Medicine for acne: Isotretinoin (Accutane)

Isotretinoin (Accutane 10-, 20-, 40-mg capsules)
Isotretinoin (13-cis retinoic acid), an oral retinoid related to vitamin A, is a very effective agent for control of acne and in the induction of long-term remissions, but it is not suitable for all types of acne. Isotretinoin affects all major etiologic factors implicated in acne. It dramatically reduces sebum excretion, follicular keratinization, and ductal and surface Propionibacterium acnes counts. These effects are maintained during treatment and persist at variable levels after therapy. A number of side effects occur during treatment. Isotretinoin is a potent teratogen; pregnancy must be avoided during treatment. Isotretinoin is not mutagenic; female patients should be assured that they may safely get pregnant but should wait for at least 1 month after stopping isotretinoin. Age is not a limiting factor in patient selection.
Indications
Severe, recalcitrant cystic or nodular and inflammatory acne.
A few patients with severe disease respond to oral antibiotics and vigorous drying therapy with a combination of agents such as benzoyl peroxide and sulfacetamide/sulfur lotion. Those who do not respond after a short trial of this conventional therapy should be treated with isotretinoin to minimize scarring.
Moderate acne unresponsive to conventional therapy.
Moderate acne usually responds to antibiotics (e.g., tetracycline or erythromycin 500 mg twice daily) plus topical agents. Change to a different antibiotic (e.g., minocycline 100 mg twice daily) if response is poor after 3 months. Change to a third antibiotic (e.g., ampicillin, a cephalosporin, or trimethoprim/sulfamethoxazole) if response is poor after 3 months on the second antibiotic. Change to isotretinoin if response is unsatisfactory after three consecutive 3-month courses of antibiotics. Patients who have a relapse during or after three courses of antibiotics are also candidates for isotretinoin.
Patients who scar.
Any patient who scars should be considered for isotretinoin therapy. Acne scars leave a permanent mark on the skin and psyche.
Excessive oiliness.
Excessive oiliness is disturbing and can last for years. Antibiotics and topical therapy may provide some relief, but isotretinoin's effect is dramatic. Relief may last for months or years; some patients require a second or third course of treatment.
Severely depressed or dysmorphophobic patients.
Some patients, even with minor acne, are depressed. Those who do not respond to conventional therapy are candidates for isotretinoin. They respond well to isotretinoin, although some may relapse quickly and require repeat courses.