Based on knowledge gained during approximately four decades of experience with isotretinoin for the treatment of severe acne both in clinical practice and clinical research, James J. Leyden, M.D., says he has formed some fairly opinionated conclusions about dosing of the oral retinoid.
Speaking about “this incredible drug” at Maui Derm for Dermatologists 2020, Maui, Hawaii, Dr. Leyden shared his insights, including its place in his streamlined acne treatment algorithm along with dose considerations.
Dr. Leyden says that unless patients have very severe or widespread disease, acne treatment should be initiated with a topical retinoid and benzoyl peroxide. The two medications can be prescribed either as a fixed combination product or individually and typically should be used for three or four months before deciding whether further intervention is needed.
If a female patient has not achieved sufficient inflammation suppression with the two topical agents, the next step in the acne treatment algorithm adds spironolactone 100 to 200 mg/day followed by an oral contraceptive, if needed.
“The oral contraceptive interferes with the production of androgen while spironolactone acts via peripheral androgen antagonism. Using these treatments together, I have not recommended starting isotretinoin to any female in at least five years,” said Dr. Leyden, emeritus professor CE of dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia.
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.