From the Guidelines
For severe cystic acne that is minimally responsive to isotretinoin 40mg daily and roxithromycin 150mg twice daily, I recommend increasing the isotretinoin dose to 60-80mg daily (0.8-1mg/kg/day) for this 74kg patient, as supported by the guidelines of care for the management of acne vulgaris 1. This higher dose should be continued for a full course of treatment (typically 4-6 months total, or until reaching a cumulative dose of 120-150mg/kg). The guidelines strongly recommend oral isotretinoin for acne that is severe, causing psychosocial burden or scarring, or failing standard oral or topical therapy 1. Some key points to consider in the management of this patient include:
- Combining topical therapies with multiple mechanisms of action, as recommended by the guidelines 1
- Limiting systemic antibiotic use, as the swabs show no significant pathogens and the patient is already on roxithromycin 1
- Continuing periodic intralesional triamcinolone injections (2.5-5mg/ml) for large inflammatory nodules, as recommended by the guidelines as a good practice statement 1
- Limiting oral prednisone to short courses (0.5-1mg/kg/day for 2-3 weeks with taper) only during severe flares
- Monthly laboratory monitoring should include liver function tests, lipid panel, and complete blood count, as isotretinoin can have significant side effects 1. The increased isotretinoin dosage is justified by evidence showing that higher cumulative doses improve long-term remission rates in severe cases 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Management of Severe Facial Cystic Acne
- The patient has been treated with isotretinoin 40mg daily and roxithromycin 150mg bd for six months, which has been minimally responsive 2, 3.
- The patient requires drainage of cysts and triamcinolone injections and oral prednisone, indicating a need for alternative or additional treatments 2, 3.
- Swabs show no significant pathogens, suggesting that the acne is not caused by a bacterial infection 2, 3.
Isotretinoin Treatment
- Isotretinoin is a derivative of retinol that has been widely used for the treatment of severe forms of acne and those forms not responding to conventional treatments 2, 4.
- The efficacy and safety of isotretinoin have been reported in several studies, with common side effects being mucocutaneous and reversible 2, 3.
- The optimal dosing and surveillance of isotretinoin are crucial to minimize adverse effects and maximize its benefits 3.
Alternative Treatments
- There are no standardized protocols regarding the use of oral isotretinoin and its association with other therapies, and the correct patient selection and a tailored treatment protocol should be considered to obtain optimal results 2.
- Off-label use of isotretinoin has been reported for various dermatologic conditions, including rosacea, psoriasis, and hidradenitis suppurativa, with varying degrees of success 5, 6.
- Further prospective, randomized human trials are needed to clarify when and how to prescribe off-label isotretinoin for maximum efficacy and safety 6.