Manage expectations with ISOtretinoin

Continue to consider isotretinoin for patients with severe cystic or nodular acne, or with less severe, scarring acne when first-line meds....

As a clinical pharmacist, you should help patients start and stay on isotretinoin for Acne. So, questions are coming up about how to manage expectations with isotretinoin (Netlook, etc) in patients with acne. Continue to consider isotretinoin for patients with severe cystic or nodular acne, or with less severe, scarring acne when first-line medications (topical retinoids, etc) aren’t enough.

Educate that acne may worsen for 4 to 6 weeks before it gets better, and it may take the full 15- to 20-week course to see benefit. But point out that one course of isotretinoin may “cure” acne. Advise taking most isotretinoin forms with food for the best efficacy. Absorica and Absorica LD "available in US and Canada" are absorbed differently and can be taken with or without food, but aren’t interchangeable with other forms.

Tell patients to expect dry eyes, lips, and skin, and to use artificial tears, lip balm, and moisturizers. Recommend using saline nasal spray or petroleum jelly to prevent nosebleeds. Generally STOP all topical acne medications, including OTCs (benzoyl peroxide, salicylic acid, etc) to limit irritation. Inform patients that joint or muscle aches may occur, and it’s okay to try OTC analgesics (ibuprofen, etc). But stop isotretinoin if patients have symptoms, such as a persistent headache or vision changes. These could be due to rare increases in intracranial pressure.

Explain there’s no good evidence that isotretinoin causes depression or suicidal ideation, and acne itself can cause self-esteem concerns and mood changes. Continue to encourage patients to report mood changes and suicidal thoughts. Ensure patients have regular monitoring of liver enzymes and lipid panels. Both can be affected by isotretinoin.

References

Research, C. for D.E. and (2022). iPLEDGE Risk Evaluation and Mitigation Strategy (REMS). FDA.
Landis MN. Optimizing Isotretinoin Treatment of Acne: Update on Current Recommendations for Monitoring, Dosing, Safety, Adverse Effects, Compliance, and Outcomes. Am J Clin Dermatol. 2020 Jun;21(3):411-419.
Zaenglein AL, Pathy AL, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2016 May;74(5):945-73.e33.