DermHelpCentral

Lab Testing When of Isotretinoin

Article: British Journal of Dermatology, August 2022

Is routine laboratory testing in healthy young patients taking isotretinoin necessary - a critically appraised topic
Andrew Affleck et. al.

Abstract
Adverse events were very rare (less than 1 in 10,000) and either idiosyncratic or not preventable by monitoring, were accompanied by symptoms, or occurred in identifiable predisposed individuals that may benefit from monitoring because of pre-existing conditions.

Recommendation for clinical care: We could not find evidence to support the benefit of monitoring to detect adverse events. We suggest that in healthy young people laboratory monitoring for oral isotretinoin is unnecessary and risks detecting non-serious biochemical abnormalities. However, we recognise that new information about adverse events may change that recommendation.

Br J Dermatol. 2022 Aug 20. PMID: 35986616

Marius Rademaker's Talks on Isotretinoin and Atopic Dermatitis

Marius Rademaker practices dermatology in Hamilton, New Zealand.
He has been at the forefront of research into the use of isotretinoin for acne and other disorders as well as the treatment of atopic dermatitis with methotrexate.

Here are notes from his presentations at Hot Spots in Dermatology
August 17 - 19, 2018, Kahuku, Hawaii

1. Isotretinoin:  Download Notes from Marius Rademaker’s Talks on Isotretinoin
2. Methotrexate: for Atopic Dermatitis : Download Marius Rademaker on Atopic Dermatitis

Key References:

1. Download Isotretinoin- Dose Duration Relapse

2.We do not have a pdf.  Here is the citation + the abstract:

Methotrexate for treatment of atopic dermatitis in children and adolescents

Marius Rademaker et. al.

Int. J. Dermatoil 2014 https://doi.org/10.1111/ijd.12314 (06 March 2014)

Abstract: Low‐dose methotrexate is becoming established as a second‐line treatment for atopic eczema in the adult population, but there has been a paucity of data to support its use for this indication in the pediatric population.

Methods A retrospective review was undertaken of patients aged 18 years and under started on methotrexate between January 2005 and April 2010, at a hospital‐based dermatology department in New Zealand.

Results: Thirty‐one patients (17 females, mean age 10 years, range 3–18 years) were reviewed. Methotrexate was found to be effective or very effective in 75% and ineffective in 25%. The mean duration of treatment for those who responded to methotrexate was 14 months (range 2–38 months), 74% of patients were still on treatment at the time of last review. The most common adverse effect was minor nausea in four patients (14%) and non‐significant elevation of liver enzymes (four patients). No serious adverse effects were noted.

Conclusion: In our experience, methotrexate has a good safety/tolerability profile when used in low dose for the treatment of atopic dermatitis in children and adolescents and appears to be effective. Formal comparative studies are needed.

 

Isotretinoin: Dose, Duration and Relapse

Article by Marius Rademaker, Hamilton, NZ

Abstract below...  Download Isotretinoin- Dose Duration Relapse

With 30 years of clinical use, it is appropriate to review the use of isotretinoin. While the standard dose of 0.5 to 1 mg/kg per day for 4 months to acumulative dose of 120–140 mg/kg per day has servedus well in the management of acne vulgaris, there is emerging evidence that much lower dosages (as low as 5 mg/day) are just as effective but have significantly fewer adverse effects.
Relapse of acne vulgaris continues to be a problem but we are beginning to recognise that this is related less to the cumulative dose and more to the length of sebaceous gland suppression.
Other factors important for relapse include
1. a macrocomedonal pattern of acne, smoking and age,
 2.both younger (under 14 years) and older ( women over 25 years).

After 30 years of use, we now understand why isotretinoin is such an effective drug. Not only does it clear acne in almost all patients, long-term remission can be achieved in 70–80% of patients with a single course. Important changes in the use of isotretinoin include using a lower daily dose for a longer period of time. New indications continue to emerge, particularly as a potential treatment for both intrinsic and extrinsic (photo) aging. Teratogenicity however, remains a very significant concern.

Key words: acne vulgaris, adverse effects, dose, isotretinoin, relapse, retinoid.

Low Dose Isotretinoin - Rademaker

Isotretinoin: dose, duration and relapse. What does 30 years of usage tell us?

Rademaker M. Australas J Dermatol. 2013 Aug;54(3):157-62  Download Low Dose Isotretinoin Rademaker

Abstract: With 30 years of clinical use, it is appropriate to review the use of isotretinoin. We now understand that retinoids influence cellular growth, differentiation, morphogenesis and apoptosis, inhibit tumour promotion and malignant cell growth, exert immuno-modulatory actions and alter cellular cohesiveness. This has expanded the indications of isotretinoin from just acne and rosacea to a wide range of inflammatory and malignant skin disorders. While the standard dose of 0.5 to 1 mg/kg per day for 4 months to a cumulative dose of 120-140 mg/kg per day has served us well in the management of acne vulgaris, there is emerging evidence that much lower dosages (as low as 5 mg/day) are just as effective but have significantly fewer adverse effects. Relapse of acne vulgaris continues to be a problem but we are beginning to recognise that this is related less to the cumulative dose and more to the length of sebaceous gland suppression. Other factors important for relapse include a macrocomedonal pattern of acne, smoking and age, both younger (under 14 years) and older (over 25 years). After 30 years of use, we now understand why isotretinoin is such an effective drug. Not only does it clear acne in almost all patients, long-term remission can be achieved in 70-80% of patients with a single course. Important changes in the use of isotretinoin include using a lower daily dose for a longer period of time. New indications continue to emerge, particularly as a potential treatment for both intrinsic and extrinsic (photo) aging. Teratogenicity however, remains a very significant concern.

Dr. Rademaker's Guide to Isotretinoin Dosing

Making sense of the effects of the cumulative dose of isotretinoin in acne vulgaris
Marius Rademaker, BM, FRCP, FRACP, DM   Int. J. Dermatol. 25. 518-23;2016

More complete notes.

Of 1453 patients treated with isotretinoin, 326 (22.4%) received a second course of treatment (study population). The remainder served as controls (n = 1127). Dosage varied from 10 mg/week to 1.1 mg/kg/d, cumulative dosage from 1 to >300 mg/kg, and duration of treatment from 8 weeks to 5 years. Compared with controls, patients who received a second course were more likely to be women (61 vs. 47%; P < 0.001) and received higher daily (0.71 vs. 0.58 mg/kg/d; P <0.001) and cumulative (126 vs. 101 mg/kg; P < 0.001) doses. Patients treated with very low doses (e.g. 10 mg three times per week) and/or low cumulative doses (e.g. 25–50 mg/kg) did not appear to relapse more often than controls. In Conclusion, neither daily nor cumulative dosages influenced relapse of acne patients treated with varying doses of isotretinoin as long as treatment was continued for ≥2 months after the acne had completely resolved.

Full article:  Download Rademaker Isotretinoin

Isotretinoin Option Grid

Isotretinoin (aka Accutane) is commonly used for severe acne because it is universally effective whereas other therapeutic options are less predictably successful.  However, many patients (or their parents) are frightened by anecdotal reports of bad side-effects they find about on the Internet.

The decision to take isotretinoin is value-based for patients or their guardians.  This tool may help to make the choice easier.

See: Isotretinon Option Grid.

Updae on the management of Rosacea

This is a helpful review with special reference to isotretinoin.  It is available free full text.

Abstract. Refining diagnostic criteria has identified key characteristics differentiating rosacea, a chronic skin disorder, from other common cutaneous inflammatory conditions. The current classification system developed by the National Rosacea Society Expert Committee consists of erythematotelangiectatic, papulopustular, phymatous, and ocular subtypes. Each subtype stands as a unique entity among a spectrum, with characteristic symptoms and physical findings, along with an intricate pathophysiology. The main treatment modalities for rosacea include topical, systemic, laser, and light therapies. Topical brimonidine tartrate gel and calcineurin inhibitors are at the forefront of topical therapies, alone or in combination with traditional therapies such as topical metronidazole or azelaic acid and oral tetracyclines or isotretinoin. Vascular laser and intense pulsed light therapies are beneficial for the erythema and telangiectasia, as well as the symptoms (itching, burning, pain, stinging, swelling) of rosacea. Injectable botulinum toxin, topical ivermectin, and microsecond long-pulsed neodymium-yttrium aluminum garnet laser are emerging therapies that may prove to be extremely beneficial in the future. Once a debilitating disorder, rosacea has become a well known and manageable entity in the setting of numerous emerging therapeutic options. Herein, we describe the treatments currently available and give our opinions regarding emerging and combination therapies.

Also see:  All About Rosacea.

A Rational Approach to Isotretinoin

I started prescribing isotretinoin (then called Accutane) when it was first approved for use in 1982. Since then, there has been no time during my career when I have not had patients taking the drug. Isotretinoin has revolutionized the treatment of acne and is responsible for the fact that we see far fewer cases of severe disfiguring cystic acne today than we did prior to its approval.

I would like to share some of my observations over the past 32 years of prescribing this drug.

Read full article:   Download Isotretinoin_ Elpern -- edit

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