Last Updated on January 6th, 2020
By Dr. Jaggi Rao, MD, FRCPC, Double board-certified dermatologist
Since 1984, oral isotretinoin, the medication that is still known as Accutane but that has been labeled as Roaccutane since 2009, has been one of the most commonly prescribed medications for severe acne that forms nodules and cysts. Basically a super-charged version of vitamin A, Accutane causes the skin to grow so rapidly that it opens up naturally over cysts and nodules, allowing them to drain without lancing or surgery. It’s only in the last few years, however, that doctors have started prescribing Accutane for rosacea.
Researchers actually recognized the value of Accutane for treating rosacea before the drug was ever released to the public. Accutane is usually prescribed for common acne because it opens up pores and shrinks oil-producing sebaceous glands, but it also can fight the inflammation that causes rosacea.
Article Table of Contents
There are four subtypes of rosacea, erythematotelangiectatic rosacea (ETR), papulopustular rosacea (PPR), phymatous rosacea, and ocular rosacea. Erythematotelangiectatic rosacea is a condition of permanent redness with a tendency to flush and blush easily. Papulopustular rosacea is a condition with permanent redness with papules (bumps) and pustules (bumps filled with pus) that is easily confused with acne. Phymatous rosacea is a condition of rough skin and bumpiness on the nose. Ocular rosacea is a condition of dry and red eyelids that can cause a feeling of grit in the eyes.
One kind of rosacea does not lead to another, but it’s possible to have more than one kind of rosacea at the same time. Different kinds of acne treatments have different effects in rosacea. The US Food and Drug Administration approves some medications to treat “temporary effects” of rosacea but does not approve medications to treat “permanent effects” of rosacea.
The feature of rosacea that tends to come and go is the accumulation of papules and pustules. They may break out and they may clear up. Sometimes they are worse than others. The US Food and Drug Administration approves metronidazole 0.75% and 1% formulations and azelaic acid gel 15% formulations for papules and pustules, but their approved use is limited to treating PPR.
Other features of ETR, phymatous rosacea, and ocular rosacea are more or less permanent. Redness of the skin caused by ETR usually does not come and go. Bumpiness on the nose and irritation of the eyes are more or less permanent features of phymatous rosacea and ocular rosacea respectively.
Since rosacea is not caused by bacterial infection, the US Food and Drug Administration only approves one antibiotic for rosacea, doxycycline, in doses that are too small to kill bacteria but large enough to relieve inflammation in the skin. Sometimes doctors use combinations of benzoyl peroxide and the antibiotic clindamycin or combinations of the antibiotics erythromycin and clindamycin “off label” to treat rosacea.
Retin-A, which is sold under the generic name tretinoin, is used to open pores, shrink oil-producing sebaceous glands, and reduce inflammation in severe common acne. Since rosacea is not caused by excessive oil production, the US Food and Drug Administration does not approve the use of Retin-A or tretinoin topical for rosacea, although some doctors prescribe both products “off label.”
Antibiotics, benzoyl peroxide, and Retin-A are used to treat “permanent” features of rosacea, such as papules, pustules, and broken blood vessels. Face washes are used to treat “temporary” features of rosacea, such as inflammation.
If there are effective medications that aren’t approved for your form of rosacea and your doctor will prescribe them for you, then what’s the problem? For rosacea sufferers on a budget, there’s a big one In the United States, if your doctor prescribes a product off-label, your insurance company will not pay for it.
Dermatologists have over a quarter of a century’s experience with Accutane. It’s a product that has some serious drawbacks—the risk of liver damage and devastating effects in early pregnancy best known among them—but doctors know how to prevent these problems. And there’s growing evidence that it may be helpful in dealing with some of the “permanent” symptoms of rosacea.
A multi-center study found that taking Accutane (in pill form) was very helpful in severe PPR (the kind of rosacea for which FDA-approved products are currently available).
A study treatment-resistant PPR found that taking Accutane for nine weeks reduced not just pustules and papules, which are generally considered treatable, but also reduced redness, after about 18 weeks of treatment.
Five studies have found that Accutane shrinks rhinophyma, the swelling of the nose that can be caused by phymatous rosacea, for which there are currently no FDA-approved treatments. Accutane has to be used before the lesions in the nose develop fibrous casings, however.
One young woman experience remission from perioral granulomatous rosacea (lumpy and bumpy redness around the mouth not caused by infection in pores of the skin) after 20 weeks of Accutane treatment.
A study of 573 rosacea patients found that taking antibiotics led to remission of symptoms in 13% of patients but that taking Accutane led to remission of symptoms in 24% of patients.
And researchers have also investigated continuous low-dose treatment of rosacea with Accutane, giving patients just 0.03 mg of Accutane per day (about 1/16 of the regular dose). This tiny amount of Accutane did not cause side effects but did lead to significant improvement in quality of life for most of the patients in a preliminary small-scale study.
The simple fact is that only you and your doctor can determine whether Accutane is likely to help your rosacea symptoms. Ask your doctor about low-dose Accutane treatment, and make sure you inquire about reducing medication costs by the very simple method of pill-splitting (which should be done by the pharmacist at the pharmacy following the orders of the prescription, not at home). Even if the FDA does not approve Accutane for your form of rosacea, you and your doctor may be able to work out effective and affordable off-label use of the medication or otherform of acne treatment if the doctor believes it may work for you.
Thanks for the post, it was very helpful and informative.
I was diagnosed with granuloma rosecea 4 months ago . It is all over my face neck and chest. I am a 47 year old female. I haven’t left my house in 7 months which is when this occurred . I am desperate for help and answers because my ddrmatologist does t know what to do . She is the most knowledgeable derm as far as I know where I live. I have been on prednisone for 4 months 20 ml a day and Myorisan for a month but it’s almost worse. Can you give me any hope at all or direction .
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