of conventional, low-dose and intermittent oral isotretinoin in the treatment of acne: a randomized, controlled comparative study. The British Journal of Dermatology. 2011;164(6):1369-75.
- Layton A. The use of isotretinoin in acne. DermatoEndocrinology. 2009;1(3):162-9.
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