Debunking Myths About Isotretinoin

Unlock the secrets to effective acne treatment with isotretinoin and safeguard your skin's future. On this episode of Derm-It Trotter! Don't Swear About Skincare, Dr. Shannon C. Trotter is joined by Dr. Francisca Kartono, a board-certified dermatologist with a focus on cutaneous T-cell lymphoma, as we unveil the mysteries behind isotretinoin, commonly known as Accutane. Discover how this powerful medication has revolutionized the approach to tackling moderate to severe acne and why early intervention can be a game-changer in preventing scarring. 

Transcript

Talking Isotretinoin in Dermatology

Speaker 1 0:00

Welcome to Dermot Trotter Don't Swear About Skin Care where host Dr Shannon C Trotter, a board-certified dermatologist, sits down with fellow dermatologists and skin care experts to separate fact from fiction and simplify skin care. Let's get started.

Speaker 2 0:19

Hi everyone and welcome to Dermot Trotter. Don't Swear About Skin Care the podcast for all of you out there that want to know everything about skin. We're expert-led but patient-centered. And today we've got one of my special friends and colleagues on the podcast today, dr Francisca Cartona. I worked with her back in our days at Ohio State. She's a board certified and fellowship trained dermatologist in cutaneous T-cell lymphoma. She's got a great passion for everything skin and dermatology, general dermatology, cosmetic and surgical dermatology. She practices in Southeast Michigan at the MI or my Skin Center. So welcome to the podcast, dr Cartona.

Speaker 3 0:58

Thank you. Thank you for the invitation, dr Trotter. You're an amazing dermatologist too. I'm always in awe of what you've accomplished and, just like you, have a very big passion to educate patients and everybody else about dermatology. So I am excited about talking about isotretinoin in this podcast.

Speaker 2 1:15

And that's what we're going to tackle. Just like she mentioned, guys, a topic that I know a lot of you are familiar with, you may have been prescribed the drug isotretinoin for acne Maybe you know more about it known as Accutane, a branded version of it, that we have different versions now that are available and on the market. So we're going to dive deeper into this topic to dispel some myths and really get you comfortable thinking about this medication, because you know you know I'm of the opinion it's one of the best drugs we have in dermatology. So, dr Cartona, do you want to explain a little bit about what isotretinoin is and when it's actually appropriate to use it when we treat acne?

Speaker 3 1:48

yes, so isotretinoin or accutane is a derivative of vitamin a, so similar. Like vitamin a, it's a molecule that is that is helpful for us. Actually it's a natural occurring molecule, so 13 cis retinoic acid is the actual chemical name and it is something that is approved as a prescription agent to treat moderate to severe, especially nodule, cystic or scarring acne. We'd love to treat acne as much as we can without strong medicines, but when it comes to a point where it's painful, cystic, perhaps like a quality of life is changing our patients because of the severity of the acne, this medication is one of the amazing, effective and reliable tools that we have as board-certified dermatologists to use.

Speaker 2 2:33

So you mentioned a good point. You know using it in patients that you know might have that nodular cystic acne and I think there's other times too. Do you feel that, like you, have to have that kind of acne to be, you know, eligible or good candidate to actually take iatratretinoin?

Speaker 3 2:47

Yeah, so the more we have worked with this molecule and prescribed it like, the molecule came about from a drug company called Roche, and early on in the 1980s is when it first came about and has long since begun generic. So it's under different brand names right now Absorca, Amnesty, Clarivus, Myrosan, Xanetane so there's different variations of it. But also with the length of time that it's been used also comes our knowledge in terms of how to use this molecule safely, and so the earlier we can catch patients and administer and start the medication in appropriately selected patients, we can oftentimes prevent the scarring that we see later on in severe cystic acne. So perhaps if we catch the right patient at the right timing, where it's moderate and you know it's about to more likely to become worse later on in the future, we can start that conversation early and introduce the concept of using this medication In other instances too.

Speaker 3 3:43

In the past, I think, a lot of times we were so robust in prescribing a certain way with certain dosing regimens that we want to clear the acne quickly and strongly and effectively that I think it brought up some potential side effects. However, that nowadays, knowing how to fine tune it appropriately and not use it so heavy handedly. I think we're able to have some tips and tricks for our patients and make it an easier to tolerate medication getting to the endpoint safer as well, and so we can we can touch on some of those tips and tricks.

Speaker 2 4:17

Yeah, we're going to dive into that too, because I think what's really important, what you mentioned is that how we could kind of halt the process or what we like to call, you know, disease modifying. You know we don't really have a lot of medications in the acne space we consider truly disease modifying. We're really going to prevent that hopeful progression or interference with it, and I think that's really where isotretinoin, or Accutane, as a lot of us still call it, really has that niche to really make a difference and, like you said, prevent, which is really what we're looking at for those patients that have, you know, pretty aggressive inflammatory acne. So early intervention key, like you mentioned. One of the challenges, though, you know, with taking this drug is the main side effect that all of us, you know, especially in the dermatology world if you're for them, of course, patients is the side effects issue of birth defects Do you mind commenting on? You know what requirements you know do we talk about with, you know, those patients that get pregnant that they need to do to?

Speaker 3 5:10

prevent pregnancy if they're actually on the medication. Yeah, so there's some rules set in place when practicing in the U S there's a registry called I pledge that is in place to keep our patients safe. So the worst side effect that can happen when you're on this medication is seen in women that can become pregnant. So it is a molecule itself. Isotretinoin is a teratogen, so if a woman becomes pregnant while taking the medicine, the baby gets very sick. So in order to prevent that, there's restrictions put in place that when you are considered to start Accutane, we need two negative pregnancy tests in women. We consider a negative pregnancy test on day zero and then day 30, we repeat it again to ensure that the patient is still not pregnant. And then, when that is established, we also talk about how to prevent pregnancy during the duration of taking the medicine. We don't have to go that in-depth for those who are unable to get pregnant and men so, but for those that can still get pregnant we definitely take the necessary precautions because we don't want to have sick babies as a result of of unprevented pregnancy. So unfortunately, even with the program in place that's pretty strict here in the U S, it leaves still 200 to 300 pregnancies annually still happen, and so we're trying our best to prevent that.

Speaker 3 6:26

That being said, I think that the criteria is easily doable and it's not too strict of options that we can do to prevent pregnancy, but we have that. We need to have that transparent conversation with our patients. We work with them. We don't always have to start medications like birth control pills or anything like that. I think abstinence is an option as well, and then it's more in the safety of the patient rather than strictly following checkboxes. But the US is a safe country, so there are checkboxes in place that we have to abide by. So if you find Agatain online where you can get it without these restrictions, you better be careful, don't do it.

Speaker 2 7:04

No, that's great advice because, you're right, you want to protect the patient. That's the main reason we're doing this to prevent, you know, pregnancy in a situation where we know developing fetus would have severe birth defects. We're often terminations. You know the recommended, you know course of therapy. So to not put our patients in that situation, you know is ideal. And then obviously, like you talked about, you know the opportunity there's abstinence and other options to if somebody can get pregnant, that we can talk about and have an educated decision.

Speaker 2 7:30

So I always tell patients, you know, like you mentioned, it's an open conversation for your safety and we prescribe a lot of drugs. You know that can cause birth defects. So that should be a part of a lot of conversations we're having in the office. You know, I think beyond, you know the birth defect issue, one of the things that you know parents especially get concerned, and rightly so too, you know, when they hear about oh, I read online that you know isotretinoin. It causes depression, it causes anxiety or I've heard it could cause suicide thoughts or attempts. What do you respond to that? What do you tell them? That's actually out there. That we know is the evidence.

Speaker 3 8:00

So at this point in time, we know the use of actin can be associated with mood swings and mood swings can happen. Now, that being said, a big chunk of the patients that we treat with isotretinoin or actin are in a kind of a. They're young, they're at school, they have a lot of pressures around them, socially, educationally, and I think throwing their severe cystic acne, I think, is also a reason for one to have mood swings and depression. So, even though there are some findings of mood swings occurring, it is not a contraindication, meaning I can still have an open communication with the patient.

Speaker 3 8:40

I usually ask them if they're on antidepressants, have any mood disorders? Are working on stabilizing anything mood disorders wise? And if they are, then we can take a step back and not push for having to start isotretinoin because there are other options too. But should everything be stable? It's something that we can monitor with the patient. We have to see our patients monthly, whether it's a combo of in-person visits with telehealth or all in-person visits. We always screen for these potential mood swing side effects, but at this point in time there's no causative proof between the two. If anything, I think having severe cystic scarring acne, I see, is something that causes a lot of mood swings and depression in these young kids.

Speaker 2 9:23

Yeah, and that's a great thing to highlight from the standpoint that you know we take depression very seriously. Even as dermatologists, we see the impact of a lot of skin disease and it can be associated with depression or anxiety. Or, like you said, if somebody has terrible acne it's of course going to affect self-esteem or it's going to impact their confidence. And I think you know what's nice is they have some evidence with these studies to show, if we do treat their acne, that actually anxiety or depression symptoms may improve because of the value we bring with improving their skin and then in turn, how it may help them with that self-confidence and also the self-esteem issues that kind of come along with having severe acne. So I think that's a good idea to put in perspective, like you mentioned, for parents to make them feel more comfortable with it. And, as you mentioned, you're going to monitor those patients, so we're going to keep a close tabs and eye on them throughout their therapy.

Speaker 2 10:09

You know, when you talk about some of the other things to you know, depression, anxiety obviously gets mentioned. The other big one is inflammatory bowel disease and I've had some patients come in and say oh, I heard I can't take those drugs, I heard that it causes Crohn's or ulcerative colitis. What do you tell patients when they have, you know, fears about that being an issue with taking isotretinoin or Accutane?

Speaker 3 10:29

Yeah, so that also has been something that is a big discussion oftentimes and truly should be. There is no direct correlation at this point evidence-based research that proves for sure that isotretinoin causes ulcerative colitis or inflammatory bowel disease. But it can cause some irritable bowel symptoms that we can see even with the other counterpart. The other option if we don't go on isotretinoin, oftentimes oral antibiotics, and so oftentimes our acne patients that are on oral antibiotics too can feel a little bit of that gut discomfort. But there is no clear cut correlation between agatine start or isotretinoin start and causing inflammatory bowel disease or ulcerative colitis and Crohn's disease.

Managing Isotretinoin Side Effects and Expectations

Speaker 3 11:13

I think research is still ongoing. Some studies have pointed one way and the other study would contradict it. So the research still needs to happen there. By typically screen the patients, by asking if there is a history of irritable or bowel disease in the past in the patient's chronic diarrhea, chronic gastritis, if in the family history. If there's a lot of inflammatory bowel disease like Crohn's or ulcerative colitis, I go gentle. So a lot of these side effects too are dose dependent with isotretinoin. So you can modify all this. So we customize the start of the medication as well and in terms of the dosing, we start low, it goes low. And the side effects too we watch for carefully and that way we don't shock the system with a high dose and likelihood for high side effects.

Speaker 2 12:01

You're really treating the individual. There. It sounds like where you can modify, as you mentioned, the amount you're giving somebody and maybe the side effects you know aren't as prominent, or you can kind of observe and see how patients do, which I think that's what patients want. They love that individualized approaching care for them and just that close monitoring and follow up. You know, I always look at isotretinoin as being kind of one of those drugs we try to tell patients like hey, you may have some side effects from it. You know these are probably we talked about depression, anxiety, inflammatory bowel, there are some of the things that we can kind of put a little bit more into the background. But when you're really highlighting potential side effects that you're most concerned a patient might go through, what do you tell them to expect when they're on a course of therapy?

Speaker 3 12:42

Yeah, so I mentioned to them these um rare side effects, but 99.999% like the main um side effect that can happen is oftentimes dryness. It's dryness, dryness, dryness. So it could be dryness of the skin for sure, Cause uh, uh, the way actin works is it helps with, uh, modifying the proliferation of skin or sloughing, or shedding of the dead skin cells that clog up the pores, and so dryness is part of it. But we give them tips in terms of how to combat that. The dry, chapped lips. That will happen.

Speaker 3 13:13

There's ways to combat that as well, but the dryness probably is the main thing. And sometimes it goes as dry, as in the nostrils where you get nosebleeds, and we recommend them to use humidifiers and other little tricks too at home. So it is doable, I think we give them a selection of all the moisturizers, gentle washes, gentle cleansers, and also in terms of the co like using other drying agents at the same time with oral isotretinoin is something that, as a prescriber, I don't like. So I always like take the prescription medicines away 99% of the times. Unless it's a different mechanism by which the medication works, then I can combine it with isotretinoin, but most of the time isotretinoin will be your main player to clear the acne and we support the patient and with all kinds of ways to keep them from having excessive dryness.

Speaker 2 14:08

I think, like most things, you get ahead of it. You know you get ahead of those side effects. You give them kind of a instruction sheet on how to maintain everything. More likely patients are going to be able to handle the medication okay, see the benefits and really want to stay on it. So getting ahead of the game. Really good point there that you highlighted is that they're also worried about getting blood work when they're on therapy. Is that something that you often do and what do you like to look for and what do you tell them about the likelihood of having abnormal blood work if they do go on therapy?

Speaker 3 14:39

Yeah. So I think there's variations amongst different clinicians how often they need blood work. Most of us do. I think baseline blood work is needed because one of the side effects that can happen with taking isotretinoin is sometimes your cholesterol profile will change and can go up and some of us, genetically, are just tend to run high on the cholesterol level. But as young adults it doesn't get checked very often, like if you were a 50 year old male.

Speaker 3 15:07

So I think I always do baseline check. So at least definitely I need one set of blood work and then, depending on the side effects and how they tolerate higher dosages, I may take one at the peak or at the end of when we're done with the course of Accutane. Some people do really well and, like we talked about the dryness, have no dryness whatsoever, but others get really dry, super dry, to the point where I have to recommend all kinds of tips and tricks to calm it down. But same thing with the blood work is just to see like who's having elevations in certain lab values. And what can I do? Maybe I should hold the dose safer and lower. Perhaps we need to take a break.

Speaker 3 15:46

Perhaps we can go higher and actually nothing's happening here at the highest dosages, and we need more efficacy of the drug, and so I think the blood work is more to guide us so we can get to the end point safely and effectively.

Speaker 2 15:58

So, yeah, Okay, no, I think that's a great approach. A lot of people, I think, use that because, again, with your, as you mentioned, and most you know, young, healthy adults or adolescent population, we don't tend to see too many abnormalities, but sometimes you have those outliers. But for all your 50 year olds out there, we are not calling anyone being older, dr Cartona, your young age, I'm just trying to highlight that. So we have, you know, for our patients there's not more likely necessarily happen. Age is something that's relative, as we know with health, but in general, yes, our patients tend to be pretty healthy that we're putting on these medications, so those lab abnormalities aren't as common as we tend to see, though you know patients that are significantly older or on multiple other drugs, especially if they impact liver function or cholesterol as well, and then, kind of, when you explain the drug, do you tell patients this is, like you know, a cure for their acne, or how do you explain it? So there's realistic expectations when you put them on isotretinoin.

Speaker 3 16:50

Yeah, because if you look at all the data combined that's out there from research, it's definitely not 100% cure. Rarely anything is 100% cure for a disease or a condition. So I think, for for Accutane itself, anywhere in the 70%, 80% would be even high. So maybe, like three out of four cases, it's a perfect happy ending where you do, uh, the calculation based on one's body weight in terms of the dosing that you want to reach cumulatively and so, and they are able to finish that dosing, which typically takes around you know, the six, five to six month mark. Uh, we typically see, you know, three out of four patients if you want to be generous, four out of five patients having that happy ending of, like their, their oil glands shrink, um, their oil production calms down, the, the acne bacteria doesn't roam around and party on the clogged up pores as much that inflammation calms down. Oftentimes even the scars remodel themselves really nicely towards that end point. And then I always expect, um to see, you know, two to three months of complete clearance of their acne before before being done with what we call a you know, quote, unquote one course of Accutane in these patients. But it is not a hundred percent. And so then the question might be like what do you do with the other ones? You know, typically if you tend to flare, I typically expect it in the first one to two months after we're done with the first course, where they might present with some challenging cysts here and there. And so then I try to not go directly back to oral isotretinoin again, but perhaps giving them a rescue agent if we can get by with one monotherapy of just one topical agent to use and give it a couple of months to see.

Speaker 3 18:31

Or sometimes we know already that we're going to need an oral antibiotic, and if it's a female patient then we get things in order again to potentially have that door open in 30 days to restart again another course of Accutane, another third course of Accutane. So that is possible. But usually there's some clues along the way, kind of hinting at it. So I can kind of like prep the patients beforehand. But what's interesting is in some patients even that go through one, two or three months of agutain and they decide, you know, this isn't for me, I just can't keep up with all the appointments, or like the co-pays, or maybe like insurance is just not too friendly about covering it. That's fine. I see the acne going from this much oftentimes to a little bit less, and that lasts for a long time, if not permanently actually. And yeah, it's not like 100% of the acne going away, but that the dialing down of the intensity of the acne sometimes means a lot to my patients already and then it makes it easier for the conventional treatment to go back into the routine.

Speaker 2 19:32

Great tips, great tips. You know, I think today, with just this conversation, hopefully for those of you out here that you've really thought about going on this drug or maybe you're on it right now or you're like I know, my acne has been terrible. I saw a video on TikTok and how amazing somebody's skin did. I think social media is helping people get a better understanding of this medication, where I think there are a lot of fears and myths.

Speaker 2 19:53

Hopefully today, with our conversation with Dr Cartona, you've hada chance to really kind of get through some of that work, through that and really inspire you to have that conversation with your dermatologist about potentially taking this drug if it is right for you. It's a joint conversation obviously to have, but with the tips and tricks you've heard today, hopefully some of your fears are alleviated, because I think that's one of the things we're trying to do is really educate people on what potential risks are and really make a decision that works for you, especially in the treatment of acne. So we know the impact it has on our patients. Now, Dr Cartona, if you're interested in finding her, she's out there on social media. Do you mind sharing where our listeners can find you, Dr Cartona, if they're looking for you out on the internet.

Speaker 3 20:30

Yes, we're on Instagram, so miskincenter is our tag, and then mine is at drcartono. And yeah, I think if you go to drcartonocom you'll find our website as well. Thank you, dr Trotter.

Speaker 2 20:45

Thank you so much for coming on today, Dr Cartona. We'd love to have you back to talk more about everything skin. Stay tuned for the next episode of Dermot Trotter Don't swear about skincare.

Speaker 1 20:57

Thanks for listening to Dermot Trotter. For more about skincare, visit DermotTrottercom. Don't forget to subscribe, leave a review and share this podcast with anyone who needs a little skincare sanity. Until next time, stay skin smart.