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Oral Isotretinoin:  Worth It?

Julia Rushing

February 21, 2011

 

 

 

 

 

 

 

 

 

 

 

 

Introduction

            The question of oral isotretinoin and the tolerance of it is not answered quickly or simply.  People with acne vulgaris (or acne) have conflicting emotions towards its effects.  So much good emerges from the medication, but do the positive outcomes outweigh the side effects?  The clean crisp face of someone who has undergone isotretinoin treatment does not always reflect an easy and comfortable course of treatment.  There are many different degrees of acne and a variety of treatment options for each.  While physicians can usually decipher what is best for acne sufferers, hopefully we can develop our own views for the case of oral isotretinoin by answering these questions.

 

Acne:  What is it?

First off, what is acne?  Acne is a common skin condition seen in many people from age ten to forty that appears in the form of whiteheads, blackheads, pustules, pimples, or cysts.  The breakouts mostly surface on the face, back, and chest because that is where pores are likely to become congested with oil.  Acne mostly reveals itself in teenagers, but people experience it in the mid-to late-twenties as well.  Everyone usually grows out of it by age forty (Rockoff, 2008).

            Puberty plays a large factor in causing acne.  When oil glands develop in adolescence they sometimes become clogged by other cells on the skin (i.e. dirt).  This then leads to oil accumulation, which causes bacteria to grow and inflame surrounding tissue.  The inflammation is a healing tactic, but it often causes scarring.  If the oil builds up deep beneath the skin, a cyst forms.  If oil builds up closer to the surface, a pimple forms.  If oil builds up even closer to the skin, a pustule forms, and if the oil breaks through the skin, a whitehead has formed.  Blackheads are simply the oil turning from white to black.  Other factors that may influence but not directly cause acne are heredity, stress, food, hormones, and makeup (Rockoff, 2008).

 

Oral Isotretinoin:  What is it?

Oral isotretinoin is a retinoid (a chemical compound related to Vitamin A that regulates epithelial cell growth).   It is a yellow/orange crystalline powder of 13-cis-retinoic acid that treats severe acne that is otherwise nonresponsive to spot treatments.  Market drug names for oral isotretinoin include Roaccutane (known as Accutane in the United States before July 2009), Amnesteem, Claravis, Clarus, Decutan, Isotane, Izotek, Oratane, ISOTRET, and Sotret.  These medications treat acne by reducing oil secretion, which in turn lessens inflammation and scarring (Ogbru, 2010).  The substances come in the prescription and generic form of capsules.

 

Oral Isotretinoin:  What is the purpose and expected outcome?

            For those taking isotretinoin, a cumulative dose of between 100-150 mg/kg alleviate acne and prevent relapse.  The daily dosage is based on the weight of the patient (Chivot, 2002).  More success has been seen by taking a lower daily dosage for a longer amount of time, especially for those with moderate acne (Bettoli, 2010).  This method has been shown to relieve side effects and result in a more stable remission by lessening maintenance later in life.  Therefore, the duration of treatment is usually four to six months.  If a second treatment has to be given, it is started at least eight weeks after the original course. 

 

Oral Isotretinoin:  What are the side effects?

            It seems that one cannot go through oral isotretinoin treatment without at least a few side effects.  Some of the most prevalent side effects are cheilitis, eczema, tiredness, and mood change.  Cheilitis is defined as inflammation (chapping) of the lips and is linked to isotretinoin making the skin more sensitive to sunlight.  Eczema is defined as irritation of the skin caused my scaly and itchy rashes.  There is an explicit correlation between dosage and severity of side effects.  The higher the dosage one takes, the worse the cheilitis, eczema, tiredness, and mood change.  In one study, isotretinoin was discontinued in 1.4% of patients, most often because of cheilitis, but was also discontinued because of mood change in 0.75% of patients (Rademaker, 2010).  Other undesirable side effects include brittle nails and hair thinning.  For the most part, acne patients do not stop treatment for these reasons, and if they do, they start again soon after.

            More serious undesirable side effects include birth defects and depression.  Despite guidelines given by physicians warning women of what could happen if they become pregnant on isotretinoin, there are still cases of it.  If a fetus reaches week twenty of development, it has been found that 25-30% of the time, he or she will be born with malformations (Hanson, 2001).  When the fetus is exposed to isotretinoin, congenital defects occur in craniofacial, cardiac, thymic, and central nervous structures.  Common defects include abnormal or lack of auditory canals, immunosuppression (makes babies more susceptible to infection), a depressed midface, and external ear, aortic, optic nerve, and structural and cognitive brain abnormalities.  50% of isotretinoin-exposed children also show sensory and motor defects (Hanson, 2001). 

According to the FDA, isotretinoin ranks in the top ten for user reports of suicide and depression.  Depression symptoms seen include unusual sadness, tiredness, moodiness, irritability, and loss of appetite, which may lead to suicidal thoughts and attempts (Hanson, 2001).  Numerous studies have been done to prove that these side effects are possible and relevant to isotretinoin.

 

Oral Isotretinoin:  What studies have been conducted to observe these side effects?

Rademaker

Out of the patientsŐ observed side effects of isotretinoin, the most frequent adverse one is cheilitis, and some discontinue use because of it but continue at a later date.  This study shows that side effects such as tiredness, eczema, mood swings, and cheilitis are less prominent at lower doses.  The study also shows no cases of severe side effects like depression or suicidality (Rademaker, 2010).

 

Brito

The conclusion of this study is that oral isotretinoin is a safe drug whose side effects can mostly be treated by symptomatic medication.  Cheilitis is the most widespread side effect.  Brito concludes that the benefits of the drug outweigh the minor biochemical alterations (Brito, 2010).

 

Lammer

Lamner observes that out of 154 women exposed to isotretinoin in pregnancy, 95 are aborted, 12 are spontaneously aborted, 21 are malformed, and 26 are normal.  The results conclude that the teratogenesis harms the cephalic neural-crest cell activity, which causes the observed malformations (Lammer, 1985).

 

Morb Mortal Weekly Report

The Case 1 patient in this study loses her child to multiple anomalies caused my isotretinoin.  The Case 2 patient has three isotretinoin-exposed pregnancies, but only the third one results in a live baby.  The Case 3 patient has an abortion because she is taking isotretinoin and fears the fate of her baby. 

 

Strahan

This study shows that there is a correlation between mood and isotretinoin, but the link between psychiatric diseases like depression with the drug is absent.  There are not enough strong scientific studies to prove the association (Strahan, 2006).

 

Kaymak

The conclusion of this study is that those taking oral isotretinoin do not show an increase in depression or anxiety compared to those taking topical treatments.  Instead, depression and anxiety symptoms diminish in patients under each treatment (Kaymak, 2009).

 

Oral Isotretinoin:  How To Alleviate Side Effects

            Most serious adverse effects of isotretinoin can be avoided by the close watch of a physician, the alteration or discontinuation of treatment, and consistent checking for toxicity (Ganceviciene, 2010).  For the more trivial effects, one should wear sunscreen because the skin is more sensitive to sunlight, exercise because it improves focus, restlessness, and mood, eat a healthy diet high in protein to help joint problems and dry skin, or take doctor recommended medications to control symptoms like hormone imbalances, cholesterol levels, and blood cell counts. 

 

Oral Isotretinoin:  Benefits

            Besides the obvious, less acne, oral isotretinoin most of the time results in higher self-confidence as a result of better appearance and less acne maintenance in the long run.  As opposed to what studies say about isotretinoin inducing depression, there seems to be more evidence suggesting the oral isotretinoin treatment leads to reduction of depression and anxiety and an overall higher morale (Rubinow, 1987).

 

 

Oral Isotretinoin:  Alternative Options

            Say after considering all of the above information, an acne sufferer decides maybe oral isotretinoin is not for them.  What are their other options?  Several treatments produce similar results.

            Topical antibiotics (i.e. clindamycin and erythromycin) are used in combination with benzoyl peroxide to control inflammation.  Benzoyl peroxide, which comes in the form of creams, lotionsm and gels promotes the peeling of skin and cleans pores.  Therefore, fewer bacteria thrive.  Topical retinoids (i.e. tazarotone, adapalens, tretinoin) peel away upper layers of skin in order to alleviate inflammation and lessen amount of black and whiteheads.  Birth control increases globulin, thereby decreasing testosterone and decreasing sebum production (what makes skin oily).  Topical azelaic acid treatments (i.e. azelex, finacea) treat acne by stopping bacterial growth.  Vitamin A supplements, when used in healthy amounts, helps skin growth (Archer 2006).

 

Oral Isotretinoin Versus Alternative Treatments

            Compared to all of the alternative options, oral isotretinoin is very efficient but uncalled for in scenarios of minimal and moderate acne.  In most cases, topical antibiotics retinoids, and benzoyl peroxide, birth control, and vitamin A do the job in a quick, convenient, and endurable manner (Shalita, 2002).  Topical antibiotics are not as cost effective as isotretinoin though (Newton, 1997).  This is because oral isotretinoin has a greater efficacy in the long term. 

 

 

Summary And Conclusion

            In summary, through the research I have done on oral isotretinoin, I have learned that it is a drug with astounding curative abilities.  I have also discovered that it is not always the wisest remedy depending on the intensity of acne vulgaris.  Oral isotretinoin is somewhat of an overkill on minor and moderate forms of acne.  A weaker treatment with less powerful side effects could be used instead.  When it comes to an extreme case of acne though, a patient will have the most luck with isotretinoin.  It is forceful and reliable although sometimes aggravating, painful, and risky.

            The case studies show that cheilitis is a common side effect that is annoying and discomforting, but it is tolerable when considering long-term results (Brito, 2010).  Also, cheilitis can be controlled and monitored by changing up dosage.  Usually with higher dosage come more irritating effects, as seen in the studies (Rademaker, 2010).  Therefore, the problem of chelitis should not really be a deciding factor when choosing whether oral isotretinoin is right for a patient or not.

The case studies also reveal that oral isotretinoin has a huge risk factor when taken by pregnant women.  Although there is not an exceptional amount of malformations in babies born of the drug-exposed mothers, there are still babies that do bear the consequences, and that is very heartbreaking and tragic (Lammer, 1985). When something as serious as a life is at stake, every precaution should be taken to prevent it from happening.  Because not most people who take oral isotretinoin are pregnant, the possibility of teratogenesis should not play a factor either in the treatment decision process.  However, many females are sexually active and so should be exceedingly careful and mindful while on the drug.

Lastly, depression side effects are a sizeable concern when debating whether or not to use oral isotretinoin.  The above case studies disclose that depression might not actually be an issue.  There is a bridge between mood change and isotretinoin, but saying that the drug leads to depression and suicide is not a true statement (Strahan, 2006).  In fact, oral isotretinoin may boost spirits by increasing self esteem (Kaymak, 2009).

In retrospect, we now see that most side effects can be eased with the help of slight alterations in lifestyle or basic drug store remedies and that the benefits of oral isotretinoin on serious acne are very well worth the common side effects (Ganceviciene, 2010).  Alternative treatments will have the same outcome but maybe not with long lasting power oral isotretinoin shows.  The optional treatments may be more logical and suitable for some cases of acne though (Shalita, 2002).  Judgments should be left up to medical professionals and the treatment should be assessed consistently throughout the course.

When brutal acne vulgaris sets in and starts hampering oneŐs well being they should not settle for a remedy that does not work efficiently enough.  Oral isotretinoin will cause some unpleasant side effects, but it also will bring transformation. 

 

References

 

Rockoff, Alan (2008).  Acne (Pimples).  MedicineNet.  Retrieved February 17, 2011, from http://www.medicinenet.com/acne/article.htm

 

Ogbru, Omudhome (2010).  Isotretinoin, Sotret, Claravis, Amnesteem, (Accutane is no longer available).  MedicineNet.  Retrieved February 17, 2011, from ;http://www.medicinenet.com/isotretinoin/article.htm

 

Chivot, M (2002).  Treatment of acne by isotretinoin (general course).  U.S. National Library of Medicine National Institutes of HealthRetrieved February 17, 2011, from

http://www.ncbi.nlm.nih.gov.proxy.library.vanderbilt.edu/pubmed/12053792

 

Bettoli, V (2010).  Low-cumulative dose isotretinoin treatment in mild-to-moderate acne: efficacy in achieving stable remission.   Journal of the European Academy of Dermatology and Venereology.  Retrieved February 17, 2011, from http://onlinelibrary.wiley.com.proxy.library.vanderbilt.edu/doi/10.1111/j.1468-3083.2010.03933.x/abstract

 

Rademaker, Marius (2010).  Adverse effects of isotretinoin: A retrospective review of 1743 patients started on isotretinoin.  Australasian Journal of Dermatology.  Retrieved February 19, 2011, from http://onlinelibrary.wiley.com.proxy.library.vanderbilt.edu/doi/10.1111/j.1440-0960.2010.00657.x/abstract

 

Hanson, Nathan (2001).  Safety issues in isotretinoin therapy

Seminars in Cutaneous Medicine and Surgery, Volume 20, Issue 3, September 2001, Pages 166-183.

 

Brito, Maria de F‡tima de Medeiros (2010).  Evaluation of clinical adverse effects and laboratory alterations in patients with acne vulgaris treated with oral isotretinoin. An. Bras. Dermatol.  Retrieved February 19, 2011, from http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962010000300006&lng=en&nrm=iso&tlng=en

 

Lammer, Edward J (1985).  Retinoic Acid Embryopathy.  The New England Journal of Medicine.  Retrieved February 19, 2011, from

http://www.nejm.org/doi/full/10.1056/NEJM198510033131401#t=article

 

Strahan, Jamison E (2006).  Isotretinoin and the controversy of psychiatric adverse effects.  International Journal of Dermatology.  Retrieved February 19, 2011, from

http://onlinelibrary.wiley.com/doi/10.1111/j.1365-4632.2006.02660.x/full

 

Kaymak, Yesim (2008).  Comparison of depression, anxiety and life quality in acne vulgaris patients who were treated with either isotretinoin or topical agents.  International Journal of Dermatology.  Retrieved February 19, 2011, from

http://www.ncbi.nlm.nih.gov/pubmed/19126049

 

Ganceviciene, Ruta (2010).  Isotretinoin: state of the art treatment for acne vulgaris.  Journal der Deutschen Dermatologischen Gesellschaft.  Retrieved February 19, 2011, from http://www.ncbi.nlm.nih.gov/pubmed/20482692

 

Rubinow, David R (1987).  Reduced anxiety and depression in cystic acne patients after successful treatment with oral isotretinoin.  Journal of the American Academy of Dermatology, Volume 17, Issue 1, July 1987, Pages 25-32.

Archer, Pamela (2006).   The Complete Guide to Acne Prevention, Treatment and Remedies.  eBookWholesaler.  Retrieved February 20, 2011, from  http://www.the-wow-collection.com/software/acne.pdf

 

Shalita, A (2001). The integral role of topical and oral retinoids in the early treatment of acne. Journal of the European Academy of Dermatology and Venereology.  Retrieved February 20, 2011, from

http://onlinelibrary.wiley.com/doi/10.1046/j.0926-9959.2001.00012.x/abstract

 

Newton, John N (1997).  How Cost-Effective Is Oral Isotretinoin?  S. Karger AG, Basel.  Retrieved February 20, 2011, from http://content.karger.com/ProdukteDB/produkte.asp?Doi=246014

 

Picture References (left to right)

http://www.realsimple.com/beauty-fashion/skincare/face/ways-to-treat-acne-00000000038296/page10.html

http://acnezit.com/Prescription-Acne-Medications.php

http://www.duejustice.com/defective-product-liability/sotret-lawyer/

 

 

 

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