When I was growing up, acne treatment was completely different than the methods used today. Makes me sound really old doesn't it? However, acne therapy has come a long way in the past 10-15 years. When I reached medical school, after years of unsuccessful acne therapy, I read about a "new" drug that made the worst cystic acne imaginable go away. Accutane was new in the early 1980's and I promptly called my dermatologist to ask if I would be able to take such a drug. As it turns out, 5 months later, I had clear skin for the first time since puberty.

ALL ABOUT ACCUTANE

Let me first review what Accutane is and why it is helpful for acne. Accutane is basically a Vitamin A derivative given as an oral medication for the treatment of significant cystic acne. Most dermatologists will also consider giving it to patients who have other forms of significant acne but have failed multiple other therapies. I've always tried to explain it as controlled vitamin A poisoning, as the potential side effects are similar to those that would occur if you took far too much oral vitamin A. We know that Accutane helps resolve acne by attacking the actual cause of the condition as opposed to just controlling symptoms. In a gland prone to forming cystic acne, the lining is too sticky, so when cells are shed, they clog the gland, blocking the secretion of oils. The oils and debris back up below the skin and enlarge, just like blowing up a balloon. The bacteria, which live in the area, take advantage of the situation as well. At some point, the gland breaks, causing the painful, red acne cyst. So you can understand that something needs to be reaching the area below the surface of the skin to really help treat these cysts.

While topical vitamin A preparations like Retin A can help keep glands clear to a point, as can the use of glycolic acid products like MD Formulations Facial Cleansing Gel for Oily and Very Oily Skin and MD Formulations Glycare Lotion, more advanced cases require oral medications. For acne that is not as severe, antibiotics like Tetracycline or Minocycline are used. Not only do they help control the bacteria (remember, that acne isn't of itself an infection), but they have anti-inflammatory properties which are really what's most important here.

INSURANCE ISSUES

For those cases when these treatments aren't enough to control cystic acne, Accutane may be an option. Accutane isn't for everybody. It's a true commitment, has potential side effects, which require frequent follow-up office visits and blood work, and is also expensive. Not until the past year or so did I ever have problems with insurance companies related to Accutane coverage. But in their attempts to cut back on drug costs, many have at least initially refused to pay for this medication, particularly if the patient is over age 25. Many times I have had to educate the medical insurance company that acne has no age cut-off and that it can be even more devastating to someone in the work force than to a teen. Not to mention, age discrimination. That usually takes care of that issue. Be sure to insist upon a review if your medical insurance company refuses to pay for your medications. It's often worthwhile.

SIDE EFFECTS

Accutane has a wide array of potential side effects, some more common than others. I always warn my patients that they may experience one or more of the following problems: dry cracking lips (the most common and expected problem), dry eyes and skin with a potential exacerbation of eczema, increased sun sensitivity, muscle or joint pains, hair loss (uncommon and it should grow back), depression, stomach upset, nose bleeds, migraine-style headaches perhaps associated with visual disturbances or night blindness called Pseudotumor Cerebri, tiny bits of bone deposited along the bones of the neck (usually asymptomatic), an increase in susceptibility to colds while on the medication (if your white blood count goes down), or jaundice (if your liver is effected).

Also, the skin becomes more fragile during the time while on Accutane, so patients are informed not to wax their skin for hair removal. The skin can literally rip when the wax is removed. I have also seen patients who were exercising or doing sports who found their skin was much more prone to injury, (and also didn't heal as well as normal), during this time frame.

I find that nosebleeds have always occurred for my teenage male patients during the wintertime. It may simply be that they tend to be more active and prone to this condition.

Let me say a word about depression on Accutane. I have had 2 patients, without any history of depression, who experienced a mild form develop while on this medication. I always ask patients how they're feeling whenever I see them to see if I can determine if there is any problem arising. Both patients responded very quickly to stopping the medication and taking a short- term course of antidepressants. This was done in conjunction with a therapist. On the flip side, I have had at least 3 patients who presented with already documented significant depression, on medication and seeing a therapist who were clinically Accutane candidates. After evaluation and discussion with their physicians and psychiatrists, they were placed on Accutane and did very well. So while I don't consider pre-existing depression an absolute reason not to use Accutane, if used, it's done under controlled circumstances and I will discontinue it if there are any problems.

BIRTH DEFECTS

As many of you know, birth defects are the most serious consequence of taking Accutane. Accutane will ONLY affect a DEVELOPING FETUS. It has no affect on the ovaries, sperm or reproductive organs. One of the most misunderstood issues about Accutane is related to this. So many people will say they don't want to take Accutane as it will cause problems with having children in the future and this just is not true. I took Accutane and have 2 beautiful healthy children. However, no woman should get pregnant while on Accutane or for 30 days after discontinuing it's use. Accutane can cause birth defects of the head or heart in a developing fetus. For this very significant reason, both the manufacturer, the FDA and any respectable dermatologist will insist that any woman or teen capable of having children be on 2 methods of contraception, and have one of them be birth control pills or depo provera. Roche (the manufacturer of Accutane) makes it extremely clear about this, even packaging and labeling their pills in bubble packs with a pregnant woman's belly with a slash through it. How much more obvious could this be? Despite this, there have been at last count approximately 300 women who still got pregnant while on Accutane, and many of these babies had birth defects.

I feel very strongly about following strict guidelines related to the use of Accutane, because I don't ever want to see it removed from the market. I've heard stories of dentists and vets, or other nondermatologists prescribing Accutane to friends, family or patients, and naturally, those individuals get into trouble from taking a product that requires strict supervision and a thorough understanding of the subtleties of the medication. That has also been a trend I've seen with certain HMOs which pressure their primary care physicians to treat even the worst acne cases without dermatology referrals. So by the time the patient has arrived at my doorstep, all sorts of problems may be present.

I for one don't want to see any babies born with birth defects and I certainly also don't want Accutane removed from the market. So I stand by my policy when prescribing this medication. If someone doesn't want to be protected, then I won't prescribe. In special circumstances where BCPs can't be used for medical reasons, we work around this. Unfortunately in this day and age, not only can the unexpected happen and you meet Mr. Right, but heaven forbid a rape occur. It's best to be safe and not have to deal with issues such as birth defects and abortion simply because of acne.

TESTING

So what to expect when you're on Accutane? First of all, you are put through a blood screen to make sure you're healthy enough to take the medication. Blood tests which check the liver, kidneys, (complete metabolic panel with SGOT, SGPT and T. Bili) along with blood count (CBC with Platelets and Differential), blood fats (Triglycerides), and if you're a woman, a blood pregnancy test called a Serum Quantitiative Beta HCG (this is much more accurate than a urine test early on in a pregnancy) are all performed. In addition to being educated about all of the various potential side effects, again if you're a woman, you take a few quizzes which basically tell you in 20 different ways that you can't get pregnant while on the medication. You are also asked to enroll in a study performed by Boston University. They call you typically once during the therapy and make sure you understand you're not to get pregnant. They are the agency which keeps track of the pregnancies arising despite our best efforts at education. They send you $10.00 for your participation.

Once this is all taken care of, a 2 week supply of Accutane and a prescription for your next blood work is given. The dose of Accutane is based upon the patient's weight. Typically it's 2mg/kg, so a man who weighs 160 lbs receives 80 mg of Accutane a day in divided doses. Follow-up blood work and dermatology visits are done at 2 weeks, 4 weeks, and once a month for the final 4 months of treatment. No blood work or follow-up, no prescription renewal. I realize this probably sounds strict, but I am very cautious about my patient's health while on this medication. It's not a product to be taken lightly. The dose of Accutane may need to be lowered if a patient is having symptomatic problems or if their blood work is showing abnormalities. With all of the Accutane patients I treat, usually I have 3-4 annually who need to have their Accutane stopped. Fortunately, none of my patients has ever experienced any type of continued problems from the medication.

WHAT TO EXPECT

As with all vitamin A types of therapy (think Retin A), there is always the potential for acne to initially flare with treatment before it clears. This is actually the medication bringing acne , which is already forming below the surface out and resolving it. It's a problem, which can cause anxiety for patients, and while it doesn't always happen, it's simply something which needs to be acknowledged, while it's happening. I find that most of the significant improvement in Accutane is seen about the 3 rd month of treatment. If that is not happening, and the patient feels well and their blood work is normal, I may increase the dose and consider the possibility of extending their treatment an additional month. This is done on an individual basis.

SKINCARE

I'm often asked about what type of skin care should be done while on Accutane. First of all, typically all prescription acne medications are stopped during this time. The skin can become very dry and irritated. I always give my patients a prescription for 2 % Hydrocortisone Ointment which they can apply to their dry and/or cracking, bleeding lips if their other lip products are insufficient. Usually products like plain Vaseline or Aquaphor Healing Ointment   are great choices for dealing with the lips. Frequent application is best. Waxy lip balms don't usually offer the type of emollient protection required while on Accutane. For simple skin care that's gentle, washing with a product like Cetaphil Gentle Skin Cleanser is great. Many of my patients may have been using oil-reducing agents like MD Formulations Facial Cleansing Gel for Oily and Very Oily Skin and want to continue using it. They certainly may as long as it doesn't seem to be drying them out too much. They may ultimately find they need to shelve it until they're off Accutane. And hopefully, their oiliness will be reduced enough that they end up switching to the less drying product MD Formulations Facial Cleanser.

For a moisturiser, non-comedogenic products like MD Formulations Moisture Defense Antioxidant Hydrating Gel is ideal. Other moisturizers like Cetaphil Moisturizing Cream or Cetaphil Moisturizing Lotion, Moisturel Therapeutic Cream  16 oz or Lubriderm would also be appropriate selections. Some patients, particularly during the winter, may want to use a body moisturizer after bathing to seal in moisture and cut down on any dry, eczematous patches which might arise. The above moisturizing creams would all be fine emollients.

An oil-free sunscreen is important as the Accutane increases the chance for sunburn. DERMAdoctor Body Guard Exquisitely Light SPF 30 For Face & Body, Murad Oil-Free Sunblock SPF 30 or Peter Thomas Roth Ultra Lite Oil-Free Sunblock SPF 30 are great.

ACCUTANE AFTERMATH

Now that you've finished your Accutane, what can you do? First of all, you need to continue those 2 methods of contraception for another full month. As for dealing with any acne scars, it's important to know that Accutane can cause excess wound healing. That means no dermabrasion, laser surgery, or I'd recommend no cosmetic surgery, for 3 years out. There have been reports of significant keloid scar formation due to dermabrasion if performed early on after stopping Accutane. Certainly, life-threatening or major surgery, which needs to be done will be, but there is a small chance that the scar may not be quite as pretty as you might like it. For the right patient, I may perform some very mild glycolic acid peels by M.D. Forte about 3-6 months out from the Accutane to help improve the appearance of their acne scars. This time frame for chemical peels is somewhat controversial, and I can't caution you enough that if a peel is done, it needs to be VERY mild, without inflammation of any kind to try to prevent any problems. Discuss this very thoroughly with your physician.

As for acne therapy after Accutane is finished, I'd "guestimate" that about 90% + of my patients remain clear of their acne either for more than a year or indefinitely. The other 10% either never completely cleared or have a flare soon after discontinuation of the drug. A second course of Accutane may be started 6 months after the first course if need be. Many times, the next treatment course will use a higher dose of Accutane than used previously. Again, this is based upon each individual. During the 6 months off, other acne therapies may be used. Unfortunately no drug works perfectly 100% of the time. There will always be people who just don't respond to Accutane the way we'd hope.

I love using products like Cellex-C High Potency Serum after the skin is no longer dry due to Accutane. Typically within a month of stopping the drug, I have patients start applying the Cellex-C High Potency Serum every morning. I find this tends to help acne scars and discoloration. Mederma would also be an acceptable choice.

As I read through this article, I realize that it makes Accutane sound scary. It's not meant to be. Accutane is meant to be looked at with the respect it's due. If you are an Accutane candidate and monitored closely by your dermatologist, that is the best case scenario in which to find great improvement hopefully without any major side effects. Accutane is a truly wonderful drug used correctly. I can say from personal experience having taken it, that it can make a major difference in your skin's appearance. If you've suffered from acne, check with your dermatologist to see what steps you can take to look your best.

As always, I hope you have enjoyed reading my newsletter and have found it informative.

Audrey Kunin, M.D.

(Any topic discussed in this article is not intended as medical advice. If you have a medical concern, please check with your doctor.)

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