I feel there is this big mystery about Accutane (generic name isotretinoin, which is how I will hence refer to it). So let me break it down for you. Accutane is a synthetic form of Vitamin A. That’s it. Every cell in our bodies has receptors for Vitamin A. Our bodies know what to do with it. I am always amazed at the ease with which doctors prescribe and patients are willing to take long term oral antibiotics for acne, but not prescribe or take isotretinoin. I would put my own children on isotretinoin but not on chronic antibiotics for acne. Antibiotics are foreign to our bodies. They mess up the natural bacterial balance of our digestive systems, which is being linked to many inflammatory conditions elsewhere in the body (Rosacea is one example, with its recent connection to SIBO, a future blog topic!). It messes up women’s vaginal systems (hello yeast infections). By the way, if I have a strep throat, or if my kids do, I take Penicillin. I think antibiotics are one of the miracles of the 20th century, and I prescribe them for skin infections when they are needed. BUT, I think they should be used judiciously, and not just given out like water for CHRONIC conditions like acne.
Why do I love isotretinoin? It is simple. It is by far the most effective acne medicine out there. If you take a sufficient cumulative dose for you weight over 6 months, close to 99% of people have no acne, and depending on the study, up to 70% have a long-term remission of years without acne. I think acne has a terrible impact on people’s self-esteem. I have heard many stories from patients about not going to work because of their acne, not dating because of their acne. I have frequent crying in my office from patients who feel lousy about themselves because of their acne. Studies show people with acne have a higher rate of depression than those without acne. If I can have my patients wake up in the morning not having to worry about pimples on their faces, then I have done my job well. My favorite part of being a dermatologist is, no joke, seeing patients blossom from someone insecure about his/her skin to someone who says ” My skin is amazing”, “I don’t have to wear makeup any more”, “My skin is a non-issue”. Hallelujah. I am not going to go through all the side effects of isotretinoin, But I want to address a few issues that I think there is a lot of misinformation about.
1. You cannot get pregnant if you are on isotretinoin. It causes bad birth defects. You CAN get pregnant 32 days after you stop taking it, although I tell my patients 3 months to be extra compulsive. Taking isotretinoin will NOT affect your ability to have a normal, healthy baby down the road.
2. There have been reports of depression from people taking isotretinoin. I think this if for the following reasons:
A) People with acne have a higher rate of depression than those without acne
B) Statistically, the people most likely to take isotretinoin are teenagers, and statistically, they have the highest rates of depression age-wise
In my 12 year experience with isotretinoin, I have had one patient feel depressed on isotretinoin, but she had a lot of other stuff going on in her life which could have accounted for it. I find my patients feel so much happier as their skin improves. An excellent article from the October 2000 issue of Archives in Dermatology compared 13,700 orl antibiotic users and 7195 isotretinoin users, and found no difference in the risk for depression, suicide, or other psychiatric disorders.
3. There has been much speculation about whether isotretinoin causes Inflammatory Bowel Disease (Ulcerative Colitis and Crohn’s) - These are serious diseases with a strong genetic component NOT to be confused with Irritable Bowel Syndrome, which in my opinion, is a poorly defined entity which probabaly has a lot to do with gut dysbiosis, or abnormal microflora of the gut. But I digress. A study from 2013 (JAMA Dermatology, 2/13) of 45000 women showed no increase of either colitis or Crohn’s.
So why, then, is there so much negative media coverage of isotretinoin? I think the answer is simple - Negative stories get more publicity than positive ones. And why so many lawsuits regarding isotretinoin? I blame ambulance chasing lawyers who see a lot of money in suing a drug company or a doctor. It sounds cynical, but I think it is true. For the majority of people, the only side effect they have is dry lips and dry skin. Some have muscle or joint aches in the morning which get better with movement. I have had marathoners and triathletes compete while on the medicine. If you have had positive results with isotretinoin, I implore you to post your good experience on acne forums like acne.org so people considering this medicine will have a more balanced representation on the internet.
Here’s to a pimple-free, happy life!
Be well, Cybele Fishman, MD