Isotretinoin, also known as 13-cis-retinoin, was approved by the U.S. Food and Drug Administration (FDA) in 1982 for clinical use in the treatment of acne, and has been used for more than 30 years. Both domestic and international acne guidelines list it as a first-line treatment option for moderate to severe acne. However, the side effects of the drug make many patients very reluctant to accept it. The answers to the relevant questions are now as follows.
1. Why do I need oral isotretinoin for acne treatment?
Oral isotretinoin can directly inhibit the proliferation of sebaceous gland cells, lipid synthesis and induction of sebaceous gland cell apoptosis as well as antagonize peripheral androgenic effects, and is currently an irreplaceable drug that inhibits lipid secretion. It has also been found to modulate natural immunity, inhibit neutrophils, suppress inflammatory mediators and anti-microbial peptides, and exert immunomodulatory, anti-inflammatory and anti-scarring effects. In addition, the inhibition of lipid secretion disrupts the lipophilic and anaerobic environment required for the proliferation of Propionibacterium acnes, while producing indirect antibacterial effects. Therefore, isotretinoin is the only effective drug that affects the four links in the pathogenesis of acne (follicular mouth keratinization, sebum secretion, bacterial colonization, and inflammatory response), making it an important drug of choice for the treatment of acne.
2. Do acne patients have to choose isotretinoin?
Given the effects and side effects of isotretinoin, not every patient needs to choose this class of medication. The indications mainly include.
(1) Nodular cystic acne.
(2) Severe acne in which other treatments have not been effective.
(3) Acne with scarring or a tendency to form.
(4) Acne with frequent recurrence.
(5) With severe excess seborrhea.
(6) Acne with mild to moderate acne but where the patient has a need for rapid healing.
(7) Acne variants such as fulminant acne and coalescent acne. It is now considered that its therapeutic effect is certain, its long-term application can prevent recurrence, its side effects are acceptable, and it has been significantly expanded in terms of indications.
3.What are the side effects of isotretinoin?
Adverse reactions to oral isotretinoin are very common, but serious reactions are rare.
(1) skin and mucous membrane reactions: is the most common adverse reactions in treatment, of which lipitis occurs in 98% of treated patients.
(1) Skin mucosal reactions: These are the most common adverse reactions in treatment, with labyrinthitis occurring in 98% of treated patients, but are also a sign of drug efficacy. Usually there is no obvious dryness of the mouth and lips, and the treatment effect is relatively poor. Dry lips need to be protected with lip balm, etc. Drinking more water will not solve the problem. Once the reaction such as chapped mouth and lips occurs, the dosage should be reduced or even stopped, and never tear off the skin lesions to avoid aggravating the mouth and lip reaction.
(2) Elevated blood lipids: Some people can develop hyperlipidemia after oral intake, especially obesity, hyperinsulinemia
Some people may develop hyperlipidemia after oral administration, especially those with obesity, hyperinsulinemia, apoE gene, family history of hypertriglyceridemia, family history of diabetes and alcohol addiction are the high risk factors. The symptoms usually appear in the first two months of treatment and recover in two to four weeks after stopping medication. Therefore, avoid high-fat diet while taking medication.
(3) Liver damage: A small number of people will experience liver damage while taking the drug, but most of them have mild transaminase elevation, which can be recovered after stopping the drug and usually does not affect the treatment. Usually there is no need to check liver function before and after taking the drug, unless there is obvious discomfort in the liver area, yellow urine, poor appetite and so on. However, people with a history of hepatitis B or long-term alcohol consumption should avoid taking the drug as much as possible.
(4) Teratogenic: It is the most serious consequence of adverse reactions, and also the most certain reaction. It can lead to serious malformations such as craniofacial defects, cleft lip, earlessness, narrowing of the ear canal, small eye deformities, hydrocephalus, short limb defects, etc. After birth, even infants without anatomical defects may develop neuropsychological dysfunction or developmental delays later in life. Therefore, female patients of childbearing age should use strict contraception one month before, during, and for three months after treatment. If an unwanted pregnancy occurs during the course of treatment, it must be aborted.
(5) Bone effects: Considering the potential risk of this drug on bone development, it is not recommended for use under 12 years of age.
It should also be emphasized that sunlight should be avoided during the administration of the drug to avoid phototoxic reactions.
4.How to control the use of isotretinoin?
The first choice is that the efficacy of isotretinoin in the treatment of acne is certain and in many cases irreplaceable. Therefore, when deciding to use this drug, physicians must take into account the therapeutic value of this drug and the control of side effects. You should trust that experienced physicians who prescribe this drug will control the side effects of this drug and take the initiative to accept this drug therapy to avoid losing the time of treatment.
Secondly, although the side effects of these drugs are very common, serious side effects are rare. Moreover, the use of this drug for acne treatment has a history of more than 30 years, and its side effects have been monitored for a long time in many countries, and its occurrence pattern has been well known. With the exception of fetal malformations, they are all reversible and can be returned to normal after discontinuation of the drug, and can be avoided with the right response.
Finally, there have been major changes in the current strategy for the use of isotretinoin. It is emphasized that the daily dose should not be too high, but the course of treatment needs to be extended. Experienced physicians will take into account a person’s weight, severity of illness, and combination of medications to determine the dose and duration of treatment to achieve therapeutic benefits and control adverse drug reactions. The recommended dose is 20mg daily or lower, and after the effect (with dry mouth and lips) can be reduced to maintain, usually 10mg daily or every other day can play a very good therapeutic effect, and effectively avoid the occurrence of adverse reactions.
Emphasis is placed on the role of the duration of treatment in ensuring efficacy and preventing relapse, which usually requires more than 20 weeks of administration. The onset of action is significantly improved within 1 month of isotretinoin administration, and 85% of patients are clinically cured after approximately 20 weeks of treatment. International studies have concluded that the cumulative treatment amount of the drug is closely related to the recurrence rate of acne. The cumulative dose is set at no less than 60-120 mg/kg to ensure a low recurrence rate after acne treatment, but such a cumulative dose is still on the high side. However, this cumulative dose is still too high. It is obvious that a treatment course of more than 20 weeks is more in line with the clinical reality.
It should be reminded that some people may experience short-term aggravation of skin lesions within one month after taking it.