Safety provisions rightly in place for powerful acne treatment

DEAR DR. ROACH » Our 31-yearold daughter has fought a losing battle with acne since adolescence. Accutane has been suggested many times, and now she is about to begin treatment. We have always been too afraid of this powerful drug to try it. Are we right to be afraid? — L.E.M.

DEAR READER » Isotretoin (Accutane) is indeed a powerful medication, and although it clearly is beneficial for acne, its side effects are sufficiently important that a thorough discussion is appropriate before starting this medication, especially in a woman of childbearing age.

Isotretoin is a powerful teratogen, meaning it causes birth defects. These sometimes are severe enough to cause a stillbirth, but a child born to a woman taking Accutane has a high risk of a serious congenital malformation. Even babies who appear normal at birth are more likely to have developmental problems in the brain. For this reason, any woman of childbearing potential must commit to effective birth control (abstinence from heterosexual intercourse or two effective methods, such as oral contraceptive plus a barrier method). Women also need monthly pregnancy tests and counseling visits, and prescribers require extra training to be able to prescribe this medication. The manufacturer recommends against getting pregnant in the cycle following cessation of treatment; however, at least one case report noted a birth defect consistent with isotretoin in the second month, so I think waiting an additional month, with extra precautions, is prudent.

Both men and women are at risk for additional side effects of Accutane. Depression and other mental health issues, including psychosis, are possible, and people should be screened for depression and thoughts of suicide. Dry skin and inflammation around the lips are common, and often require lotions to treat. A connection with bowel disease is controversial. Elevations in cholesterol and triglyceride levels also are common, but seldom require stopping medication. I don’t have space to cover all of the less-common possible side effects.

On the other hand, isotretoin is the most effective treatment for severe nodular acne that has not responded to other treatments. Severe acne is associated with its own problems, including risk of depression. Despite its risk of side effects, isotretoin is a reasonable choice in carefully selected patients who agree to the necessary conditions of treatment. At 31, your daughter certainly can make her own choice about this.

Contact Dr. Roach at ToYourGoodHealth@med. cornell.edu.