Severe Acne and Roaccutane: Everything You Need To Know

Everything You Need To Know About Severe Acne and Roaccutane (isotretinoin)

Dr Hiba went live on her Instagram account on the 21^st of October with Fiona from the Harley Street Emporium to discuss severe acne and Roaccutane (isotretinoin).

Severe acne can be very distressing. If you or a family member suffer from severe acne read on to find out answers to some of the most common questions regarding this condition.

In the live session, Dr Hiba discussed severe acne and how to treat it with isotretinoin (Accutane/Roaccutane). She answered some of her patients’ questions related to acne and its treatments.

She also chatted about:
→ Dosages
→ Precautions→ Restrictions
→ Side effects
→ Treatment protocols
→ and answer all your questions!

Check out her answers to some of these questions below:

What is acne and what happens with acne and the different stages of it?

Acne is a disease that happens in teenagers as well as adults. It can persist into adulthood, or it can start in adulthood.

It is basically due to hormones as well as excessive oil secretion that will clog the pores and cause blackheads and whiteheads and these can get inflamed.

Later on, bacteria will come in excessive ratio, due to hormones, which will cause the acne and it will cause the pimples as well as the pustules.

We classify acne as mild, moderate, severe as well as nodular cystic. Depending on the classification or the stages, this will dictate the treatment. Acne Treatments can be oral, topical or a combination.

What roles do hormone levels play in Acne? A lady has had hormone test and everything’s okay however she still has acne on her face and body. So, what sort of other things are going on there?

Hormones do not have to be elevated to cause acne. Acne is a disease that can be due to hormones, but it doesn’t mean that your hormones are abnormal, there’s a misconception.

A lot of patients come to me and they say we’ve done hormonal profile, everything’s normal, we do not have PCI polycystic ovaries, but we still have acne.  Well, yes of course you can still have acne. It could be hormonally mediated but it is not strictly related to elevated hormones.

Testosterone is a hormone that rises in puberty and that causes a lot of acne but acne is multifactorial, so you can have acne without elevated testosterone.

We see it a lot in adult women, which is called acne cosmetica. They’re applying a lot of oily makeup and cosmetics that are clogging the pores so they get that break out with blackheads and whiteheads and this causes the acne.

You can get acne from medications like steroids and some anti-epileptics. Thus, it’s not strictly like only due to hormones, and it can happen without any precipitating reason.

Even in adults, they can have acne and they have a normal hormonal profile. They don’t have a polycystic ovary, have regular periods, but they have acne.

What sort of truth is there about acne misconceptions?

There are a lot of misconceptions about Acne. People aren’t cleaning their face well and thus acne is caused because their skin is dirty. People are eating too much chocolate or too much fatty food.

 

Does not cleaning your face cause acne?

Acne is not something related to not cleaning your face. However, as a dermatologist, I always suggest a cleanser. Of course, if you have acne it’s good to wash your face twice a day with a cleanser specifically for acne-prone skin that will degrease the skin and reduce your oils, but this will not treat your acne.

If you don’t wash your face for a week, this will not give you acne if you’re not predisposed to acne.

If you have acne and you scrub and wash your face vigorously thinking that this might help, it will actually worsen your acne.

All you need to do is wash thorough twice a day. Sometimes once a day with a cleanser and to use oil-free products. But you must understand that in doing so, doesn’t necessarily clear your acne. These are just a few tips and tricks.

Can acne be triggered if you eat chocolates and certain types of food?

Studies in this area are controversial. Some studies have found a link, with dairy foods and chocolate while others have not found it.

In practice. very few patients tell me that if they eat dairy or chocolate their acne worsens, so we don’t limit diet as dermatologists. We tell patients if you notice that when you eat, fatty food, junk food, dairy or chocolate excessively that your acne gets worse, just reduce it. But we don’t impose a strict diet on all our acne patients, we treat them.

Does sugar play a role in increasing inflammation in Acne?  Should people try to limit it?

Studies found a correlation with chocolate itself as well as dairy, rather than just sugar. And, like I said, studies have been controversial. Previously, all the studies told us that there is no relationship. Recently, there are some studies that have a relationship, but it varies between patients.

So, if your acne is worsened by chocolate and you already have acne but if you stop the chocolate, it’s unlikely that your acne will disappear.

It’s not a food allergy unlike some rashes that are a relation to food allergy and if you stop that food, the rash is gone. This is not the case with acne.

What is it that makes some people end up with nodular or cystic acne or far worse acne while other people just have the odd breakout? Are some people just predisposed to this or is there a progression?

Acne does not have to progress in all patients.

If there is a predisposition of course it can be hereditary. So, if your parents have had bad nodulocystic scarring acne, you are definitely more prone to progress in that range.

For example, if I see patients or teenagers, and they come with their parents and I see their parents have scars and they tell me they’ve had very bad acne. In this case, we need to be a bit more aggressive with that patient because it can go that route too.

Acne can start off as very severe, it can start off as moderate, it can start as mild and it does not have to progress.

So it’s like all other diseases, some patients have mild diseases, some have severe diseases. But there’s no test to say, who gets what, and it can progress of course but it doesn’t have to.

How would you treat a person with mild acne? 

If you have mild acne, what we call comedogenic acne with a few spots, few blackheads and whiteheads, the main preventive measures for all patients is to avoid greasy makeup, avoid oily products creams use products for oily, acne-prone skin including the cleanser the wipes the foundation, your sunscreen even. And you need a treatment, all acne cases, require some sort of treatment. When we say mild, like a few pimples and blackheads, we treat it topically with prescription products like tretinoin, benzoyl peroxide, a combination of those with topical antibiotics. And then we advise patients on maintenance so they use the maintenance treatment once the acne disappears.

 

What is the maintenance treatment for a person with mild acne?

All acne medications dry the skin and you need a good moisturiser especially when you’re doing the treatment – but it has to be an oil-free moisturiser specifically designed for acne-prone skin.

The mild acne maintenance would then be:

• To use the prescription product once or twice a week, not only the wipes and the cleansers. Once they clear , I usually tell the patient to use it two to three times a week for maintenance to keep your oil glands under control and to keep your pores open.
• Usually, we like topical retinoids for maintenance because they keep the acne under control. They’re the best maintenance treatments.

When they’re on this maintenance, I always tell them you might get a flare-up, whether it’s stress-related like going through exams, or whether it’s just the acne that decides to come back or perhaps you might progress from mild to moderate. In this case, this would require a different treatment.

So if things start to change and you start to see your acne flare up again, either go back to using your original treatment daily, or come back for another dermatologist consultation, as perhaps you may need something different now.

How would you treat nodular or cystic acne?

First by giving the patient antibiotics. We use things like doxycycline or minocycline at a low dose for a long period. These work as an anti-inflammatory rather than killing the bacteria.

A combination of treatment works. We as dermatologists do not prescribe antibiotics for long periods of time because it defeats the purpose. It only works on one aspect of acne, which is the inflammation, but you still need to target the oily secretion and all of those things.

The problem with using antibiotics for many months, it will cause resistance, and it will change your gut flora and you don’t need any of that.

So, when we get to moderate acne and inflammatory acne we start introducing first oral antibiotics in combination with topical treatments. We use it for a few months. (more than 12 weeks). If after that period the acne is still persisting, we would then need to change this treatment.

 

What can you do if you have sensitive skin, as well as acne?

It’s quite a tricky question because a lot of patients think they have sensitive skin. This is because as soon as they start using the acne medications, their skin starts to get red, flaky and may even peel. That is why it is important to counsel patients on how to use these treatments, how to gradually start applying them and how to use a special moisturiser along the treatment to avoid this initial reaction.

I just had a consultation today with a 35-year-old lady, who thought she had acne and was previously treated as having acne. Yet, upon examining her, it turns out that she actually suffers from rosacea. I explained why her skin was super sensitive because she didn’t have acne but in fact, it was rosacea, which is a completely different thing

Usually, patients with acne, don’t have specifically sensitive skin, because their skin would be quite oily. However, patients should be aware that using topical treatments will cause some sensitivity, dryness and flaking initially.

During the consultation and follow up I counsel my acne patients on how to avoid such reactions as well as how to live with it until their skin starts tolerating the treatment.

Are antibiotics used less often now for treating acne, than they used to be in the past?

I don’t like to prescribe antibiotics for a very long time. Sometimes we have to prescribe for six months which is not unusual to hear of.

I often find patients who come to me and say that although they have been on antibiotics for a year or two they medicine is not working. My answer is yes of course it won’t. This is because they have not been prescribed any topical treatments to go along with the antibiotics. Also, patients have to understand that if they are on antibiotics for many months this can cause bacterial resistance.

That is why I don’t prescribe antibiotics for long periods of time.

Can you order Accutane online and take it with no doctor supervision?

There are a lot of restrictions to prescribing Accutane. Only consultant dermatologists can prescribe Accutane. Even GP’s have to refer patients to a hospital or a private dermatologist if they feel a patient is in need of it.

What is Accutane and why is it so controversial?

Isotretinoin is often called by brand names, such as Roaccutane or Accutane. This medication is a derivative of vitamin A, and it’s in a class of treatments we call retinoids.

Isotretinoin (Roaccutane or Accutane) in itself is a breakthrough in acne treatment. It’s a magical treatment for acne.

It works in all patients. It treats even the most severe nodulocystic scarring debilitating acne.

It’s one of those medications, which is very well known to the public. I have numerous patients who come asking for it, and you know they know they’ve reached the stage whereby this is what they want. They’ve seen their friends or they’ve seen their family members take it and they’ve seen the results. So, they’re like desperate for Accutane too, because they know how effective it is, even on the most severe acne.

It does not require a combination treatment, so it’s used alone for acne treatment.

Whereas before I talked about combination treatment using benzoyl peroxide, tretinoin, topical antibiotics, or antibiotics and changing the combination, isotretinoin works on it’s own.

It doesn’t need any further treatment, and it is the only medication for acne that can cure patients.

All the other treatments, topical, antibiotics, as I said, need maintenance treatment and your acne can jump from mild to severe.

With Isotretinoin you can get a cure so 70 to 75% of patients who take a full course of Accutane, which is a minimum of 120 milligrams per kilo, so it’s given according to a person’s weight. By cure I mean that’s it it’s gone forever.

25%, do not achieve the cure, but most patients, even if they are not cured it can skip a few years like they might need a second course but usually, it’s like two or three years later, and usually, their acne is very severe to start with. In these cases, they might have hormonal problems or familial acne. So there is usually a reason why this medication did not work for them.

Very few patients within my practice and I’ve been practising for more than 23 years, have required a second or third dose of Roaccutane.

To get that 75% chance of cure, you need to take the full course, so if you’ve taken less than that your chance of cure is much less.

Do you recommend blackhead strips for Acne?

Blackhead strips are more for the blackheads you get on the nose. They are not necessarily for acne. They’re dilated pores with dirt and secretions. These strips don’t work specifically for acne.

No, I don’t recommend these for Acne. I know a lot of people get those black clay masks they put them and they claim to remove their blackheads, even if it does, it’s not a treatment for acne because they come back immediately. You need an acne treatment to actually treat your Acne. It’s the same as going for a facial and letting them squeeze these blackheads out for you but they will come back, you need a treatment to have acne.

 

Is it required to have very oily or greasy oily skin prior to using Roaccutane?

Any patient with acne has oily skin, whether they can see the oil or not. Their oil glands are excessively active. And even if they have a bit of dryness or flaking, they should treat the skin as oily skin.

We don’t necessarily need to see the oil to treat with Roaccutane. They are treating acne not the oil. Some patients have really excessive oil and shiny skin and they love it when they take the Accutane because it dries it up.

Is dryness a side effect of taking isotretinoin?

Isotretinoin like I said is only prescribed by dermatologists. We have a lot of experience with it. We know how to counsel patients; we know how to detect side effects. We know when to stop when we need to stop when to reduce the dose, and what to tell patients.

The initial consultation takes at least 30 minutes because I go through all the side effects.

So dryness and dry lips is not a side effect it’s actually an effect. So if you do not get dry lips it means your stomach is not absorbing the Accutane. We question whether you’re really taking it on with fatty food or are you taking it properly because if you don’t get the dry lips, it just means it’s probably not working.

Accutane works on the oil glands by shrinking them and reducing their activity, so you get generalised dryness. So face gets dry, hair gets dry, eyes going to get dry, and generally, the skin gets dry.

If patients have eczema, eczema might flare-up. So we know how to treat it. And we know what to prescribe to reduce that.

Dryness is an effect rather than side effects. Most patients, more than 95%, only get the lip dryness, some can get dryness elsewhere or some eczema and but we know how to treat it. I tell these patients to moisturise a lot, use some masks and if their eyes have already dry they need to use the refreshing eye drops more frequently.

Is Cataracts a side effect of using Accutane?

No, not with Accutane. Not to my knowledge is doesn’t cause cataracts in itself. No.

Are fatigue and muscle pain a side effect of using Accutane?

I do not see fatigue, muscle and back pain frequently at all. It’s more common in patients who exercise and who go to the gym regularly.

So they may get some fatigue and muscle pain and that is why I warn patients, before they start on it, that if you do get that side effect, to let me know. I will then reduce the dose or stop it for a short period.

Sometimes reducing the severity of their exercise will help. So just stepping down a bit will help with this problem. Some patients find that if they take some paracetamol they will be fine.

Is having back pain while on Accutane common?

 No not as common as the dryness, but it can happen. It’s one of the more uncommon side effects.

Can taking Accutane affect male and female fertility?

 Accutane doesn’t affect the fertility of the person taking it however you cannot get pregnant, while you’re using it because it is a teratogenic drug. This means that it can disturb the development of the fetus. Accutane affects the fetus in a very high percentage and can cause abortions, miscarriages and even fetal abnormalities.

Females taking this medication need to be on contraception (two kinds of contraception is preferable like what is done in the US) Females should not get pregnant while on it and for one month after stopping it. In fact, a negative pregnancy test is a requirement to prescribe Accutane in all females of childbearing age, until they reach menopause. I have to specify on the prescription that pregnancy test is negative, and repeat the pregnancy test every month. This is done both privately as well as in the NHS.

So patients have to take a pregnancy test and then make sure it’s negative, and it has to be reported on the prescription and actually, the prescription expires in two days I think so the pharmacy will not prescribe it if it’s more than two days old.

As for males, they should not get their partner’s pregnant while they are taking it for the same reason.

Does isotretinoin affect fertility?

Isotretinoin (Accutane) does not cause permanent fertility issues. I know there’s a vibe on the internet and influencers talking about it affecting the ovaries.

Dermatologist, however, rely on evidence-based medicine. We rely on studies that are randomised, placebo-controlled and double-blinded and there is no evidence in our medical literature that it can cause infertility.

Hormones fluctuate anyways during the cycle and with patients who have acne anyways. They might have a fluctuation of hormones. But, books, medical books medical literature, doctors and medical science say women can get pregnant once they stop the medication. I tell my patients to wait two months, and then they can get pregnant again.

Can Accutane cause arthritis and joint issues?

Accutane can cause what we call premature epiphyseal closure. This is rare, but it is a side effect of Accutane. That’s why we avoid giving it to children who are still growing. unless we badly need it. There’s always that risk-benefit ratio. We have to weigh the benefits of the drugs to its side effects.

In some literature, it can cause bone spurs or changes in the bones but this is more with long term use. Sometimes we do give Accutane for a long time, not for acne but for a year or two to treat other diseases and this is when the side effects are more common.

Accutane, it’s not a drug that will affect fertility. There are some other medications we use in dermatology that affect fertility, of course, but not Accutane. There are some other medications that will affect the DNA, like methotrexate.

Can there be delayed side effects of taking Accutane in the long run?

Do we know what happens 10 years down the track after we’ve taken it? Could you suddenly find that you have a bone or joint issues 10 years later, that is attributed to that? Is there a long term cost of taking Accutane?

If you didn’t get the side effects, while you were taking it, you will not get it 10 years after stopping. This is because it’s gone from your system. The drug is not there anymore. If it’s going to cause, bone and joint problems, arthritis or back pain, it will happen when you are taking it – not years after stopping it.

We do not do x rays and MRI before prescribing Accutane because it’s not needed.

 

You can see the full Instagram Live event below: