“In the case of males in whom pregnancy is not an issue; however, I believe dermatologists are underutilizing isotretinoin.”
DOSE AND DURATION
Dr. Leyden emphasized that to reduce the risk for a severe acne flare, the starting dose for isotretinoin should never exceed 0.5 mg/kg/day.
“There is no way to predict who will experience a severe flare. It seems reasonable, however, that the flare occurs because massive sebocyte apoptosis results in the release of preformed pro-inflammatory cytokines into the dermis. Using a low isotretinoin helps to avoid massive sebocyte apoptosis,” Dr. Leyden says.
The isotretinoin dose can then be increased, and it should be administered at the highest dose that can be tolerated, recognizing that side effects of isotretinoin are dose-related and that there is interpatient variability in absorption and what individuals find acceptable in terms of side effects.
Dr. Leyden says he continues the treatment for one to two months after the acne is cleared, noting that he does so without evidence proving that it is necessary.
Minor recurrences after isotretinoin treatment are managed with a topical retinoid and benzoyl peroxide, but isotretinoin is restarted for a severe relapse.
1. Cunliffe WJ, van de Kerkhof PC, Caputo R, et al. Roaccutane treatment guidelines: results of an international survey. Dermatology. 1997;194(4):351-357.