Based on the stage isotretinoin is used. ususally beyond 2nd and 3rd stage.

prefer antibiotics and topicals initially

it depends on the severity of acne.

Topical therapy for mild to moderate acne.

Moderate to severe acne : combination therapy Topical + a systemic antibiotic.

Severe acne: oral isotretinoin.

We can use isotretinoin as second line therapy (After 4 to 6 weeks) for mild or moderate not responding to the first line therapy.

Regards

Depending on the grading of acne, the treatment is decided. So in grade 3&4 the first choice is isotretinoin for rapid control of the disease and thereby preventing the scarring.

Prof Criton

Thank you all:

All: what doses do you use ? Who have experience with low doses and who maintain the dose of 0.5 mg/Kg or more ?

Dear Americo Figuiredo,

Yes, i have recommended for many patients both (low , medium and high doses) and monitored them for 6 months to 1 year.

Most of patients could not tolerate it at 1 mg/kg due to adverse effects. I prefer to start with 0.5 m/kg and increase it to 0.7 mg/kg after 2 months till reach the accumulative dose 150 mg/kg and monitor the side effects, adherence and other monitoring parameters.

The most common drug isotretinoin has the most flexible dosing to control acne.

Often the problem would arise when a young lady has acne before her marriage,. At what dose is isotretenoin safe not to cause any fetal abnormalities.

Isotretinoin is always unsafe in which concerns fetal abnormalities. We don,t have unsafe doses.

Isotretinoin is NOT always unsafe. Only thing is that the physician should have a thorough understanding of the drug, its indication , dose schedule, when to use and when not to and above all patient education regarding the drug

Always unsafe in which .....!

What about adverse effects?

Lip and skin xerosis, dislipidemia and very rarely liver alterations.

It is also the more teratogenic drug we use now in ambulatory medicine because vitamin A acts in celular differentiation.

No, not first line. I always try something else first even if just a temporary measure. I never prescribe isotretinoin to a female of childbearing age without some form of contraception. I start 0.5mg/kg/d for 1 month and if the blood tests are okay I increase the dose to 1mg/kg/d working to a maximum of 120mg/kg - normally a total of 5-6months. Side effects are manageable.

What happens when isotretinoin is taken for more than 6 months and beyond total accumulative dose.

Yes, if indicated by severity and patient (and parent) wishes. With iPLEDGE in USA the rules for females are strict and must be followed re: contraception.

If inflammatory and papulopustules extending into hairline, Malassezia is highly likely and I routinely use oral ketoconazole to eliminate that, using 200 mg tablets. If patient under 50kg / 110 lbs, one tablet per WEEK taken with a swallow of water and a tablespoon of peanut butter or some other fat, then an hour wait before other food. If over 50 kg, use 2 x 200 mg tabs and same routine, once a WEEK only - usually clear of Malassezia in 8 weeks. Try it in your next ten inflammatory acnes. See PubMed PMID: 2964856 for the reason.

Always start with low dose 0.5 mg / kg but have found that patients usually do well on simple 40 mg / day regimen. Isotretinoin works far better if absorption is enhanced with peanut butter - I have used peanut butter in patients for almost 30 years - just watch lips and if they are not chapped / peeling then likely not absorbing (or not taking meds) - discuss and counsel re: need for fatty meal (bacon and eggs for breakfast is low glycemic and zero dairy - also important).

Importantly there is no need for the new Absorbica brand of isotretinoin recently released (at $27 per capsule) here in USA.

Thank you Dr. Danby.

What is Absorbica brand of isotretinoin and what the main differences to the normal one ?

Absorica™ (isotretinoin), a retinoid, is available in 10 mg, 20 mg, 30 mg and 40 mg hard gelatin capsules for oral administration. Each capsule contains isotretinoin USP, stearoyl macrogolglycerides, soybean oil, sorbitan monooleate and propyl gallate. Gelatin capsules contain the following dye systems: 10 mg – iron oxide (yellow) and titanium dioxide; 20 mg – iron oxide (red) and titanium dioxide; 30 mg – iron oxide (yellow, red and black) and titanium dioxide; and 40 mg – iron oxide (yellow, red and black) and titanium dioxide.

The combination of the soybean oil and the surfactants is designed to enhance absorption. It has never been compared to the regimen of peanut butter with isotretinoin that I have advocated. The amount of soybean oil in the capsule is a tiny bit of lipid compared to what would be present in a tablespoon of peanut butter, at 1/10th the cost in most of the world (and about 1/2 to 1/3 the cost in the USA).

I'm sticking with peanut butter.

The cost of Absorbica in USA is $1416.82 for 30 days of 60 mg/day.

That would buy a LOT of peanut butter!

The cheapest isotretinoin in USA is $550.50 for same dose above.

Ridiculous!

Reference The Medical Letter JAMA may 28, p 2123

depends on the grade of acne. If the question is isotretinoin as first line therapy for grades lesser than nodulocystic then I believe systemic minocycline with topical BOP does the job most of the time and isotretinoin can be reserved for the minority who do not respond to above.

Do you have many flares of acne during the three or four weeks since the beginning of treatment ?

If Yes how do you treat them ?

yes I prefer using Isotretinoin in Gr 3 and 4 acne,it gives better and earlier response

Yes, but usually other meds have failed in other hands first.