Living with any degree of acne can leave marks on the outside—and on the inside.
After all, acne outbreaks can do more than just change a person’s physical appearance; they can cause pain, impact work or relationships and take a major toll on emotional wellbeing.
This leaves many people searching for a treatment that actually works, and that can deliver long-term clear skin.
While the market is saturated with acne products that promise results, the reality is that everyone’s skin is different and there’s no one treatment that’s a magic fix, especially for those whose acne is severe or persistent.
Perhaps the closest thing to a long-term cure that exists is a prescription drug called isotretinoin (often referred to by its former brand name, Accutane).
What is Accutane or Isotretinoin?
Isotretinoin is an oral retinoid, derived from vitamin A, that targets root causes of acne such as excess oil production and inflammation.
After finishing a course of Accutane treatment, most people experience lasting or even permanent results, but some may need multiple rounds of therapy for the results to stick.
While isotretinoin can be incredibly effective for acne, it’s not right for everyone. Side effects, access challenges and other barriers such as cost can limit use of isotretinoin.
Isotretinoin can also cause birth defects, and everyone taking isotretinoin must be registered in the iPLEDGE pregnancy prevention program.
John Barbieri, MD
Isotretinoin is associated with many different—but often temporary—side effects, which can cause understandable concern for some people.
In fact, typing “does Accutane…” into a search bar pops up questions like, “Does isotretinoin cause hair loss? Does it cause depression? Does it stunt growth?”
These fears may keep people from starting isotretinoin, even when the treatment is warranted, generally safe and could vastly improve their quality of life.
In this Q&A, we asked John Barbieri, MD, director of the Advanced Acne Therapeutics Clinic at Mass General Brigham, to help us parse out the facts from the fiction when it comes to this powerhouse drug for severe acne.
Dr. Barbieri is also the host of a popular YouTube channel about all things skin health (including Accutane use), and we've included lots of links to related videos throughout this article.
Isotretinoin is a drug derived from vitamin A that targets the root causes of acne,
such as excess oil production and inflammation.
Q: What your patients’ most common concerns about the physical side effects of Accutane use?
Patients and their families often have concerns about Accutane symptoms such as acne flaring (also called “purging”), dryness, hair changes and joint pains.
They may also worry about potential effects on mental health, the liver or risk of inflammatory bowel disease (IBD).
Q: Are these concerns about Accutane backed by science?
Acne flaring or purging, the temporary increase in the production of acne, can indeed happen when starting isotretinoin.
Starting slowly with a low dose and combining treatment with an antihistamine can help minimize this risk. It’s also true that almost everyone on this medication will have some skin and lip dryness, and some may have dryness in other areas, such as the eyes.
This can often be managed by using a lower dose of the drug or taking Omega-3 supplements, but for some people, dryness can persist even after stopping treatment, which is an important risk to consider.
Secondly, isotretinoin can cause a temporary type of hair loss called “telogen effluvium” that typically improves after treatment. Using a lower dose seems to be associated with a reduced risk of hair changes.
Only about 5% of those treated with isotretinoin experience joint pains and muscle aches, but they can occur. These side effects typically improve with a lower dose and will typically resolve after stopping the drug. Additionally, L-carnitine supplements may help patients with muscle aches.
Isotretinoin also causes sun sensitivity, so it’s important for patients to use sun protection while on this drug—whether it’s broad-spectrum sunscreen (SPF 50+), sun-protective clothing or avoiding the highest UV index periods of the day.
And last—but certainly not least—isotretinoin can cause serious birth defects, so pregnancy prevention is crucial among those who can become pregnant.
Acne flaring or purging—the temporary increase in the production of acne—can happen when starting isotretinoin. Starting slowly with a low dose and combining treatment with an antihistamine can help minimize this risk.
Q: Which of these concerns about Accutane haven't been proven?
To date, the highest quality studies have not identified any association between isotretinoin use and inflammatory bowel disease. However, oral antibiotics, a common alternative to Accutane/isotretinoin, are associated with increased risk of inflammatory bowel disease.
There is also no evidence that isotretinoin is associated with meaningful long-term harm to the liver.
In fact, it’s just as common for patients to have liver test abnormalities before treatment as it is for them to have these results during treatment, suggesting that many abnormal tests are unrelated to isotretinoin.
Q: Did you discover any associations between Accutane and growth and height in your recent studies?
There have been concerns about whether isotretinoin might affect growth, due to case reports of premature closure of the epiphyses (the growth areas at the ends of long bones) in the treatment of neuroblastoma, where much higher doses of this drug are given to younger children than what is typically prescribed for acne.
We recently conducted two studies, one using the Rochester Epidemiology Project Cohort and the other using TriNetX, both of which found that the treatment of acne in adolescents is not associated with any meaningful effects on final adult height or increased risk of short stature.
The findings reassure against an association between pediatric isotretinoin use for acne and stunted growth and can help guide shared decision-making when deciding whether to use this medication.
Barberiei and team conducted two studies which both showed that the treatment of acne in adolescents is not associated with any meaningful effects on final adult height.
Q: Interesting! What about the emotional side effects?
Yes, some patients have concerns about Accutane and mental health issues, which is a complex topic.
On one hand, multiple studies have found that it reduces the risk of depression and suicide compared to other acne treatments. This is likely because severe acne itself can cause depression, and isotretinoin is the most effective treatment of this condition to date.
However, there have also been cases of people having mood symptoms while on isotretinoin that improved when they stopped treatment and returned when they restarted it, suggesting that this drug can, in rare instances, cause meaningful mood changes.
Therefore, it is important to monitor these symptoms.
That said, the general expectation is that isotretinoin will improve mood.
Q. Given all this, how to dermatologists weigh pros and cons of Accutane treatment?
There are many ways to treat acne, including topical creams and washes (best when combining multiple mechanisms of action), oral antibiotics, hormonal therapy (spironolactone and birth control pills), lasers (such as AviClear & Accure devices) and dietary and lifestyle strategies.
It is important for clinicians to work together with patients to consider what treatment approach best fits their goals and acne severity.
While isotretinoin is not right for everyone, it is the most effective prescription acne treatment and the only one that can deliver long-term remission of acne after discontinuation.
Q: What does the medical community still need to learn about Accutane treatment?
We still need to learn more about the ideal dosing regimens to balance long-term clearance of acne and potential side effects.
For example, higher cumulative dose (in other words, more medicine) is associated with better acne outcomes but may also be associated with increased risk of chronic dry skin and eyes.
Researchers are continuing to study who benefits most from longer versus shorter treatment courses.
We also need more data on potential side effects of concern to guide shared decision making with patients in the clinic.
"While isotretinoin is not right for everyone, it is the most effective prescription acne treatment and the only one that can deliver long-term remission of acne after discontinuation." — John Barbieri, MD
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